May 2013 PHOENIX 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: Helena Valenzuela Date: 5/31/2013 10:25:37 AM
Corrective Plan: Sick call at Phoenix Complex is conducted seven days a week in order to keep up with the influx of
Intakes submitting HNRs. Inmates are triaged by nursing and either addressed with a Nursing Encounter Form,
(NET), or are put on the line at the clinic. Please see NEO II binder -Nursing Encounter Guidelines and Tools. A
copy can be provided to you by written request, (email is fine).
CAP Revision #1 - NEOII Binder is reserved for Health Monitor at the AA's desk in Medical Admin. NEOII Training
roster has been sent to you via email.
Problem Identified: Sick call needs to be conducted 5 days a week.
Discussion and Action Plan: As a result of this finding, the FHA has instititued a plan to ensure compliance. Nursing
staff have been instructed that sick call is to be conducted in a clinical setting five days a week. DON shall ensure
that sick call lines are being properly documented and are being conducted 5 days a week in a clinical setting.
Responsible Person: DON shall ensure that sick call is being conducted in accordance with this compliance
measure.
Status: Nursing staff have been informed and the DON will continue to monitor for compliance.
Anticipated Completion Date: Ongoing process that will require ongoing monitoring and as such, no date of
completion can be given.
Date Completed: See immediate previous response.
8/16/13 - Please see Findings of Space Utilization Committee and Position Paper submitted on this subject matter:
ARIZONA DEPARTMENT OF CORRECTIONS
ARIZONA STATE PRISON COMPLEX – PHOENIX
ALHAMBRA UNIT
MEMORANDUM

DATE: October 24, 2012
TO: Charles L. Ryan, Director
THROUGH: Robert Patton, Division Director
THROUGH: Carson McWilliams, Northern Region Operations Director
THROUGH: Al Ramos, Warden
FROM: Meegan A. Muse, Deputy Warden
Helena Valenzuela, Wexford Health Medical Compliance Monitor
Holly Massey, Interim Wexford Health Complex Site Manager
SUBJECT: COMPLIANCE WITH THE AMERICAN HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT OF 1996 (HIPAA)
POSITION PAPER
ISSUE
Should the Department of Corrections, Phoenix/Alhambra Complex, address the spatial arrangement of the inmate
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May 2013 PHOENIX COMPLEX
intake area to ensure confidentiality of obtaining inmate medical and mental health information in order to comply
with American Health Insurance Portability and Accountability Act of 1996, (HIPAA) and the Standards for Health
Services in Prisons by the National Commission on Correctional Health Care?
BACKROUND
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules
to be followed by doctors, hospitals and other health care providers. This protects all "individually identifiable health
information" held or transmitted by a covered entity or its business associate, in any form or media, whether
electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI)."12 “Individually
identifiable health information” is information, including demographic data, that relates to:
• the individual’s past, present or future physical or mental health or condition,
• the provision of health care to the individual, or
• the past, present, or future payment for the provision of health care to the individual, and that identifies the
individual or for which there is a reasonable basis to believe it can be used to identify the individual.13 Individually
identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security
Number). www.hhs.gov/ocr/privacy
The Arizona Department of Corrections follows the accreditation program by complying with the requirements in the
manual, Standards for Health Services in Prisons, developed by the National Commission on Correctional Health
Care. The Standard states, “Discussion of patient information and clinical encounters are conducted in private and
carried out in a manner designed to encourage the patient’s subsequent use of health services.” (Standards for
Health Services, p. 15)
The Wexford Health Sources, Inc. Contract states in section 2.10.15.1: Information Confidentiality
”Confidentiality/Exchange of Information: The Contractor shall ensure that inmate health information is handled in
accordance with any applicable procedures established by Federal and State confidentiality of health information
laws and regulations.” Additionally stated, “To ensure compliance with HIPAA regulations, Wexford Health will set
forth protocols that meet or exceed accepted privacy standards of the correctional health care industry.” (section
2.10.15.1, p. 443)
CURRENT PRACTICE
Inmate medical and mental health intake evaluations are conducted in Delta run. The top portion of the Physical
Examination form (#1101-77P) and the Reception Center Screening form (#1101-21P), demographics, is conducted
in the hallway in Delta run by Patient Care Technicians (PCT’s). The nursing portion of the Reception Center
Screening form (#1101-21P) is conducted in one room in Delta run utilizing 2 to 5 nurses. Mental Health
evaluations are conducted in another room in Delta run by two Psych Associates utilizing the Initial Mental Health
Assessment form (#1103-27) and if needed, additional SOAPE notes are written in the inmate’s medical file to
address additional needs (i.e. – continuous watch, etc.). Mobile partitions (from 5 to 6 feet tall and 5 feet wide) are
being used in both rooms in an attempt to address confidentiality compliance. There is no partition in the hallway
surrounding the PCT desk.
OPTIONS
1) Possibility of any open offices or other areas within the unit to expand into.
Comments: An inspection was conducted by key staff. The current infrastructure does not support additional areas
to be utilized by medical or mental health staff. Other office areas are currently occupied by other staff and there
are no empty rooms.
2) Possibility of introducing additional office spaces (i.e. - mobile trailer, etc.) within the Alhambra yard.
Comments: Cost and utility installation may be prohibitive. As well, an additional security officer would need to be
allocated for additional location.
3) Possibility of expanding the current Nursing and Mental Health staff hours.
Comments: Changes have already been made to the staff hours to better accommodate the needs of the unit.
Variations to the staff hours are limited due to the dependence of the time that the new arrivals come in to the unit
and the daily operational activities of the unit.
4) Possibility of mirroring community standards utilized in regional healthcare facilities, mental health institutions,
and correctional practices.
Comments: At regional healthcare facilities, such as hospital emergency departments, patients are screened,
triaged, evaluated, and treated, often in medical bays separated by cloth material (i.e. – curtains made of paper,
linen, or other thin cloth, etc.) in an attempt to address confidentiality compliance. At regional mental health
institutions (i.e. – walk-in mental health clinics and psychiatric emergency rooms), mental health screenings are
often conducted in much the same manner as hospital emergency departments. At regional correctional facilities
(i.e. – jails and prisons), the medical and mental health screening practices are often conducted in similar situations.
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RECOMMENDATION
This committee recommends that the Phoenix / Alhambra Unit mirror the community standards utilized in regional
healthcare facilities, mental health institutions, and correctional practices (Option 4). The committee will review this
issue annually to evaluate and determine new viable options.
Corrective Actions: Approved by H. Valenzuela. 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: Helena Valenzuela Date: 5/24/2013 4:03:27 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Process to address, to include but not limited to:
a.Daily pick up.
b.Date stamp.
c.Triage within 24 hrs, immediate triage of patient if emergent.
d.Seen within 48 hrs after date stamp or 72 hrs weekend/holiday.
e.Nurse line sees patient, then to provider line when appropriate.
f. Submit final site process to RVP.
2.In-service staff on policy titled ”Routine Appointments – Request” Chapter 5, Section 3.1 (
(Attachment II.2.) and per Sick Call 2.20.2.2 contract performance outcome 2 (Sick Call
Attachment);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Sick Call 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/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 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: Helena Valenzuela Date: 5/24/2013 4:26:20 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service nursing staff on per Sick Call 2.20.2.2 contract performance outcome 3 (Sick Call
Attachment);
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call 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/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 – VS will include weight when appropriate.
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: Helena Valenzuela Date: 5/24/2013 3:49:23 PM
Corrective Plan: Physician and Site Medical Director, (SMD), deny the physician in question is using preprinted
templates. SMD and physician questioned separately in my office regarding the behavior in question. SMD and
physician both report physician 'preps' charts, by way of reviewing the charts allocated to him first thing in the
mornings, and prepping the paperwork. Physician has been counseled by the SMD and myself that while reviewing
charts and beginning to prep paperwork is not the preference of the SMD, it is the physician's prerogative. The
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May 2013 PHOENIX COMPLEX
physician in question has been instructed that he may not time and date forms ahead of time, under any
circumstances. SMD to counsel and monitor his practice.
CAP Revision: There are too many issues to address on one CAP. Please be specific about what you still require an
answer to and I will provide an answer to the best of my ability. Thank you!
See below.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call 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
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 –NETs to be used for all Nursing sick call.
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: Helena Valenzuela Date: 5/24/2013 3:49:23 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call 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
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 –NETs to be used for all Nursing sick call.
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: Helena Valenzuela Date: 5/24/2013 3:49:23 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call 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
Target Date- 11/30/13
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May 2013 PHOENIX COMPLEX
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 –NETs to be used for all Nursing sick call.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Helena Valenzuela Date: 5/24/2013 3:55:16 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on Sick Call 2.20.2.2 contract performance outcome 5
(Sick Call Attachment); Seen by Physician or Midlevel within 7 days
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call 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
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 nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Helena Valenzuela Date: 5/24/2013 4:00:32 PM
Corrective Plan: 9/9/13 - Nursing Encounter Tools are used with standing orders that can be located in the NETs
binder found on every unit. These forms are to be used with every nursing-inmate encounter. The process of
completeing Nursing Encounter Tools, (NETs), will continue to be reviewed on a monthly and ad lib basis.
Corrective Actions: See above.

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May 2013 PHOENIX COMPLEX
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
documented in the medical record? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Patricia Arroyo Date: 5/28/2013 2:49:48 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1. Standardized process for documenting in medical record chronic condition education per
Chronic Condition and Disease Management Programs 2.20.2.4 contract performance
outcome 3.
2. In-service staff on:
a. Documentation of chronic condition education at each visit.
b. 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
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.

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May 2013 PHOENIX COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
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: Nicole Taylor Date: 5/31/2013 11:23:53 AM
Corrective Plan: Problem Identified: Treatment plans not in compliance.
Discussion and Action Plan: As a result of this finding, the Clinical Director met with all Mental Health Staff between
5/27/13 and 6/7/13 to express expectations of treatment plan compliance and patient contact. Staff were instructed
that treatment plans were to be updated as described in the MGAR question and as ADC policy dictates. A chart
audit process (previous described in another MGAR finding) was initiated to address treatment plans and patient
contact expectations. These audits are being submitted and reviewed by the Clinical Director on a weekly basis
since early June 2013. Since that time, significant improvement has been demonstrated in chart audits. This
process is expected to continue to ensure ongoing compliance. Documentation of chart audit findings can be
reviewed in the Clinical Director's office.
Responsible Person: Mental Health Staff for task completion. Clinical Director is responsible for oversight and
review of charts as well as staff redirection/coaching when non-compliance is discovered.
Status: Chart audit process has been in place since early June 2013.
Anticipated Completion Date: As this is an ongoing monitoring process, no completion date can be given for
monitoring of charts.
Date Completed: See immediately previous response.
Corrective Actions: Will continue to monitor and implement as described 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: Nicole Taylor Date: 5/31/2013 11:26:20 AM
Corrective Plan: Problem Identified: Inmates not being seen/no documentation of clinical visits by licensed staff.
Discussion and Action Plan: As a result of this finding, the Clinical Director met with all Mental Health Staff between
5/27/13 and 6/7/13 to express expectations of treatment plan compliance and patient contact. Staff were instructed
to see all inmates in admitted areas every seven days on an individual basis as well as ensure that those inmates
also were afforded group treatment by licensed and unlicensed staff. A chart audit process (previous described in
another MGAR finding) was initiated to address treatment plans and patient contact expectations. These audits are
being submitted and reviewed by the Clinical Director on a weekly basis since early June 2013. Since that time,
significant improvement has been demonstrated in chart audits. This process is expected to continue to ensure
ongoing compliance. Documentation of chart audit findings can be reviewed in the Clinical Director's office.
Responsible Person: Mental Health Staff for task completion. Clinical Director is responsible for oversight and
review of charts as well as staff redirection/coaching when non-compliance is discovered.
Status: Chart audit process has been in place since early June 2013.
Anticipated Completion Date: As this is an ongoing monitoring process, no completion date can be given for
monitoring of charts/contacts.
Date Completed: See immediately previous response.
Corrective Actions: Will continue to monitor and implement as described above.

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May 2013 PHOENIX COMPLEX
Section 1.1.1.1 A Panorex x-ray or two bite wing x-ray is completed when an inmate arrives.
This is completed during intake.
Section 1.1.2 Dentist shall classify all patients according to dental treatments needs via the visual exams or
screening of the Panorex x-ray.
Our Dental Doctor keeps all records on an electronic program.
Base on the research I have completed and a follow up visit with the dentist here at Alhambra Complex, I am
unclear with the time frames from above. Is their something in the Dental contract (our dentist is under a different
contractor than Corizon) that we are not aware of at this time? Can you please provide this information? See below
Corrective Actions: Reinforce to staff the necessity that the medical records need to be reviewed within 12
of an Inmate’s arrival to the unit by dental staff.
Responsible Parties = dental
Target Date – 11/30/13

hours

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May 2013 PHOENIX COMPLEX
review and a copy of this report shall be maintained in the DON's office for compliance inspection by contract
monitors. These reports shall be made available on the second Monday of each month. Inventory coordinators may
assist in this task as supervised by nursing staff.
Responsible Person: Nursing staff assigned to units for task completion. DON for review and training. FHA for
process implementation/development/direction.
Status: Initial reviews will begin immediately and the formal process is to begin August 2013. First reports with any
luck will be available on August 12th.
Corrective Actions: See above.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Patricia Arroyo Date: 5/28/2013 3:36:29 PM
Corrective Plan: This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee meeting
is Friday, August 2, 2013. Is not site specific.
Corrective Actions: See above.
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: Patricia Arroyo Date: 5/29/2013 3:07:21 PM
Corrective Plan: Problem Identified: Incomplete MARs
Discussion and Action Plan: As a result of this finding, the FHA and DON have instituted a process of confirming
that all medications currently prescribed for patients have an accurate MAR. The 26th of each month prior to the
printing of the MARs, the DON shall run a census (through AIMS) of all inmates in designated housing areas
(excluding intakes) and distribute this census to the nursing staff responsible for those areas. Nursing staff shall
then do a chart review of each patient and confirm that MARs are accurate and present in the MAR books. Nurses
shall notate on the census report if MARs are present and accurate and shall immediately correct or replace any
missing or inaccurate MARs. At the completion of this task, the census report shall be delivered back to the DON for
review and a copy of this report shall be maintained in the DON's office for compliance inspection by contract
monitors. These reports shall be made available on the second Monday of each month. Inventory coordinators may
assist in this task as supervised by nursing staff.
Responsible Person: Nursing staff assigned to units for task completion. DON for review and training. FHA for
process implementation/development/direction.
Status: Initial reviews will begin immediately and the formal process is to begin August 2013. First reports with any
luck will be available on August 12th.
Corrective Actions: See above.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Patricia Arroyo Date: 5/30/2013 11:05:07 AM
Corrective Plan: This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee meeting
is Friday, August 2, 2013.
Corrective Actions: See above.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Patricia Arroyo Date: 5/30/2013 11:06:11 AM
Corrective Plan: This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee meeting
is Friday, August 2, 2013.
Corrective Actions: See above.

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May 2013 PHOENIX COMPLEX
in his area. He now receives and electronic copies of the inventories by e-mail (from AFHA) and the hard copies
area forwarded through institutional mail.
4 Are medical tools engraved, where practical, to identify the tools as health services items?
Level 1 Amber User: Helena Valenzuela Date: 5/24/2013 4:28:02 PM
Corrective Plan: Corizon site leadership working with ADOC site leadership to correct. Tools scheduled to be
engraved 6/3/13.
Just a note - Tools being engraved as we speak! I will send you the stuff when it's all done, which should be by COB
tomorrow, per Freudenthal, Asst FHA.
Meeting schedule within second week in July with DW Tyford to ensure all tools are in compliance. Will submit
verification doucmentation to contract monitor upon the completion of this meeting. Approximate date of completion
is July 19th 2013.
Corrective Actions: Approved. See above.
6 Are sharps being inventority at the beginning and end of each shift?
Level 2 Amber User: Helena Valenzuela Date: 5/24/2013 4:12:43 PM
Corrective Plan: Baker Nurse educated on tool count procedure. The rest of the nurses to be retrained during the
month of June and sign off on training at the June nursing staff meeting.
Corrective Actions: Please leave feedback or kindly remove from MGAR. Thank you.
7 If sharps count is off is nursing notifying the shift commander?
Level 2 Amber User: Helena Valenzuela Date: 5/24/2013 4:13:30 PM
Corrective Plan: Corizon site staff and ADOC site staff work together to assure counts are accurate and timely.
Corrective Actions: If Green, please remove from MGAR. Thank you.
8 Are officers present for sharps inventories with the nursing staff?
Level 2 Amber User: Helena Valenzuela Date: 5/24/2013 4:14:06 PM
Corrective Plan: This is an ADOC Security issue. Corizon staff directed to radio/call for a shift supervisor if no officer
turns up for count.
Corrective Actions: Please leave feedback or kindly remove from MGAR. Thank you.

PRR ADC00856