September 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 Red User: Jen fontaine Date: 9/27/2013 3:04:52 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Process to address access to care, to include but not limited to:
a.Scheduling patients
b.Staffing
2.In-service staff on process expectations per Sick Call 2.20.2.2 contract performance outcome 1
Sick call shall be held five days a week, Monday through Friday (excluding Holidays), for all
inmates (Sick Call Attachment); and site specific process
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Monitoring (Sick Call 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 = 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 – All HNR s to be triaged by nursing, inclusive of MH.
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: Jen fontaine Date: 9/30/2013 8:06:54 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: Troy Evans Date: 9/26/2013 3:11:13 PM
Corrective Plan: See October action plan as submitted by Corizon.
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
PRR ADC01964

September 2013 FLORENCE COMPLEX
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.
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: 9/30/2013 8:23:58 AM
Corrective Plan: See October action plan as submitted by Corizon.
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.
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: 9/30/2013 8:37:11 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
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.
10/11/13 Update –NETs to be used for all Nursing sick call.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Troy Evans Date: 9/26/2013 3:36:02 PM
Corrective Plan: See October action plan as submitted by Corizon.
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
PRR ADC01965

September 2013 FLORENCE 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/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.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Jen fontaine Date: 9/30/2013 8:54:08 AM
Corrective Plan: See October action plan as submitted by Corizon.
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.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Jen fontaine Date: 9/30/2013 9:04:32 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
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.
10/11/13 Update –NETs to be used for all Nursing sick call.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Troy Evans Date: 9/26/2013 3:41:46 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
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
PRR ADC01966

September 2013 FLORENCE COMPLEX
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 –NETs to be used for all Nursing sick call.

PRR ADC01967

September 2013 FLORENCE 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 =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: Jen fontaine Date: 9/30/2013 1:32:55 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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 ADC01973

September 2013 FLORENCE COMPLEX
documented in the medical record? [P-G-01, CC 2.20.2.4]
Level 1 Amber User: Jen fontaine Date: 9/27/2013 11:25:32 AM
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.
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: 9/27/2013 12:11:34 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 ADC01980

September 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Records (Q))
2 Are provider orders noted daily with time, date and name of person taking the orders off? [NCCHC
Standard P-H-01; HSTM Chapter 5, Section 7.0]
Level 1 Amber User: Jen fontaine Date: 9/30/2013 10:53:37 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff to note charts regularly. Continue to monitor.
Responsible Parties = RN/LPN
Target Date= 11/30/13
3 Does the Medication Administration Record (MAR) in the medical chart reflect dose, route, frequency,
start date and nurse’s signature? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Jen fontaine Date: 9/30/2013 11:26:03 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff the importance of a complete MAR. Continue to monitor.
Responsible Parties = RN/LPN
Target Date= 11/30/13
4 Are medical record entries legible, and complete with time, name stamp and signature present? [HSTM
Chpt. 5, Section 6.4, CC 2.20.2.5]
Level 1 Amber User: Jen fontaine Date: 9/30/2013 11:58:40 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff the importance of using name stamps. Continue to monitor
Responsible Parties = RN/LPN
Target Date= 11/30/13

PRR ADC01986

September 2013 FLORENCE COMPLEX
Level 2 Amber User: Martin Winland Date: 9/30/2013 3:24:26 PM
Corrective Plan: See October action plan as submitted by Corizon.
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.

PRR ADC01989

September 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
4 Are inmates with a mental score of MH-3 and above seen by MH staff according to policy? [CC 2.20.2.10]
Level 2 Red User: Nicole Taylor Date: 9/30/2013 1:10:32 PM
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 1:13:27 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.

PRR ADC01994

September 2013 FLORENCE COMPLEX
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: 9/30/2013 3:38:28 PM
Corrective Plan: See October action plan as submitted by Corizon.
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: Jen fontaine Date: 9/30/2013 3:08:45 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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
PRR ADC02005

September 2013 FLORENCE COMPLEX
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.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Jen fontaine Date: 9/30/2013 3:08:54 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Jen fontaine Date: 9/30/2013 3:07:47 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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.

PRR ADC02006

September 2013 FLORENCE COMPLEX
Corrective Action Plans for PerformanceMeasure: Staffing
2 Are the adequacy and effectiveness of the staffing assessed by the facility's sufficient to meet the needs
of the inmate population? [NCCHC Standard P-C-07; HSMT Chapter 3, Section 2.0]
Level 3 Amber User: Jen fontaine Date: 9/30/2013 3:27:20 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Corizon continues to evaluate staffing patterns and assignments and make adjustments as
needed.
3 Are all positions filled per contractor staffing pattern?
Level 2 Amber User: Jen fontaine Date: 9/30/2013 3:20:09 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Corizon's recruiting team is working tirelessly at recruiting for the open positions.
Locums/Registry and over time being utilized to fill open positions.

PRR ADC02008