September 2013 YUMA COMPLEX
Corrective Action Plans for PerformanceMeasure: Sick Call (Q)
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 Red User: Anthony Medel Date: 9/30/2013 2:21:12 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: Anthony Medel Date: 9/30/2013 2:23:09 PM
Corrective Plan: By October 6th we will survey each of the sick call process areas todetermine which areas do not
havea working scale by Briseno
On October 6th scales will be ordered for any unit that does not have a working scale by Lowell
On October 8th all staff will be trained that all sick calls that require a face to face encounter will include vital signs
and weights by Robles
On October 9th all staff will take all vitals signs including weights on any sick call that requires a face to face
encounter
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.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Anthony Medel Date: 9/30/2013 2:34:36 PM
Corrective Plan: As of October 1st there is no wait list on any unit for the provider greater than 1 week.
PRR ADC02282

September 2013 YUMA COMPLEX

On October 8th all staff will be trained that Nurse Sick Call patients who need to be seen by the provider will be
scheduled to be seen within 7 days by Robles DON.
Beginning October 9th All patients who need to see the provider from nurse line will be scheduled within 7 days by
the PCT's on each yard.
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.

PRR ADC02283

September 2013 YUMA COMPLEX
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
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 Red User: Nicole Taylor Date: 9/30/2013 3:13:37 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: Nicole Taylor Date: 9/30/2013 3:20:34 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.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
Regional office for tracking and trending
Responsible Parties = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/MH Lead
Target Date- 11/30/13
Continue to monitor monthly until within compliance, then quarterly; monitoring frequency using audit tool per audit
results.

PRR ADC02305

September 2013 YUMA COMPLEX
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Brenda Mcmullen Date: 9/26/2013 6:10:35 PM
Corrective Plan: On October 4th there was a meeting with FHA and pharmacy to develop a plan for medications to
eliminate the medications and delay.
Pharmacy will develop a typed process to distribute to each staff member at the October 8th staff meeting by Lowell
and Salmone.
On October 8th all staff will be trained in the new Pharmacy process and will sign an acknowledgement to the
process by Rogers/Robles/Lowell/Salmone
On October 9th the new process will be in place regarding medications.
The process will be available to staff, and monitors on each unit by October 9th.
Corrective Actions: Approved.

See above.

PRR ADC02315

September 2013 YUMA COMPLEX
filled.
Corizon will post position throughout the country on the website by 10-01-13 for positions of the mid-level provider
and practitioner.
Smallwoods would actively recruit for dental hygenist until filled. Smallwoods will post the dental hygenist position by
10-01-13.

Dental Assistant is 100percent
Mid-Level Diana Curd (FNP) has just passed background
Corrective Actions: See above.

PRR ADC02318