May 2013 FLORENCE COMPLEX
Level 1 Amber User: Jen fontaine Date: 5/31/2013 7:19:07 PM
Corrective Plan: Nursing Encounter Tools (NETS) have been approved by ADC and implemented on all units.
These are considered nursing protocols and list complaint (subjective ) , VS, including weight when indicated
(objective), (plan) treatment and or referral, (education).
Corrective Actions: See above.

PRR ADC00734

May 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Specialty Consultations (Q)
1 Are urgent consultations being scheduled to be seen within thirty (30) days of the consultation being
initiated? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 5/31/2013 5:01:43 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 5/31/2013 5:13:23 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
3 Is the utilization and availability of off-site services appropriate to meet medical, dental and mental health
needs? [CC 2.20.2.3]
Level 3 Amber User: Jen fontaine Date: 5/31/2013 5:20:57 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00737

May 2013 FLORENCE 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: 5/31/2013 3:49:55 PM
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 ADC00741

May 2013 FLORENCE COMPLEX
Corrective Actions: Reinforce to staff the necessity that the medical records need to be reviewed within 24 hours of
an Inmate’s arrival to the unit by mental health staff. Continue to monitor
4 Is dental staff reviewing inmate medical record with 24 hours of Inmate arrival (72 hours Friday /
Weekend)?
Level 1 Amber User: Jen fontaine Date: 5/31/2013 11:42:27 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce to staff the necessity that the medical records need to be reviewed within 24
of an Inmate’s arrival to the unit by dental staff. Continue to monitor

hours

PRR ADC00752

May 2013 FLORENCE COMPLEX
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Jen fontaine Date: 5/31/2013 6:00:30 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC00756