May 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Sick Call (Q)
1 Is sick call being conducted five days a week Monday through Friday (excluding holidays)? P-E-07, DO
1101, HSTM Chapter 5, Sec. 2.04.2, Chapter 7, Sec. 7.6]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:00:17 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
2 Are sick call inmates being triaged within 24 hours(or immediately if inmate is identified with emergent
medical needs)? [P-E-07, DO 1101, HSTM Chapter 5, Sec. 3.1]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:08:02 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
2 Are sick call inmates being triaged within 24 hours(or immediately if inmate is identified with emergent
medical needs)? [P-E-07, DO 1101, HSTM Chapter 5, Sec. 3.1]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:08:02 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: Mathew Musson Date: 5/30/2013 3:13:56 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
4 Is the SOAPE format being utilized in the inmate medical record for encounters? [DO 1104, HSTM Chapter
5, Section 1.3]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:40:04 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
4 Is the SOAPE format being utilized in the inmate medical record for encounters? [DO 1104, HSTM Chapter
5, Section 1.3]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:40:04 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:29:46 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Mathew Musson Date: 5/30/2013 3:37:28 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00698

May 2013 EYMAN COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00703

May 2013 EYMAN COMPLEX
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
Plan weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using audit tool per
audit results.10/11/13 Update – Documentation on education sheet located in front of chart, medical records
responsible for making sure in chart.
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: Jen fontaine Date: 5/30/2013 11:45:28 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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 ADC00709

May 2013 EYMAN COMPLEX
Responsibility Parties = ADON/DON/Nursing Supervisor/RN/LPN/RCQI
Target Date= 11/30/13

PRR ADC00713

May 2013 EYMAN 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: Mathew Musson Date: 5/30/2013 5:20:19 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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: Mathew Musson Date: 5/30/2013 5:33:03 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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: Mathew Musson Date: 5/30/2013 5:33:03 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
4 Are inmates with a mental score of MH-3 and above seen by MH staff according to policy? [CC 2.20.2.10]
Level 2 Amber User: Mathew Musson Date: 5/30/2013 7:09:25 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
7 ***Deleted
Level 2 Amber User: Mathew Musson Date: 5/30/2013 5:53:56 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00716