June 2013 TUCSON 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: Marlena Bedoya Date: 6/26/2013 1:06:20 PM
Corrective Plan: CAP: Nursing staff have been provided with instruction to complete an IR every time a line is
cancelled and they are to notify the FHA. A copy of the IR is to be kept in the appointment book for the contract
monitor to locate when she is doing her audits.
This is something that we will have to re-visit periodically due to all the new hires happening at this complex. This
will be included during NEO_-I.
Corrective Actions: Approved per Marlena.
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: Marlena Bedoya Date: 6/28/2013 7:03:46 AM
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: Marlena Bedoya Date: 6/28/2013 7:57:38 AM
Corrective Plan: Corrective action plan is to provide education to the staff. Staff are required to take a complete set
of vital signs including weights.
Corrective Actions: Approved per Marlena.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Marlena Bedoya Date: 6/28/2013 10:00:33 AM
Corrective Plan: Our plan is to continue to recruit and fill the vacant positions. There are 1.5 FTE's remaining to fill.
Once filled then we should be able to see the inmate requests withing 7 days.
Our secondary CAP is to do telemedicine on the some of the yards. We are unable to do telemedicine at this time
due to the abatement going on in the HUB. As soon as ADC completes this project and we move back in we can
begin telemedicine again.
Corrective Actions: Approved per Marlena.

PRR ADC01184

June 2013 TUCSON 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: Trudy Dumkrieger Date: 6/27/2013 2:23:44 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit 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 =ARMD/RDON/RVP/RDCQI/DON/
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 consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Trudy Dumkrieger Date: 6/26/2013 2:27:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit 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 =ARMD/RDON/RVP/RDCQI/DON/
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 consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Trudy Dumkrieger Date: 6/26/2013 2:27:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit 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 =ARMD/RDON/RVP/RDCQI/DON/
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 consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Trudy Dumkrieger Date: 6/26/2013 2:27:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by CorizonPRR ADC01189

June 2013 TUCSON COMPLEX
1.Standardized monitoring process
2.Communicate expectations via FHA/DON at quarterly training Regional office and obtain sign
off sheet to verify
3.Monitoring (UM Audit 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 =ARMD/RDON/RVP/RDCQI/DON/
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 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: Trudy Dumkrieger Date: 6/27/2013 1:16:06 PM
Corrective Plan: We had two providers for Urology and one of the providers said he did not want to see anymore
inmates. We now have only one; Dr. Banti, and we are in the process of getting another. This is being handled in
our regional office.
Corrective Actions: October Action plan submitted by Corizon1.Retrain FHA/DONs on ED management and expectations
a.Agenda/sign off sheet to verify
2.Develop a site level process to assure, but not limited to:
a.ED log completed and submitted daily to Regional office
b.Access to custody transport logs
c.Access to AIMS
3.Train site staff on ED management and expectations
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
4.Review ED activity daily (in AM) with FHA/DON/MD (lead provider in absence of MD) to determine
patient status and appropriate treatment plan
a. Agenda/sign off sheet to verify, inclusive of all pertinent staff
5.Regional staff conduct weekly review of compliance to daily submission and appropriate patient
disposition
6.Monitoring tool developed for self-monitoring and submission to site management and regional
CQI
7.Initiation of monitoring tools at sites
8.Monitoring (UM Audit 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 = VPO/ARMD/RDON/RVP/FHA/DON/MD/RDCQI
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 – ED log sent to Regional office daily.

PRR ADC01190

June 2013 TUCSON COMPLEX
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.
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: Trudy Dumkrieger Date: 6/26/2013 3:38:06 PM
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.
5 Has the contractor submitted his/her quarterly guideline audit results by the 15th day following the end of
the reporting quarter? [CC 2.20.2.4]
Level 2 Amber User: Trudy Dumkrieger Date: 6/10/2013 2:51:09 PM
Corrective Plan: Has the contractor submitted his/her quarterly guideline audit results by the 15th day following the
end of the reporting quarter?
have not been here a quarter yet.
Corrective Actions: Approved per Trudy.

PRR ADC01202

June 2013 TUCSON COMPLEX
b.Re-order medications
c.Invalid chart orders (Appendix I.1.c.)
i.Therapeutic dose ranges
ii.Dose changes must have supporting documentation
d.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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/IC/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 – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

PRR ADC01204

June 2013 TUCSON COMPLEX

MH treatment plans for MH-3’s are not up to dated on yearly treatment plans. Staffing issues have posed this
problem with getting all MH-3 charts updated in a timely manner.
Mental health is working to correct the lack of staff needed to maintain updated charts for the inmates with MH-3
scores, and will continue to work on making these 12 month deadlines.
Corrective Actions: See above.
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: Steve Bender Date: 6/25/2013 10:29:42 AM
Corrective Plan: Are reentry/discharge plans established no later than 30 days prior release for all inmates with a
MH score of MH-3 and above?
Once an inmate is scheduled for release, 180, 90 and 30 days prior to release he will submit an HNR to mental
health for direction of his mental health needs. MH will advise the inmates MH needs while he is incarcerated.
Once the notification is submitted by the inmate to MH prior to his 30 day release - Mental health forwards the
HNR’s to Corizon release planner Jacqueline Miller for discharge instructions.
Once inmate is discharged from the facility MH no longer treats inmates outside the facility.
See below.
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 ADC01208

June 2013 TUCSON COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Administration
3 Is there a tracking system for KOP medications to determine if medications have been received by the
inmate? [NCCHC Standard P-D-01]
Level 1 Amber User: Trudy Dumkrieger Date: 6/26/2013 3:42:26 PM
Corrective Plan: Is there a tracking system for KOP medications to determine if medications have been received by
the inmate?
KOP’s are delivered to the medical units and nursing staff distributes the KOP medications to the inmates.
Nurses run a daily KOP line and the inmates come to get their KOP meds at their medical unit. The nurses are
required to sign off once they hand off the inmate cards. This signature log book is kept on each unit in the med
room and checked by the unit supervisor.
Corrective Actions: Approved. 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: Trudy Dumkrieger Date: 6/27/2013 2:15:39 PM
Corrective Plan: Are the Medication Administration Records (MAR) being completed in accordance with standard
nursing practices?
Yes, MARS are logged daily by nursing staff and checked by unit nursing supervisor to ensure they are properly
logged.
All inmate MARs are updated with new medication orders and with new inmates to the unit.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
c.Administration of DOT/KOP.
d.Printing MARs (Pharmacy Appendix).
e.Medication error documentation/reporting (Pharmacy Appendix).
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
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/FHA
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.
5 Are medication errors forwarded to the FHA to review corrective action plan?
Level 2 Amber User: Trudy Dumkrieger Date: 6/19/2013 3:06:10 PM
Corrective Plan: medication error reports are sent to the DON and ADON. The purpose of sending it to Nursing
managment team is because it is nursing related. The medication error form is used as a reporting tool. corrective
action is handled with the employee on a differnt form. We do not provide corective action on the reporting form.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Medication error documentation/reporting (Pharmacy Appendix).
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
PRR ADC01218

June 2013 TUCSON COMPLEX
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/FHA
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.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Trudy Dumkrieger Date: 6/28/2013 1:14:05 PM
Corrective Plan: Are there any unreasonable delays in inmate receiving prescribed medications?
Clinical
There are delays in medicaion passes due to ICS’s, lock-downs, security and movements.
These things can help delay the distribution of medication during regularly scheduled med pass,
Certain units will bag mediations and distribute them throughout the yards if a security officer is available to assist in
med pass.
Nursing will stay after working hours to ensure that med pass is completed. If a unit is having trouble in getting a
med pass done - nursing staff from other units are required to assist in the med pass to ensure that all medications
are passed.
See below.
Corrective Actions: October Action plan submitted by CorizonIntakes1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
a.Intake Orders
b.Private Prisons
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
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
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
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
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
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/Custody/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.
8 Are chronic condition medication expiration dates being reviewed prior to expiration to ensure continuity
of care?
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June 2013 TUCSON COMPLEX
[NCCHC Standard P-D-01]
Level 2 Amber User: Trudy Dumkrieger Date: 6/27/2013 2:15:07 PM
Corrective Plan: Are chronic condition medication expiration dates being reviewed prior to expiration to ensure
continuity of care?
Chronic care medications are a priority and are monitored by both the provider and the nursing staff to ensure
inmates are receiving all care plan medications for their condition.
Pharmacy sends each medical unit a weekly expiration list for the upcoming week of meds that are to be renewed.
The supervisors on the units intercept the list and begin the process to renew, order, or discontinued all medications
accordingly. This ensures that the medication renewals are done prior to expiring.
Chronic care medications are listed on these weekly lists for assurance of renewal.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
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
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
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
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds
4.Monitoring (Appendix I. - IV Monitoring Tools)
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/Custody/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.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 6/19/2013 3:03:43 PM
Corrective Plan: Are providers being notified of non-formulary decssions within 24 to 48 hours?
A non- formulary is a prescription that is not on the formulary list of drugs and is required explanation by the
prescriber to indicate why the drug is needed.
Due to the amount of non-formulary requests throughout the State Dr. Williams and Dr. Bynum are aware that this
decision is taking longer than 24 to 48 hours to notify.
They are working on hiring additional staff to help elevate the overwhelming requests.
PRR ADC01220

June 2013 TUCSON COMPLEX

At this time Providers are encouraged to prescribe only from the formulary and create alternative treatment plans as
much as possible.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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/IC/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 – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 6/19/2013 3:03:43 PM
Corrective Plan: Are providers being notified of non-formulary decssions within 24 to 48 hours?
A non- formulary is a prescription that is not on the formulary list of drugs and is required explanation by the
prescriber to indicate why the drug is needed.
Due to the amount of non-formulary requests throughout the State Dr. Williams and Dr. Bynum are aware that this
decision is taking longer than 24 to 48 hours to notify. They are working on hiring additional staff to help elevate the
overwhelming requests.
At this time Providers are encouraged to prescribe only from the formulary and create alternative treatment plans as
much as possible.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
PRR ADC01221

June 2013 TUCSON COMPLEX
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/IC/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 – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Trudy Dumkrieger Date: 6/14/2013 10:44:11 AM
Corrective Plan: Are providers being notified of non-formulary decssions within 24 to 48 hours?
A non- formulary is a prescription that is not on the formulary list of drugs and is required explanation by the
prescriber to indicate why the drug is needed.
Due to the amount of non-formulary requests throughout the State Dr. Williams and Dr. Bynum are aware that this
decision is taking longer than 24 to 48 hours to notify. They are working on hiring additional staff to help elevate the
overwhelming requests.
At this time Providers are encouraged to prescribe only from the formulary and create alternative treatment plans as
much as possible.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
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/IC/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 – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Trudy Dumkrieger Date: 6/27/2013 12:50:16 PM
Corrective Plan: Are medication error reports being completed and medication errors documented?
Clinical

There is a med error document form that needs to be filled out byt the nurse and submitted to both the DON and the
unit supervisor for investigation.
The nurse will write an IR regarding the med error incident and submit to the FHA and the DON.
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There is a medication error form that is turned in to Pharmacorr by the DON when there is a medication error.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide to include, but not limited to :
a.Medication error documentation/reporting (Pharmacy Appendix).
2.In-service staff on process and PharmaCorr policy.
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Appendix I. - IV Monitoring Tools)
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/FHA
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.

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Corrective Action Plans for PerformanceMeasure: Infirmary Care
1 Does policy or post order define the specific scope of medical, psychiatric, and nursing care provided in
the infirmary setting?
Level 1 Amber User: Trudy Dumkrieger Date: 6/27/2013 1:22:47 PM
Corrective Plan: Does policy or post order define the specific scope of medical, psychiatric, and nursing care
provided in the infirmary setting?
IPC has DOC post orders that are currently being used on site.
Corizon has not provided a health service technical manual.
DOC IPC Post orders/health services technical manual will be implemented by July 31st, 2013 – per DOC policy. All
Nursing and provider staff will be educated and trained on using manual.
Corrective Actions: Approved per Trudy.
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: Trudy Dumkrieger Date: 6/27/2013 1:37:05 PM
Corrective Plan: Infirmary Care
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?
The infirmary has licensed staff trained to provider qualified health care to patients of all levels of illness. Inmates
that are in need of care beyond the institution setting are sent to appropriate hospitals for individualized care. There
are 35 beds available in the infirmary.
The number of staff on day shift in the infirmary is as follows:
1 - RN Supervisor 8a - 5p
1 - RN 6a - 6p
1 – RN (IV nurse)10a - 5p
1- LPN med pass nurse 6a - 6p
2- CNA’s 6a - 6p
1- Provider 7:30a - 5:30p
Night shift:
1 - RN night supervisor 8p - 5a
1 - RN 6p - 6a
1 – RN (IV nurse) 10p - 5a
1- LPN med pass nurse 6p - 6a
1- CNA 6p -6a
1- on call Provider 24 hours
See below.
Corrective Actions: An acuity tool will be developed to ensure appropriate staffing levels for infirmary patient care.
4 Is a supervising registered nurse in the IPC 24 hours a day?
Level 1 Amber User: Trudy Dumkrieger Date: 6/27/2013 12:02:35 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: An RN is available for coverage in the IPC 24 hours per day. DON to review schedule to ensure
RN is staffed 24/7 in IPC.
5 Is the manual of nursing care procedures consistent with the state's nurse practice act and licensing
requirements?
Level 1 Amber User: Trudy Dumkrieger Date: 6/27/2013 12:03:42 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Updated Manual ordered and Infirmary Manual in development for ADC approval.

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June 2013 TUCSON COMPLEX
7 Is the frequency of physician and nursing rounds in the infirmary specified based on categories of care
provided?
Level 1 Amber User: Trudy Dumkrieger Date: 6/27/2013 2:18:48 PM
Corrective Plan: Is the frequency of physician and nursing rounds in the infirmary specified based on categories of
care provided?
Clinical: nursing care is continuous, patient rounds are done every hour by nursing staff, and medications are given
as prescribed by provider.
All Providers meet with patients on a as needed bases, and critical cares are seen daily or as per condition.
Diagnostic testing is done twice a day for finger sticks, and labs are Mondays for PT-INR. Dialysis patients are
taken to dialysis on scheduled daily times.
Weekly blood draws for medication and critical condition patients.
New intakes to infirmary are seen immediately upon arrival, and full assessments are done within 6 hours of intake.
Charts are reviewed each shift, day and night. Orders are noted daily.
IPC Post orders/health services technical manual will be implemented by July 31st, 2013 – per DOC policy. All
Nursing and provider staff will be educated and trained on using manual. See below.
Corrective Actions: Once acuity tool is developed and implemented, frequency of physician/nursing rounds will be
based on categories of care.
12 Are there nursing care plans that are reviewed weekly and are signed and dated?
Level 1 Red User: Trudy Dumkrieger Date: 6/27/2013 12:08:48 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff to initiate a care plan upon admission and regularly update, making sure
plan is signed and dated.

PRR ADC01229