July 2013 FLORENCE 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: Jen fontaine Date: 7/30/2013 2:21:40 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: Jen fontaine Date: 7/30/2013 3:30:37 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: Jen fontaine Date: 7/30/2013 3:36:29 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: Jen fontaine Date: 7/30/2013 3:52:03 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: Jen fontaine Date: 7/30/2013 3:57:37 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: Jen fontaine Date: 7/30/2013 4:04:25 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01331

July 2013 FLORENCE 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 Red User: Martin Winland Date: 7/29/2013 3:41:03 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01338

July 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: No Shows
1 Are No-Shows being brought to health unit to sign a refusal?
[DO 1101, HSTM Chapter 5, Section 7.1]
Level 1 Amber User: Jen fontaine Date: 7/30/2013 1:12:22 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff to complete a refusal form to be signed by inmate. Continue to monitor.
Responsible Parties= RN/LPN
Target Date = 11/30/13
2 Are unresolved No-Shows being reported to the unit deputy warden for a written response? [DO 1101]
Level 1 Amber User: Jen fontaine Date: 7/30/2013 1:14:44 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that unresolved No-Shows are being reported to the unit deputy warden for a written
response. Continue to monitor.
3 Are providers being notified of medication line No-Shows?
[DO 1101, HSTM Chapter 5, Section 7.1]
Level 1 Amber User: Jen fontaine Date: 7/30/2013 1:38:18 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that providers need to be notified of medication line No-Shows. Continue to monitor.

PRR ADC01346

July 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Administration
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: Jen fontaine Date: 7/30/2013 11:11:08 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
5 Are medication errors forwarded to the FHA to review corrective action plan?
Level 2 Amber User: Jen fontaine Date: 7/30/2013 12:03:11 PM
Corrective Plan: See October action plan as submitted by Corizon.
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 Red User: Jen fontaine Date: 7/30/2013 7:38:41 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Jen fontaine Date: 7/30/2013 12:42:57 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Jen fontaine Date: 7/30/2013 12:45:09 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Jen fontaine Date: 7/30/2013 1:33:44 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01354

July 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Infirmary Care
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: Jen fontaine Date: 7/22/2013 10:59:11 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: Kathy Campbell Date: 7/14/2013 7:46:40 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: Kathy Campbell Date: 7/30/2013 3:45:51 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
5 Is the manual of nursing care procedures consistent with the state's nurse practice act and licensing
requirements?
Level 1 Amber User: Kathy Campbell Date: 7/14/2013 7:47:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
7 Is the frequency of physician and nursing rounds in the infirmary specified based on categories of care
provided?
Level 1 Amber User: Kathy Campbell Date: 7/30/2013 7:59:51 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
8 Is a complete inmate health record kept and include:
-Admitted order (admitting diagnosis, medications, diet, activity restrictions, required diagnostic tests,
frequency of monitoring and follow-up
-Complete document of care and treatment given
-Medication administration record
-Discharge plan and discharge notes
Level 1 Amber User: Kathy Campbell Date: 7/30/2013 8:05:01 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
8 Is a complete inmate health record kept and include:
-Admitted order (admitting diagnosis, medications, diet, activity restrictions, required diagnostic tests,
frequency of monitoring and follow-up
-Complete document of care and treatment given
-Medication administration record
-Discharge plan and discharge notes
Level 1 Amber User: Kathy Campbell Date: 7/30/2013 8:05:01 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
12 Are there nursing care plans that are reviewed weekly and are signed and dated?
Level 1 Red User: Kathy Campbell Date: 7/14/2013 7:50:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
PRR ADC01361

July 2013 FLORENCE COMPLEX
Corrective Actions: See above.
13 Are medications and supplies checked regularly, and who is assigned to do it? [NCCHC Standard P-D03]
Level 1 Red User: Kathy Campbell Date: 7/14/2013 7:54:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01362