April 2013 SAFFORD COMPLEX

Corrective Action Plans for PerformanceMeasure: Chronic Condition and Disease
Management (Q)
1 Are treatment plans developed and documented in the medical record by a provider within thirty (30)
days of identification that the inmate has a CC? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Kathy Campbell Date: 4/27/2013 2:36:15 PM
Corrective Plan: inmate has 5 vol. of medical records. He was house at Graham Unit in Safford complex and
moved to Ft. Grant unit in Safford complex on 1/19/2013. He had a CC appt. on 9/13/2013 for Asthma, HTN,
Cardiac, and Hep C. Provider order was to see again in 6 months. He was seen again for his CC on 3/6/2013. He
has been seen again for his CC hep C and B on 4/19/2013 and then again 5/10/2013. His chronic care visits have
been within the guidelines.
Corrective Actions: Approved.
3 Are CC/DM inmates being provided coaching and education about their condition / disease and is it
documented in the medical record? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Kathy Campbell Date: 4/27/2013 2:36:32 PM
Corrective Plan: Corizon has implemented new education logs that the inmates will be signing off. Have educated
the providers on the use of these logs. Will continue to monitor to assure that the providers are providing education
on all inmate visits.

Ann Rochelle Mullen, RN FHA
Safford Complex
5/21/2013
Corrective Actions: Approved.
4 Have disease management guidelines been developed and implemented for Chronic Disease or other
conditions not classified as CC? [P-G-01, HSTM Chpt. 5, Sec. 5.1, CC 2.20.2.4]
Level 2 Amber User: Kathy Campbell Date: 4/14/2013 6:06:04 PM
Corrective Plan: Have discussed with providers that all areas of the CC forms must be filled out to be complete. Will
all present in next CQI meeting for plans of correcting.
Ann Rochelle Mullen, RN FHA
Safford Complex
4/18/2013
Corrective Actions: Approved.

PRR ADC00534

April 2013 SAFFORD COMPLEX
Corrective Action Plans for PerformanceMeasure: Prescribing Practices and Pharmacy
(Q)
2 Are pharmacy polices, procedures forms, (including non-formulary requests) being followed? [NCCHC
Standard P-D-01, CC 2.20.2.6]
Level 2 Amber User: Leslie Boothby Date: 4/26/2013 10:17:13 AM
Corrective Plan: Safford Complex, all units, keep a log of non-formulary requests. This is checked on a daily basis
for approvals they are resent to Dr. Williams for approval if there has been no response and follow-up daily until
response is received. We pull the expiring medication report from the Pharmacorr website, which is not always up
to date, in the middle of the month for the following month. If there are medications that need to be renewed, cc
medications, the inmate is scheduled with the provider before the medication runs out.
These are the processes that we have initiated at Safford Complex to assure continuity of care.
Ann Rochelle Mullen, RN FHA
Safford Complex
May 31,2013
Corrective Actions: See above.

PRR ADC00538

April 2013 SAFFORD COMPLEX
Corrective Plan: Staff has been pulling expiring medication reports mid month for the following month. If a CC
medication is expiring the inmate is schedule to see the doctor to get orders before it expires. If an inmates
medications have expired and it has been missed the medication is pulled for the RDSA if available and issued that
day to the inmate. If it is a medication that we do not have in stock we will obtain it from the back up pharmacy. We
will continue reviewing batch reports from Pharmacorr and pulling our own reports from Pharmacorr website.
Ann Rochelle Mullen, RN FHA
Safford AZ. Complex
May 31, 2013
Corrective Actions: Approved.

PRR ADC00546