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PRR ADC00875-00930 - Monthly Compliance Rpts - 2013-05 - ASPC-Tucson (redacted), AZ DOC, 2013

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May 2013 TUCSON COMPLEX
(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.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Marlena Bedoya Date: 5/31/2013 3:26:39 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 is provided within the (7) days of request by
the providers.
Corrective Actions: Approved per Marlena.

PRR ADC00881

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Corrective Actions: October Action plan submitted by Corizon1.Retrain FHA/DONs on ED management and expectations
a.Agenda/sign off sheet to verify
2.Develop a site level process to assure, but not limited to:
a.ED log completed and submitted daily to Regional office
b.Access to custody transport logs
c.Access to AIMS
3.Train site staff on ED management and expectations
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
4.Review ED activity daily (in AM) with FHA/DON/MD (lead provider in absence of MD) to determine
patient status and appropriate treatment plan
a. Agenda/sign off sheet to verify, inclusive of all pertinent staff
5.Regional staff conduct weekly review of compliance to daily submission and appropriate patient
disposition
6.Monitoring tool developed for self-monitoring and submission to site management and regional
CQI
7.Initiation of monitoring tools at sites
8.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 = VPO/ARMD/RDON/RVP/FHA/DON/MD/RDCQI
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 – ED log sent to Regional office daily.

PRR ADC00885

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Corrective Action Plans for PerformanceMeasure: Chronic Condition and Disease
Management (Q)
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: 5/31/2013 2:46:20 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:
Weekly provider back logs are being counted on each unit to help maintain a more current Chronic care log. CNA’s
and nursing staff schedule all chronic cares suring the providers days scheduled on the units.
All patients that are seen by the provider for specific chronic conditions and most are up to date, those on the back
log list of CC’s are scheduled within 30 days of set specified treatment plan.
HIV positive are seen every 3 months and all other chronic care conditions are seen every 6 months. Chronic care
inmates that need additional monitoring will be scheduled per providers treatment plan.
All chronic care inmate charts are noted by both the provider and the nursing staff for monitoring, medications and
treatment plans.
Nursing staff follows the treatment plan orders set up by the provider and notes the chart accordingly. Charts are
noted within thirty days that inmate was seen by the provider for his chronic care. 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.
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: 5/31/2013 2:46:20 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?
Chronic care patients are seen by the provider for specific chronic conditions noted HIV positive are seen every 3-months and all other chronic care conditions are seen every
6 to 9 months depending on thier condition.
Chronic care inmates that need additional monitoring will be scheduled per providers treatment plan.
All chronic care inmate charts are noted by both the provider and the nursing staff for monitoring, medications, and
ongoing treatment plans. Providers are working to ensure all charts are up to date and inmates are seen in a timly
fashion.
Nursing staff follows the treatment plan orders set up by the provider and notes the chart accordingly - if an inmate
is in need of his appointment the nurse will schedule the inmate accourdingly. 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).
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May 2013 TUCSON COMPLEX
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.
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: Kathy Campbell Date: 5/31/2013 8:22:45 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:

Each unit is working hard to address the ongoing back log of both provider and nursing lines. The units are
concentrating on addressing all chronic care inmates within the set treatment plan time frame.
Weekly provider back logs are being counted on each unit to help maintain a more current Chronic care log. CNA’s
and nursing staff schedule all chronic cares suring the providers days scheduled on the units.
All patients that are seen by the provider for specific chronic conditions and most are up to date, those on the back
log list of CC’s are scheduled within 30 days of set specified treatment plan.
HIV positive are seen every 3 months and all other chronic care conditions are seen every 6 months. Chronic care
inmates that need additional monitoring will be scheduled per providers treatment plan.
All chronic care inmate charts are noted by both the provider and the nursing staff for monitoring, medications and
treatment plans.
Nursing staff follows the treatment plan orders set up by the provider and notes the chart accordingly. Charts are
noted within thirty days that inmate was seen by the provider for his chronic care. 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
documented in the medical record? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Trudy Dumkrieger Date: 5/31/2013 2:20:21 PM
Corrective Plan: Are CC/DM inmates being provided coaching and education about their condition / disease and is it
documented in the medical record?
The health care providers were sent to training in phoenix and education was provided to them. I have done a
follow up with the providers and asked them to include the documentation in their plan of care in the progress note.
I have informed the DON to instruct her nursing supervisors and nursing staff to use the chronic care educational
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May 2013 TUCSON COMPLEX
literature and document in the progress note whenever they provide educational teachings.
Corrective Actions: Approved per Trudy
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: 5/31/2013 2:28:36 PM
Corrective Plan: Our plan is to mirror the ADC policies and Department orders. We are to follow the ADC technical
health manual. There are some new procedures through Corizon that have been approved by ADC such as the
Warfarin protocol and some that are still in the process with ADC and soon to be rolled out which includes the
Hepatitis C treatment protocol.
Corrective Actions: approved per Trudy.

PRR ADC00898

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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: Steve Bender Date: 5/23/2013 7:31:00 AM
Corrective Plan: yes per regional psychiatry policy is being carried out accordingly.
There will be a comprehensive review of treatment plans on each yard. This is part of a Corizon initiative involving
improvments of inmate treatment plans with focus on inmate participation, identifying strengths and weaknesses
and examining behaviorial objectives. This will also be brought up at a psychology team meeting.
Corrective Actions: 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?
MH Treatment plans are updated every 30 to 90 days for SMI inmates. These updates are done by the psych
associate and/or the psychologist on each yard. Each inmates chart is given an individual treatment plan and must
be noted accordingly within the 90 days allotted policy time frame.
MH treatment plans for MH-3’s are not up to dated on yearly treatment plans. Staffing issues have posed this
problem with getting all MH-3 charts updated in a timely manner.
Mental health is working to correct the lack of staff needed to maintain updated charts for the inmates with MH-3
scores, and will continue to work on making these 12 month deadlines.
Morning chart reviews are being done Monday through Friday by MH staff to ensure that a set amount of charts are
being updated. This will help to ensure that all MH inmate treatment plans are being carried out accordingly.
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: Steve Bender Date: 5/23/2013 7:35:26 AM
Corrective Plan: Corrective action includes training new staff. There has been only one pyschiatric nurse working
PRN and two have recently been hired. One currently remains in orientation. With the new nurses working we
anticipate improvement in this area. Some innovative methods will be explored to meet the challenges.
Corrective Actions: I will contact the FHA in Perryville and see how this is being addressed.
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: 5/23/2013 7:39:31 AM
Corrective Plan: Duplicate question. Answered twice already
Corrective Actions: See previous response. Duplicate.

PRR ADC00903

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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: 5/31/2013 8:23:23 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: Trudy Dumkrieger Date: 5/31/2013 2:49:10 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: Trudy Dumkrieger Date: 5/31/2013 2:49:10 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.
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May 2013 TUCSON COMPLEX
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.
5 Are medication errors forwarded to the FHA to review corrective action plan?
Level 2 Amber User: Trudy Dumkrieger Date: 5/31/2013 3:09:19 PM
Corrective Plan: Are medication errors forwarded to the FHA to review corrective action plan?
Clinical
I receive them and sign off on them. The Corizon medication error form does not have an area for corrective action
on it. We have a seperate form for corrective action and I have instructed the Director of Nursing to provide me with
an action plan for every medication error submitted.
Corrective Actions: Approved by Trudy.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Trudy Dumkrieger Date: 5/31/2013 4:02:08 PM
Corrective Plan: Are there any unreasonable delays in inmate 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 medication are done by Pharmacorr for external moves.
Nursing and pharmacy staff work hard to ensure that inmates medications are not delayed during movement.
There is minimal delay in inmates receiving prescribed medications. 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.):
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May 2013 TUCSON COMPLEX
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.
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: 5/31/2013 4:09:32 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.
Corrective Actions: Approved. See above.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 5/31/2013 4:02:46 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.
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May 2013 TUCSON COMPLEX
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.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 5/31/2013 4:02:46 PM
Corrective Plan: Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Clinical:
non-formulary requests reviewed for approval at Pharmacorr. When they NFR is sent back to us we send it to the
unit the same day. This is available for verification on the pharmacorr site. See below.
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: 5/31/2013 1:58:48 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.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.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Trudy Dumkrieger Date: 5/31/2013 3:00:21 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 :
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May 2013 TUCSON COMPLEX
a.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.

PRR ADC00919

May 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Infirmary Care
1 Does policy or post order define the specific scope of medical, psychiatric, and nursing care provided in
the infirmary setting?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:18:13 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Develop policies/POST Orders that define the specific scope of medical, psychiatric, and nursing
care provided in the infirmary setting. Develop Infirmary Manual to be approved for use.
Responsible Parties= FHA/Medical Director/DON
2 Are patients always within sight or hearing of a qualified health care professional (do inmates have a
method of calling the nurse?)
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:19:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Ensure that inmates have a method available to contact nursing staff.
3 Is the number of appropriate and sufficient qualified health professionals in the infirmary determined by
the number of patients, severity of illnesses and level of care required?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:23:31 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: An acuity tool will be developed to ensure appropriate staffing levels for infirmary patient care.
4 Is a supervising registered nurse in the IPC 24 hours a day?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:24:22 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: An RN is available for coverage in the IPC 24 hours per day. DON to review schedule to ensure
Rn is staffed 24/7 in IPC.
5 Is the manual of nursing care procedures consistent with the state's nurse practice act and licensing
requirements?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:25:18 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Updated Manual ordered and Infirmary Manual in development for ADC approval.
7 Is the frequency of physician and nursing rounds in the infirmary specified based on categories of care
provided?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:27:44 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Once acuity tool is developed and implemented, frequency of physician/nursing rounds will be
based on categories of care.
12 Are there nursing care plans that are reviewed weekly and are signed and dated?
Level 1 Amber User: Trudy Dumkrieger Date: 5/30/2013 3:29:53 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff to initiate a care plan upon admission and regularly update, making sure
plan is signed and dated.

PRR ADC00922

May 2013 TUCSON COMPLEX

Corrective Action Plans for PerformanceMeasure: Medical Tools
1 Do nursing staff inventory and account for tools assigned to medical areas? D.O 702
Level 1 Amber User: Marlena Bedoya Date: 5/31/2013 8:22:05 PM
Corrective Plan: Do nursing staff inventory and account for tools assigned to medical areas? D.O 702
Compliance
Yes – tools are accounted for on a daily bases by nursing staff and checked by unit supervisors. The inventory and
account for tools is logged from the beginning of the month to the end of the month. A master monthly log book is
kept in the FHA’s office.
Corrective Actions: Approved per Marlena.
2 Are missing / lost health tools or instruments reported immediately to the shift commander?
Level 2 Amber User: Marlena Bedoya Date: 5/31/2013 8:25:42 PM
Corrective Plan: Are missing / lost health tools or instruments reported immediately to the shift commander?
Compliance
Plan of action is to ensure that staff are educated. The Director of Nursing will send out a signature memo with
instructions on completing a tool disposition. By signing this form the nurse understands the instructions provided
on how to complete the form and the importance of completing the tool disposition form. After signing, the forms
will be added to the employees file. If they fail to follow instructions then corrective action will follow.
Corrective Actions: Approved by M. Bedoya. See above.
3 Does the Site Manager (FHA) maintain a Master Tool Inventory for all non-disposable surgical/dental
tools, medical instruments/devices and hand-held medical/dental tools?
Level 1 Amber User: Marlena Bedoya Date: 5/31/2013 8:26:44 PM
Corrective Plan: Does the Site Manager (FHA) maintain a Master Tool Inventory for all non-disposable
surgical/dental tools, medical instruments/devices and hand-held medical/dental tools?
Compliance
yes we do. We have documentation in the HUB.
Corrective Actions: Approved per Marlena.
4 Are medical tools engraved, where practical, to identify the tools as health services items?
Level 1 Amber User: Marlena Bedoya Date: 5/31/2013 9:12:40 PM
Corrective Plan: Are medical tools engraved, where practical, to identify the tools as health services items?
Compliance:
We are in the process of completing all of the above findings. We have assistance from operations in expediting
engraving our tools to be in compliance with ADC. The director of nursing and the Assistant director of nursing are
going to each unit to follow up with the corrections made.
Corrective Actions: Approved per Marlena.

PRR ADC00928

 

 

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