June 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: 6/25/2013 2:21:23 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: 6/25/2013 6:52:51 AM
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: 6/25/2013 7:08:28 AM
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: 6/25/2013 7:27:32 AM
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: 6/25/2013 7:34:26 AM
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: 6/25/2013 7:55:31 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01012

June 2013 EYMAN COMPLEX
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: Yvonne Maese Date: 6/26/2013 10:44:00 AM
Corrective Plan: See October action plan as submitted by Corizon.
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 ADC01018

June 2013 EYMAN 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: Martin Winland Date: 6/26/2013 12:46:44 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01020

June 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: 6/18/2013 12:07:09 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: 6/28/2013 11:51:09 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1. Monitoring (Mental Health Monitoring Tool)
a. Audit tools developed
b. Weekly 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
Responsbile Parties = RDCQI/RVP/MH Director/FHA/DON/MH Lead
Target Date - 11/30/13
weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using audit tool per audit
results 10/11/13 Update – Educator and Dr. Shaw training all RNs on basic mental health and medical assessment;
Eyman nearly completed.
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: 6/18/2013 12:12:13 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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
Responsibile Parties = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/RVP/MH Director/MH Lead
Target Date- 11/30/13
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: 6/18/2013 12:18:07 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1. Mental Health staff to receive education the importance of MH-3 inmates being seen according to policy.
2. Reinforce this in monthly staff meetings.
3. Continue to perform chart reviews to ensure inmates with an MH-3 score and above are being seen by Mental
Health staff per policy.
4. Review treatment plans to ensuring that the IMs current MH score, according to the recognized system, is
captured within the current treatment plan.
Responsible Parties = MH Lead/RN/FHA/DON/MH Director/RCQI
PRR ADC01025

June 2013 EYMAN COMPLEX
Target Date-11/30/13
5 Are inmates prescribed psychotropic meds seen by a Psychiatrist or Psychiatric Mid-level Provider at a
minimum of every three (3) months (90 days)?[CC 2.20.2.10]
Level 2 Amber User: Mathew Musson Date: 6/18/2013 12:26:10 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1. 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 = RDCQI/RVP/MH Director/FHA/DON/MH Lead
Target Date- 11/30/13
Continue to monitor monthly until within compliance, then quarterly; monitoring frequency using audit tool per audit
results.
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: Mathew Musson Date: 6/18/2013 12:57:41 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon
1. In-service staff on process expectations per Mental Health 2.20.2.10 contract performance outcome 7 (Mental
Health Attachment) related to re-entry plan
a.SMI patients will be followed by discharge planners utilizing the data from the SMI monthly report tool; MH3
patients will be given community resources by MH Clinicians and documented in the chart; all patients receiving
psychotropic medications will be seen by Psychiatrist/Psychiatry CNP
b.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
Will continue to monitor monthly until within compliance, then quarterly; monitoring frequency using audit tool per
audit results.

PRR ADC01026

June 2013 EYMAN COMPLEX
Corrective Actions: See above.

PRR ADC01031