June 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: 6/24/2013 5:30:42 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: Kathy Campbell Date: 6/28/2013 3:17:54 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: 6/24/2013 5:54:52 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: 6/24/2013 6:08:05 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: Kathy Campbell Date: 6/28/2013 3:20:01 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: Kathy Campbell Date: 6/28/2013 3:20:48 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: 6/24/2013 6:16:03 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: Kathy Campbell Date: 6/28/2013 3:22:34 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: 6/24/2013 6:35:14 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
PRR ADC01043

June 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Specialty Consultations (Q)
1 Are urgent consultations being scheduled to be seen within thirty (30) days of the consultation being
initiated? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 6/26/2013 9:13:05 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Kathy Campbell Date: 6/28/2013 2:58:13 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Jen fontaine Date: 6/26/2013 9:34:47 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
3 Is the utilization and availability of off-site services appropriate to meet medical, dental and mental health
needs? [CC 2.20.2.3]
Level 3 Amber User: Jen fontaine Date: 6/26/2013 9:52:11 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01047

June 2013 FLORENCE COMPLEX
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: Jen fontaine Date: 6/24/2013 7:20:04 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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: Jen fontaine Date: 6/25/2013 4:14:47 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Action plan submitted by Corizon1. Standardized process for documenting in medical record chronic condition education per
Chronic Condition and Disease Management Programs 2.20.2.4 contract performance
outcome 3.
2. In-service staff on:
a. Documentation of chronic condition education at each visit.
b. 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
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.
PRR ADC01052

June 2013 FLORENCE COMPLEX
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: Jen fontaine Date: 6/25/2013 4:25:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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.
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: Troy Evans Date: 6/28/2013 3:34:01 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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 ADC01053

June 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Administrative Meetings and Reports
2 Is the Site Manager conducting monthly meetings with Warden and unit Deputy Wardens and include:
-responsibilities of health staff
-procedures for triage
-predetermination of site for care -telephone #s & procedures for calling health staff & the community
emergency response system
-procedures for evacuating patients
-alternate back-ups for each plan element? [DO 117]
Level 1 Amber User: Jen fontaine Date: 6/24/2013 10:44:06 AM
Corrective Plan: Administrative meetings are held regularly with Deputy Wardens in response to incidences on the
yards, and logistical planning of care. All emergency contact information has been updated and in the event that a
community response is required, the Charge Nurse on duty will notify the FHA, AFHA, DON and ADON respectively
and a determination will be made by Nursing Leadership as to who should report to site if after hours events occur.
Corrective Actions: See above.
3 Are monthly staff meetings being conducted and documented?
[NCCHC Standard P-A-04]
Level 1 Amber User: Jen fontaine Date: 6/24/2013 6:42:30 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that monthly meetings are conducted and documented. Continue to
monitor.
3 Are monthly staff meetings being conducted and documented?
[NCCHC Standard P-A-04]
Level 1 Amber User: Kathy Campbell Date: 6/28/2013 3:11:57 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that monthly staff meetings need to be conducted and documented. Continue to
monitor.

PRR ADC01060

June 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: Kathy Campbell Date: 6/28/2013 3:01:46 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: 6/26/2013 11:06:40 AM
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 Amber User: Jen fontaine Date: 6/27/2013 8:59:52 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: 6/27/2013 9:13:00 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01065