September 2013 PERRYVILLE COMPLEX
(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.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Mark Haldane Date: 9/26/2013 12:36:19 PM
Corrective Plan: Nursing staff responsible for scheduling times have been redirected/educated regarding sick-call
appointments being generated via HNR
See below.
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.

PRR ADC02065

September 2013 PERRYVILLE COMPLEX
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: Erin Barlund Date: 9/26/2013 1:56:27 PM
Corrective Plan: A urologist was made available as of 9/27/2013
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 ADC02069

September 2013 PERRYVILLE 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: Erin Barlund Date: 9/26/2013 9:30:08 AM
Corrective Plan: Provider line backlogs prevent timely scheduling, if the backlog is significently large. We have hired
new providers and are scheduling them to reduce backlogs where needed.
See Corrective Actions below.
Corrective Actions: October 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: Erin Barlund Date: 9/26/2013 9:31:54 AM
Corrective Plan: As a large number of diabeticsarrive at Perryville with this diagnosis, detailed education is not
generally provided, we have infact directed our staff to provide this education / coaching.
See below.
Corrective Actions: October 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 ADC02072

September 2013 PERRYVILLE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Records (Q))
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: Mark Haldane Date: 9/30/2013 12:45:43 PM
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
5 Are arrival logs maintained and kept current with name of inmate, ADC #, date of arrival, # of volumes?
Level 1 Amber User: Mark Haldane Date: 9/25/2013 2:29:48 PM
Corrective Plan: This issue has been corrected the number /volume is now being documented on the movement
sheet.
Corrective Actions: See above.
6 Are departure logs maintained and kept current with name of the inmate, ADC #, unit being transferred to,
date of departure, # of volumes?
Level 1 Amber User: Mark Haldane Date: 9/25/2013 2:31:36 PM
Corrective Plan: The medical records Supervisor will ensure that the Medical Records tech of each unit maintain
their own Departure / Arrival logs for that unit.
Corrective Actions: See above.
9 Are requested archived medical records merged with newly established medical records upon an inmates
return to ADC?
Level 1 Amber User: Mark Haldane Date: 9/30/2013 1:39:40 PM
Corrective Plan: This issue has been addressed and is currently being corrected. See below.
Corrective Actions: Reinforce to staff that archived medical records get merged with newly established medical
records upon an inmates return to ADC.

PRR ADC02075

September 2013 PERRYVILLE COMPLEX
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 ADC02077

September 2013 PERRYVILLE 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 1:48:10 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 1:51:49 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.
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: Nicole Taylor Date: 9/30/2013 2:04:07 PM
Corrective Plan: See October action plan as submitted by Corizon.
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 ADC02082

September 2013 PERRYVILLE COMPLEX
Corrective Action Plans for PerformanceMeasure: No Shows
1 Are No-Shows being brought to health unit to sign a refusal?
[DO 1101, HSTM Chapter 5, Section 7.1]
Level 1 Amber User: Mark Haldane Date: 9/30/2013 3:46:39 PM
Corrective Plan: IAW DO#1101.1.7.2 The refusing inmate will report to the medical unit and refuse to medical staff.
This will be a redirection for the medical staff and and a topic during training meetings.
Corrective Actions: See above.
2 Are unresolved No-Shows being reported to the unit deputy warden for a written response? [DO 1101]
Level 1 Amber User: Mark Haldane Date: 9/30/2013 3:50:52 PM
Corrective Plan: IAW DO#1101.1.8 The required Incident Report will be authored and distribution made to the
Deputy Warden for further investigation. This will be a redirection for the medical staff and and a topic during
training meetings.
Corrective Actions: See above.

PRR ADC02084

September 2013 PERRYVILLE COMPLEX
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: Erin Barlund Date: 9/26/2013 2:47:38 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.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Erin Barlund Date: 9/30/2013 1:42:25 PM
Corrective Plan: See October action plan as submitted by Corizon.
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
PRR ADC02092

September 2013 PERRYVILLE COMPLEX
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.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Erin Barlund Date: 9/30/2013 1:42:25 PM
Corrective Plan: See October action plan as submitted by Corizon.
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?
[NCCHC Standard P-D-01]
Level 2 Amber User: Erin Barlund Date: 9/26/2013 3:36:29 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)
PRR ADC02093

September 2013 PERRYVILLE COMPLEX
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: Erin Barlund Date: 9/26/2013 3:37:22 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 (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.
PRR ADC02094

September 2013 PERRYVILLE COMPLEX
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: Erin Barlund Date: 9/26/2013 3:38:44 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 (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: Erin Barlund Date: 9/26/2013 3:39:41 PM
Corrective Plan: This issue has been corrected the records have been reviewed by the DON/HSA and logged
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 ADC02095

September 2013 PERRYVILLE COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Room
1 Is the medical room kept locked when not occupied?
Level 1 Amber User: Erin Barlund Date: 9/13/2013 9:19:17 AM
Corrective Plan: We have ordered a Locking Med Box for the refrigerator that does not lock.
Corrective Actions: Approved. See above.
2 Are open medication vials being marked with the date they were opened?
Level 1 Amber User: Erin Barlund Date: 9/13/2013 9:22:18 AM
Corrective Plan: This has been a briefing / redirecting topic with the Nursing staff from the DON, they will conduct
unannounced follow-up inspections.
Corrective Actions: Approved. See above.
3 Is nursing staff checking for outdated (expiring)medications?
Level 1 Amber User: Erin Barlund Date: 9/26/2013 4:13:12 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce to nursing staff to make sure clinic stock and DOT medications are not with expired
dates. If they are expired, return to pharmacy per policy.
Responsible Parties = RN/LPN
Target Date = 11/30/13

PRR ADC02104