July 2013 EYMAN 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: Mathew Musson Date: 7/31/2013 4:55:45 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: Mathew Musson Date: 7/31/2013 4:16:51 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: Mathew Musson Date: 7/31/2013 4:27:38 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: Mathew Musson Date: 7/31/2013 4:35:48 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: Mathew Musson Date: 7/31/2013 4:48:14 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: Mathew Musson Date: 7/31/2013 4:49:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01300

July 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Administration
2 Is the documentation of completed training and testing kept on file for staff who administer or deliver
medications? [NCCHC Standard P-C-05; HSTM Chapter 3, Section 4.1]
Level 1 Amber User: Kathy Campbell Date: 7/30/2013 9:31:34 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: Kathy Campbell Date: 7/30/2013 9:16:18 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 Red User: Kathy Campbell Date: 7/30/2013 1:57:56 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 Red User: Kathy Campbell Date: 7/30/2013 1:57:56 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 Red User: Kathy Campbell Date: 7/30/2013 1:57:56 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Red User: Kathy Campbell Date: 7/30/2013 8:57:30 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: Kathy Campbell Date: 7/30/2013 8:58:02 PM
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: Kathy Campbell Date: 7/30/2013 9:11:18 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: Kathy Campbell Date: 7/30/2013 9:11:32 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
PRR ADC01319