May 2013 WINSLOW COMPLEX
Corrective Plan: All of these inmates have been seen as of this writing. Winslow did not have a Provider until the
first week in May. All inmates were prioritized and seen as soon as possible. Inmate are now being seen within the
7 day time frame.
Corrective Actions: See above.

PRR ADC00934

May 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Specialty Consultations (Q)
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: John Mitchell Date: 5/15/2013 11:00:28 AM
Corrective Plan: Winslow has not had a full time doctor or midlevel in quite some time. We recently got a locum
midlevel who has been here for one week. Since she is new to correction she takes longer to see the inmates on
line and there fore time is spent seeing line instead of charts. Another problem with the unfamilararity is she doesn't
know readly why she is getting the chart. Our plan at this time is the DON is grouping the charts that need the
same thing done ie signing off xray, labs etc. and giving them to the provider in small groups during the corse of the
day. The Provider doens't feel so over whelmed and since the stacks are marked doesn't have to search to figure
out why she has it. The charts are also being ordered as to priority of need. At present this is working.
Corrective Actions: See above.

PRR ADC00936

May 2013 WINSLOW COMPLEX

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: Kathy Campbell Date: 5/26/2013 6:34:32 PM
Corrective Plan: Apache has been with out a provider for about two months so they are still behind. A doctor has
been interviewed and is going through the hiring process presently. Inmates are being transported to Winslow at
present to see the locum here.
Corrective Actions: Approved.
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: Kathy Campbell Date: 5/26/2013 6:35:39 PM
Corrective Plan: The provider being used at Winslow at present is a Locum. She has been given direction as of this
writting that the education portion of the chronic care form needs to be filled out in order to meet our standard. She
has verbalized understanding of this direction and I will monitor to make sure the standard is met.
Corrective Actions: Approved.
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: Kathy Campbell Date: 5/26/2013 6:39:05 PM
Corrective Plan: The provider at Winslow is a locum provider and is not familar with the standard of care. This
standard has since been explained to the provider and the above examples were pulled and given to the her to
complete. She does understand the necessity of the forms being complete and has since been filling them out
correctly. I will continue to monitor these forms for completion and compliance with the standards.
Corrective Actions: Approved.

PRR ADC00938

May 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Transfer Screening
1 Are the inmate medical record being reviewed within 12 hours of Inmate arrival to unit by nursing staff?
[NCCHC Standard P-E-03 and HSTM Chapter 5, Section 2.0, 5.0; DO 1104.05]
Level 1 Amber User: John Mitchell Date: 5/6/2013 12:59:51 PM
Corrective Plan: The 12 hour review is a night nurse function and has been an issure. The nurse has been
counseled about the importance of meeting this standard and will receive a disiplinary corrective action plan which
could lead to termination if not followed. She has been doing slightly better but still not up to standard. Supervisors
are continuing to work with her.
Corrective Actions: At present Winslow is completely caught up with intake and as of last week they have been seen
with in the 12 hour window. Supervisors continue to monitor the night nurse and continue to reinforce that this takes
priority.
4 Is dental staff reviewing inmate medical record with 24 hours of Inmate arrival (72 hours Friday /
Weekend)?
Level 1 Amber User: John Mitchell Date: 5/15/2013 10:35:16 AM
Corrective Plan: This issue has been taken to the regional manager to discuss with staff as they are under a
different contract, that this standard needs to be met. He assured me he will make sure staff understand the
necessity of meeting this standard.
Corrective Actions: See above.

PRR ADC00946

May 2013 WINSLOW 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: Kathy Campbell Date: 5/26/2013 6:41:30 PM
Corrective Plan: The new narcotic books have resently been utilized and there has been some missunderstanding
over what needs to be signed. Nursing has been directed to sign both the narcotic book and the MAR. The MAR
sheet has gone back to the nursing staff on duty who gave the above mentioned meds for signature. Staff have
been given direction that both need to be signed or disiplinary will take place. At present staff have verbalized
understanding of this directive. This will continue to be monitored by the DON.
Corrective Actions: Approved.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: John Mitchell Date: 5/24/2013 8:26:13 AM
Corrective Plan: Stop date reports will be run more frequently. Nursing is finding that the reports sent to us by
Pharmcor are not accurate. At this time all renewals for May are taken care of and the Tech is beginning to work on
June.
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: John Mitchell Date: 5/24/2013 8:29:34 AM
Corrective Plan: Winslow has resently hired a pharmacy tech who is still in training. She has been trained on how to
print the 10 day med expiration report. I have directed her to print this report weekly so charst can be directed to
the provider in small lots rather then printing twice a month and loading the provider down with charts she won't be
able to get to. The tech understands the importance of running the reports insuring that inmates medications don't
expire or run out.
Corrective Actions: See above.

PRR ADC00949