October 2013 LEWIS COMPLEX
audit tool per audit results.
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: Terry Allred Date: 10/31/2013 2:58:08 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.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Red User: Terry Allred Date: 10/31/2013 2:59:51 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
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 Red User: Terry Allred Date: 10/31/2013 2:59:51 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
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 ADC02453

October 2013 LEWIS COMPLEX
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.

PRR ADC02454

October 2013 LEWIS 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: Erin Barlund Date: 10/25/2013 9:22:59 AM
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/RCQI/FHA/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.
1. Standardized process to address, to include but not limited to:
a. Approved consults scheduled/documented within 5 days by clinical coordinator
2. Schedule and conduct training for all clinical coordinators
a.Agenda/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
Responsibile Parties = DON/Clinical Systems Business Analyst II/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.
2 Are consultation reports being reviewed by the provider within seven (7) days of receipt? [CC 2.20.2.3]
Level 2 Amber User: Erin Barlund Date: 10/29/2013 11:18:18 AM
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: Erin Barlund Date: 10/29/2013 11:18:18 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See previous response to #2.

PRR ADC02459

October 2013 LEWIS COMPLEX
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.
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 12:49:18 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 ADC02462

October 2013 LEWIS COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
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 2:51:41 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 Amber User: Jessica Raak Date: 10/29/2013 2:52:42 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: 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
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 2:53:49 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
PRR ADC02468

October 2013 LEWIS COMPLEX
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 2:55:11 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 2:57:57 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 ADC02469

October 2013 LEWIS COMPLEX
Corrective Action Plans for PerformanceMeasure: Quality and PEER Review (Q)
1 Is the contractor physician conducting monthly and quarterly chart reviews? [HSTM Chpt. 1, Sec. 5.0; CC
2.20.2.12]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:31:56 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with physicians the need to conduct appropriate reviews following DOC/Corizon
guidelines. Continue to monitor.
2 Is contractor conducting monthly CQI committee meetings and meeting NCCHC standard? [P-A-06, HSTM
Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Terry Allred Date: 10/15/2013 1:55:17 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Medical, mental health, and dental disciplines are participants in the monthly CQI meetings.
3 Are CQI committee improvement recommendations acted on timely and progress reported back to
committee in the next meeting? [P-A-06, HSTM Chpt. 1, Sec. 5.0; CC 2.20.2.12]
Level 1 Amber User: Terry Allred Date: 10/15/2013 1:58:01 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that CQI committee improvement recommendations are acted upon timely
and progress is reported back to the committee at the next meeting. Continue to monitor.
4 Is the contractor conducting annual PEER reviews for physicians, nurse practitioners, physician
assistants, dentists, psychiatrists, psychiatric nurse practitioners and Phd. level psychologists? [P-A-04, PC-02, HSTM Chpt. 1, Sec. 5.1, CC 2.20.2.12]
Level 1 Amber User: Terry Allred Date: 10/17/2013 1:02:39 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that regular PEER reviews for physicians, nurse practitioners, physicians,
physician assistants, dentist, psychiatrists are to be completed. Continue to monitor.
5 Did the contractor conduct a quarterly on-site review of the site CQI program? [P-A-06, CC 2.20.2.12]
Level 1 Amber User: Terry Allred Date: 10/17/2013 1:03:49 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Regional management will monitor the site CQI program

PRR ADC02471

October 2013 LEWIS COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: This was actually a green finding. This was marked amber in error. No corrective action plan
was necessary.

PRR ADC02476

October 2013 LEWIS COMPLEX
Corrective Action Plans for PerformanceMeasure: Segregated Inmates
1 Are medical records being review for contraindications by nursing when notified an inmate has been
placed in administrative segregation and documented in the chart? [NCCHC Standard P-E-09; DO 1101;
HSTM Chapter 7, Section 6.0]
Level 1 Amber User: Terry Allred Date: 10/31/2013 2:53:51 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff the need to review medical records for contraindications when inmate has
been placed in administrative segregation; document review in chart. Continue to monitor.
1 Are medical records being review for contraindications by nursing when notified an inmate has been
placed in administrative segregation and documented in the chart? [NCCHC Standard P-E-09; DO 1101;
HSTM Chapter 7, Section 6.0]
Level 1 Amber User: Terry Allred Date: 10/31/2013 2:53:51 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff the need to review medical records for contraindications when inmate has
been placed in administrative segregation; document review in chart. Continue to monitor.
4 Are SMIs placed in segregation seen within 24 hours by mental health staff?
Level 2 Amber User: Terry Allred Date: 10/30/2013 2:16:29 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that when SMI is placed in segregation that inmate is seen within 24 hours
by mental health staff. Continue to monitor.
5 Are vital signs done on all segregated inmates every month? [HSTM Chpt. 7, Sec. 6.3.9]
Level 1 Amber User: Terry Allred Date: 10/31/2013 2:49:41 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that regular vital signs be completed on all segregated inmates. Continue to
monitor.
5 Are vital signs done on all segregated inmates every month? [HSTM Chpt. 7, Sec. 6.3.9]
Level 1 Amber User: Terry Allred Date: 10/31/2013 2:49:41 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that regular vital signs be completed on all segregated inmates. Continue to
monitor.

PRR ADC02478

October 2013 LEWIS COMPLEX
Corrective Action Plans for PerformanceMeasure: Emergency Response Plan
2 Are health aspects of the emergency response plan are approved by the Site Manager? [NCCHC Standard
P-A-07]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:21:26 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Site manager will monitor health aspects of the emergency response plan upon approval.
Continue to monitor.
3 Are mass disaster drills being scheduled / conducted annually so that all shifts have participated over a
three year period (Actual events may be used to meet this requirment)? [NCCHC Standards P-A-04; P-A-07]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:25:41 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce the need for annual mass disaster drill. Continue to monitor.
4 Are man down drills being scheduled / conducted once a year on all units for all shifts (Actual ICS may be
used to meet requirement)? [NCCHC Standard P-A-07]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:26:31 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce the need for annual mass disaster drill. Continue to monitor.
5 Are mass disaster and man down drills critiqued and shared with all health staff? [NCCHC Standard P-A07]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:27:25 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce the need for mass disaster and man down drills to be critiqued and shared with staff.
Continue to monitor.
6 Are emergency supplies stored and check monthly? [NCCHC Standard P-A-07]
Level 1 Amber User: Terry Allred Date: 10/29/2013 2:29:24 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff to regularly check emergency supplies. Continue to monitor.

PRR ADC02480

October 2013 LEWIS COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that health staff is in compliance with licensure requirements. Continue to
monitor.
4 Are all qualified healthcare professionals who have patient contact current in cardiopulmonary
resuscitation technique?
[HSTM Chapter 3. Section 4.0, NCCHC Standard P-C-03]
Level 1 Amber User: Terry Allred Date: 10/15/2013 1:52:15 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that qualified health care professionals with patient contact are current with
cardiopulmonary resuscitation technique. Continue to monitor.

PRR ADC02482

October 2013 LEWIS 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 Amber User: Erin Barlund Date: 10/24/2013 12:18:48 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.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Erin Barlund Date: 10/24/2013 12:19:43 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
PRR ADC02491

October 2013 LEWIS 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/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: 10/24/2013 12:03:04 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: Erin Barlund Date: 10/29/2013 1:53:51 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
PRR ADC02492

October 2013 LEWIS COMPLEX
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.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Erin Barlund Date: 10/25/2013 9:29:33 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 (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: 10/25/2013 9:46:10 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.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.
PRR ADC02493

October 2013 LEWIS COMPLEX
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 ADC02494

October 2013 LEWIS COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Diets
3 Do inmates who refuse prescribed diets receive follow-up nutritional counseling? [NCCHC Standard P-F02]
Level 1 Amber User: Terry Allred Date: 10/30/2013 1:42:09 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that when inmates refuse prescribed diets that they receive follow-up
nutritional counseling. Continue to monitor.
4 Are diet orders forwarded to food service liaison within 24 hours?
Level 1 Amber User: Terry Allred Date: 10/30/2013 1:43:56 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that diet orders regularly be forwarded to food service liaison. Continue to
monitor.
5 Are non-formulary diets being approved by the Medical Review Committee/Medical Director?
Level 1 Amber User: Terry Allred Date: 10/30/2013 1:45:45 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff that non-formulary diets be approved by the Medical Review
Committee/Medical Director. Continue to monitor.

PRR ADC02497