October 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: Yvonne Maese Date: 10/30/2013 4:19:09 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-1/30/13
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: Yvonne Maese Date: 10/29/2013 12:53:20 PM
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.
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: Yvonne Maese Date: 10/29/2013 12:41:47 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
PRR ADC02364

October 2013 EYMAN COMPLEX
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.

PRR ADC02365

October 2013 EYMAN 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
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
4 When a medication error occurs, is nursing staff completing a medication error report, documenting per
policy and notifying Nursing Supervisor, Facility Health Administrator, who will notify all other Program
Managers and ADC On-site Monitor? [HSTM Chapter 5, Section 6.6]
Level 2 Amber User: Martin Winland Date: 10/30/2013 12:36:56 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.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.

PRR ADC02370

October 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
1 Are HNRs for Mental Health services triaged within 24 hours of receipt by a qualified Mental Health
Professional, to include nursing staff? [CC 2.20.2.10]
Level 2 Amber User: Jessica Raak Date: 10/29/2013 1:55:01 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.Weekly 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 monitoring weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Educator and Dr. Shaw training all RNs on basic mental health and medical assessment; Eyman
nearly completed.
2 Are inmates referred to a Psychiatrist or Psychiatric Mid-level Provider seen within seven (7) days of
referral? [CC 2.20.2.10]
Level 2 Red User: Jessica Raak Date: 10/29/2013 1:58:53 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 2 (Mental Health Attachment) related to psychiatric providers seeing HNR or sick call
referrals within 7 days
a. HNR triaged by medical; seen at medical nurse line, referred to psychiatric providers
within 7 days, when appropriate
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff
c.Have MH staff increase their contacts if appointment cannot be made in 7 days
2.Monitoring ( Mental health Monitoring Tool)
a.Audit tools developed
b.Weekly 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 = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/MH Lead
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 – Educator and Dr. Shaw training all RNs on basic mental health and medical assessment; Eyman
completed.
3 Are MH treatment plans updated every 90 days for each SMI inmate, and at least every 12 months for all
other MH-3 and above inmates? [CC 2.20.2.10]
Level 1 Red User: Jessica Raak Date: 10/29/2013 2:01:10 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 3(Mental Health Attachment) related to treatment plan updates every 90 days and use of
SMI monthly report tool
a.SMI monthly report tool will be maintained by the MH Clinicians to assist with tracking
appointments; copy given to MH Leader monthly and submitted to MH Directly monthly to track
and trend (III.1.a. SMI Monthly Report)
b.Review AIMS and update when changes in MH status
c.Inmates with mental health score of three or above are seen by MH staff per policy
titled “Levels of Mental Health Services Delivery” (Appendix III.1.c.)
d.Agenda/sign off sheet to verify, inclusive of all pertinent staff
PRR ADC02376

October 2013 EYMAN COMPLEX
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
Responsible Parties = FHA/DON/Mental Health Director/RVP/RDON/RDCQI/MH Lead
Target Date- 11/30/13
Continue to monitor daily, then monthly until meet compliance, then ongoing monthly monitoring.
10/11/13 Update: Staff in-serviced on how to use SMI monthly report tool; review of audit tool data to begin in
November.
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: Jessica Raak Date: 10/29/2013 2:03:10 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: Jessica Raak Date: 10/29/2013 2:04:00 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 Red User: Jessica Raak Date: 10/29/2013 2:14:14 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
PRR ADC02377

October 2013 EYMAN COMPLEX
Target Date- 11/30/13
Continue to monitor monthly until within compliance, then quarterly; monitoring frequency using audit tool per audit
results.

PRR ADC02378

October 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Oral Care (Dental)
4 Are 911's seen within 24 hours of HNR submission? [NCCHC Standard P-E-06]
Level 1 Amber User: Yvonne Maese Date: 10/29/2013 12:01:51 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with dental staff of the added specialty in CDS of urgent care and use only emergency
specialty for true emergencies.
15 Are dental entries complete with military time and signature over name stamp?
Level 1 Red User: Yvonne Maese Date: 10/29/2013 12:03:33 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with dental staff to write signature over name stamp and use military time.
15 Are dental entries complete with military time and signature over name stamp?
Level 1 Red User: Yvonne Maese Date: 10/29/2013 12:03:33 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with dental staff to write signature over name stamp and use military time.
16 Is treatment plan section C and priority section D of the dental chart completed?
Level 2 Amber User: Yvonne Maese Date: 10/29/2013 12:03:58 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that the treatment plan section C and priority section D of the dental chart are
completed. Continue to monitor.
16 Is treatment plan section C and priority section D of the dental chart completed?
Level 2 Amber User: Yvonne Maese Date: 10/29/2013 12:03:58 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that the treatment plan section C and priority section D of the dental chart are
completed. Continue to monitor.

PRR ADC02386

October 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Medication Administration
4 Are the Medication Administration Records (MAR) being completed in accordance with standard nursing
practices? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Red User: Bryce Bartruff Date: 10/30/2013 12:19:45 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.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: Bryce Bartruff Date: 10/30/2013 10:17:07 AM
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.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.
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: Bryce Bartruff Date: 10/30/2013 12:48:50 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.
PRR ADC02396

October 2013 EYMAN COMPLEX
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: Bryce Bartruff Date: 10/30/2013 12:33:15 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.Inventory Coordinator role and responsibilities
2.In-service staff on process and expectations
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
b.Maintain non-formulary binders
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/
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: Bryce Bartruff Date: 10/30/2013 10:21:04 AM
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.Refusals/No Show - Policy titled “Appointment or Treatment Refusals” Chapter 5, Section 7.2
(Appendix VI.1.a.).
b.MAR documentation.
PRR ADC02397

October 2013 EYMAN COMPLEX
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.

PRR ADC02398