April 2013 TUCSON COMPLEX
inmate is identified with emergent medical needs)?
Compliance
Sick calls are done by a process after an inmate submits an HNR requesting to be seen.
Once the HNR is received by medical the inmate HNR’s are triaged daily and then immediately scheduled on the
nursing and provider line according to level severity.
Based on the amount of HNR requests nursing staff cannot see all inmate requests within 24 hours, however;
nursing staff must treat all critical, chronic care and injuries are seen within 24 hours.
Nursing and provider lines are run according to securities schedule, ICS’s take precedent over nursing lines.
Corrective Actions: Approved per Marlena.
3 Are vitals signs, to include weight, being checked and documented each time an inmate is seen during
sick call? [P-E-04, HSTM Chapter 5, Section 1.3]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 1:11:41 PM
Corrective Plan: Duplicate question already answered
Corrective Actions: Approved per Marlena.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 1:15:46 PM
Corrective Plan: Are referrals to providers from sick call being seen within seven (7) days?
Compliance
Each unit is given two full days with a provider Monday through Friday.
The provider will see a regular scheduled medical line, and in addition will treat any necessary critical chronic care,
and injuries that apply for the unit.
If a provider is needed at a unit on his non-scheduled day the provider will make provisions to visit that unit to meet
the need of the inmate that requires immediate medical attention.
Sick calls are being seen by the provider within the (7) days of request.
Corrective Actions: Approved per Marlena.

PRR ADC00564

April 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Specialty Consultations (Q)
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:26:30 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties =ARMD/RDON/RVP/RDCQI/DON/
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.

PRR ADC00568

April 2013 TUCSON 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: 4/30/2013 7:24:34 PM
Corrective Plan: 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?
Yes If we have an inmate diagnosed with a new chronic condition our providers will follow the instructions in the
clinical pathways for disease management. Then they fill out a form to send to medical records indicating the
chronic condition. Medical Records appropriately tags the chart. and the provider notate the problem list.
Corrective Actions: October Action Plan submitted by Corizon1. Process to for treatment plan development after identification of chronic condition, to
include but not limited to:
a. Plan development within 30 calendar days per Chronic Condition and Disease Management
Programs 2.20.2.4 contract performance outcome 1 (Chronic Care Attachment)
2. In-service staff on process expectations/policy
a. Agenda/sign off sheet to verify, inclusive of all pertinent staff
b. Preparation of chart for clinic
3. Monitoring (Chronic Condition Monitoring Tool)
a. Audit tools developed
b. Weekly site results discussed with RVP
c. Audit results discussed a monthly CQI meeting
d. Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Medical Director/RDCQI/RVP/MRL
Target Date- 11/15/13
2 Are CC inmates being seen by the provider (every three (3) to six (6) months) as specified in the inmate’s
treatment plan? [P-G-01, DO 1101, HSTM Chpt. 5, Sec. 5.1, CC 2.20.2.4]
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:27:26 PM
Corrective Plan: Are CC inmates being seen by the provider (every three (3) to six (6) months) as specified in the
inmate’s treatment plan?
Clinical:
Chronic care patients are seen by the provider for specific chronic condition scheduled as follows:
HIV positive are seen every 3 months, and are up to date, all other chronic care conditions are seen every 6
months. Each unit accounts for provider back log and submits the unit count to the FHA weekly.
Chronic care inmates that need additional monitoring will be scheduled per providers treatment plan 0 to 180 days.
All chronic care inmate charts are noted by both the provider and the nursing staff for monitoring, medications and
treatment plans and all future scheduling. See below.
Corrective Actions: October Action plan submitted by CorizonProcess statewide to include, but not limited to :
1. Chronic Care inmates seen by provider every 3-6 months, as specified in the treatment plan
per Chronic Condition and Disease Management Programs 2.20.2.4 contract performance outcome
2 (I.- IV.Chronic Care Attachment).
2. In-service staff on policy titled ”Treatment Plans” Chapter 5, Section 1.4 (Appendix II.2.)
and outcome measure .
a. Agenda/sign off sheet to verify, inclusive of all pertinent staff .
3. Monitoring
a. Audit tools developed.
b. Weekly site results discussed with RVP.
c. Audit results discussed a monthly CQI meeting.
d. Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties = FHA/DON//Medical Director/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
3 Are CC/DM inmates being provided coaching and education about their condition / disease and is it
PRR ADC00578

April 2013 TUCSON COMPLEX
documented in the medical record? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:27:39 PM
Corrective Plan: Are CC/DM inmates being provided coaching and education about their condition / disease and is it
documented in the medical record?
Both providers and nursing staff are trained and licensed professionals that provides appropriate coaching,
instructions and education for all patient care.
Chronic care patients are monitored for their condition and are educated during each medical visit with the provider
or the nursing staff.
All units provide pamphlets and handouts for new and ongoing chronic care conditions. This material is updated
and available for inmates to view and to take to their houses.
Corrective Actions: Approved per Trudy Dumkrieger.
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: Trudy Dumkrieger Date: 4/30/2013 3:28:07 PM
Corrective Plan: yes we have a disease management protocol for chronic care and other conditions in the Clinical
Pathways manual.
Corrective Actions: October Action plan submitted by Corizon1.In-service staff on Corizon Clinical Guidelines (I. – IV. Chronic Care Attachment)
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
2.Monitoring
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Medical Director/RDCQI/RVP
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Make sure guidelines available at sites; need to prep chart for clinic visit so everything the
provider needs is available.

PRR ADC00579

April 2013 TUCSON COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff the importance of using name stamps. Continue to monitor.

PRR ADC00591

April 2013 TUCSON 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 10:22:26 AM
Corrective Plan: Please send to Christy Somner. See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Expired Medications (Appendix I.1.a.)
b.Re-order medications
c.Invalid chart orders (Appendix I.1.c.)
i.Therapeutic dose ranges
ii.Dose changes must have supporting documentation
d.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

PRR ADC00593

April 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
2 Are inmates referred to a Psychiatrist or Psychiatric Mid-level Provider seen within seven (7) days of
referral? [CC 2.20.2.10]
Level 2 Amber User: Steve Bender Date: 4/25/2013 2:30:49 PM
Corrective Plan: our initial plan of action will include doing an individualiz yard assessment to determine where the
extent of the deficieny exists. The Yards that we are non-compliant will require a plan of action for that specific
yard(s).
Corrective Actions: complete see above
3 Are MH treatment plans updated every 90 days for each SMI inmate, and at least every 12 months for all
other MH-3 and above inmates? [CC 2.20.2.10]
Level 1 Amber User: Steve Bender Date: 4/25/2013 2:40:19 PM
Corrective Plan: Yes, per Regional Psychiatry policy is being carried out accordingly.
Charts will be reveiwed for the existence of treatment plans; where absent, treatment plans will be developed with
the inmate. These will then be reviewed within the prescribed time frames.
See below.
Corrective Actions: October Action plan submitted by Corizon1.In-service staff on process expectations per Mental Health 2.20.2.10 contract performance
outcome 3(Mental Health Attachment) related to treatment plan updates every 90 days and use of
SMI monthly report tool
a.SMI monthly report tool will be maintained by the MH Clinicians to assist with tracking
appointments; copy given to MH Leader monthly and submitted to MH Directly monthly to track
and trend (III.1.a. SMI Monthly Report)
b.Review AIMS and update when changes in MH status
c.Inmates with mental health score of three or above are seen by MH staff per policy
titled “Levels of Mental Health Services Delivery” (Appendix III.1.c.)
d.Agenda/sign off sheet to verify, inclusive of all pertinent staff
2.Monitoring (Mental Health Monitoring Tool)
a.Audit tools developed
b.Monthly site results discussed with RVP/MH Director
c.Audit results discussed at monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/MH Lead
Target Date- 11/30/13
Continue to monitor daily, then monthly until meet compliance, then ongoing monthly monitoring.
10/11/13 Update: Staff in-serviced on how to use SMI monthly report tool; review of audit tool data to begin in
November.
6 Are reentry/discharge plans established no later than 30 days prior release for all inmates with a MH
score of MH-3 and above? [CC 2.20.2.10]
Level 2 Amber User: Steve Bender Date: 4/25/2013 3:00:06 PM
Corrective Plan: Corizon's recruiting team is continuing to recruit for another full time Psychiatrist and we have
identified a potential candidate. Additionally, We have requested for locums thru agency to fill in the abscence of a
full time psychiatrist. Two are in the works now.
Corrective Actions: Seee above.

PRR ADC00598

April 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Quality and PEER Review (Q)
1 Is the contractor physician conducting monthly and quarterly chart reviews? [HSTM Chpt. 1, Sec. 5.0; CC
2.20.2.12]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 7:24:36 PM
Corrective Plan: Is the contractor physician conducting monthly and quarterly chart reviews?
Compliance
No, We are in the process of hiring a medical director that will implement this at the peer review meetings. We
anticipate having a medical director on site by next month.
Corrective Actions: Approved per Marlena.
2 Is contractor conducting monthly CQI committee meetings and meeting NCCHC standard? [P-A-06, HSTM
Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 7:25:58 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Medical, mental health, and dental disciplines are participants in the monthly CQI meetings.
3 Are CQI committee improvement recommendations acted on timely and progress reported back to
committee in the next meeting? [P-A-06, HSTM Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 7:30:48 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Improvement recommendations are acted on and reported back to committee. Continue to
monitor.
5 Did the contractor conduct a quarterly on-site review of the site CQI program? [P-A-06, CC 2.20.2.12]
Level 1 Amber User: Marlena Bedoya Date: 4/29/2013 7:36:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Regional management will monitor the site CQI program.

PRR ADC00600

April 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Administration
3 Is there a tracking system for KOP medications to determine if medications have been received by the
inmate? [NCCHC Standard P-D-01]
Level 1 Amber User: Kathy Campbell Date: 4/30/2013 7:25:18 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
c.Administration of DOT/KOP.
d.Printing MARs (Pharmacy Appendix).
e.Medication error documentation/reporting (Pharmacy Appendix).
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties =FHA/DON/RDCQI/RVP/FHA
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
4 Are the Medication Administration Records (MAR) being completed in accordance with standard nursing
practices? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Kathy Campbell Date: 4/30/2013 7:25:34 PM
Corrective Plan: Are the Medication Administration Records (MAR) being completed in accordance with standard
nursing practices?
Yes, each medical unit is in compliance with MARS. MARS are logged daily by nursing staff and checked by unit
nursing supervisor to ensure they are properly logged.
All inmate MARs are updated with new medications or new inmates to the unit.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
c.Administration of DOT/KOP.
d.Printing MARs (Pharmacy Appendix).
e.Medication error documentation/reporting (Pharmacy Appendix).
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties =FHA/DON/RDCQI/RVP/FHA
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:06:55 PM
PRR ADC00607

April 2013 TUCSON COMPLEX
Corrective Plan: Are there any unreasonable delays in inmate receiving prescribed medications?
Delayed med passes are caused by ICS’s, lock-downs, and security and movement.
These things can help delay the distribution of medication during regularly scheduled med pass,
Certain units will bag mediations and distribute them throughout the yards if a security officer is available to assist in
med pass. Nursing will stay after working hours to ensure that med pass is done. See below.
Corrective Actions: October Action plan submitted by CorizonIntakes1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
a.Intake Orders
b.Private Prisons
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Custody/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:06:55 PM
Corrective Plan: Are there any unreasonable delays in inmate receiving prescribed medications?
Clinical
There is minimal delay in inmates receiving prescribed medications.
The delay of medications are caused by the amount of transfers within the facility and to outside facilities.
When an inmate is transferred all KOP medications are moved with inmates by security and all DOT medications
are moved within the facility by nursing staff.
Any re-issued medications are done by Pharmacorr for external moves.
Nursing and pharmacy staff work hard to ensure that inmates medications are not delayed during movement. See
below.
Corrective Actions: October Action plan submitted by CorizonIntakes1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
PRR ADC00608

April 2013 TUCSON COMPLEX
a.Intake Orders
b.Private Prisons
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Custody/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:06:55 PM
Corrective Plan: Are there any unreasonable delays in inmate receiving prescribed medications?
Clinical

The delay of medications are caused by the amount of transfers within the facility and to outside facilities.
When an inmate is transferred all KOP medications are moved with inmates by security and all DOT medications
are moved within the facility by nursing staff.
Any re-issued medication are done by Pharmacorr for external moves.
Nursing and pharmacy staff work hard to ensure that inmates medications are not delayed during movement. See
below.
Corrective Actions: October Action plan submitted by CorizonIntakes1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
a.Intake Orders
b.Private Prisons
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
PRR ADC00609

April 2013 TUCSON COMPLEX
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Custody/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
7 Are inmates being required to show ID prior to being administered their medications?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:18:07 PM
Corrective Plan: Are inmates being required to show ID prior to being administered their medications?
Clinical
Yes, all inmates must show identification prior to receiving any DOT’s and KOP medications. No staff is to distribute
any medication without identification. See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
c.Administration of DOT/KOP.
d.Printing MARs (Pharmacy Appendix).
e.Medication error documentation/reporting (Pharmacy Appendix).
f.Check ID to Inmate and MAR.
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties =FHA/DON/RDCQI/RVP/FHA
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
7 Are inmates being required to show ID prior to being administered their medications?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:18:07 PM
Corrective Plan: Are inmates being required to show ID prior to being administered their medications?
Clinical
PRR ADC00610

April 2013 TUCSON COMPLEX

Yes, all inmates must show identification prior to receiving any DOT’s and KOP medications.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
c.Administration of DOT/KOP.
d.Printing MARs (Pharmacy Appendix).
e.Medication error documentation/reporting (Pharmacy Appendix).
f.Check ID to Inmate and MAR.
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties =FHA/DON/RDCQI/RVP/FHA
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
8 Are chronic condition medication expiration dates being reviewed prior to expiration to ensure continuity
of care?
[NCCHC Standard P-D-01]
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:12:21 PM
Corrective Plan: Are chronic condition medication expiration dates being reviewed prior to expiration to ensure
continuity of care?
Chronic care medications are a priority and are monitored by both the provider and the nursing staff to ensure
inmates are receiving all care plan medications for their condition.
Pharmacy sends each medical unit a weekly expiration list for the upcoming week of meds that are to be renewed.
The supervisors on the units intercept the list and begin the process to renew, order or discontinued all medications
accordingly. This ensures that the medication renewals are done prior to expiring.
Chronic care medications are listed on these weekly lists for assurance of renewal.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
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b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Custody/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Kathy Campbell Date: 4/30/2013 7:25:58 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 4/30/2013 3:13:36 PM
Corrective Plan: Are providers being notified of non-formulary decssions within 24 to 48 hours?
A non- formulary is a prescription that is no on the formulary list of drugs and is required explanation by the
prescriber to indicate why the drug is needed.
Due to the amount of non-formulary requests throughout the State Dr. Williams and Dr. Bynum aware that this
decision is taking longer than 24 to 48 hours to notify. They are working on hiring additional staff to help elevate the
overwhelming requests.
At this time Providers are encouraged to prescribe only from the formulary and create alternative treatment plans as
much as possible.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
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April 2013 TUCSON COMPLEX
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

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Physician one was filled and is in the process now. She should begin on 07/15
medical director position remains vacant.
Regional Director is coming in for a second interview in one week.

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