October 2013 PERRYVILLE COMPLEX
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: Mark Haldane Date: 10/30/2013 3:05:49 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.

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October 2013 PERRYVILLE COMPLEX
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: 10/18/2013 2:24:32 PM
Corrective Plan: The following has been placed into effect upon the return of a consult summary to the Clinical
Coordinator, it is closed out in the ORC and then given to the issuing provider for review. This will reduce delays
and improve turn around times.
Corrective Actions: Approved by Erin Barlund- See above.

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October 2013 PERRYVILLE COMPLEX
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.

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October 2013 PERRYVILLE COMPLEX
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 5:11:11 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 5:20:24 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.

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October 2013 PERRYVILLE COMPLEX
Corrective Action Plans for PerformanceMeasure: Oral Care (Dental)
3 Are there inmates waiting over 90 days for routine dental care? [NCCHC Standard P-E-06]
Level 1 Amber User: Mark Haldane Date: 10/17/2013 9:23:13 AM
Corrective Plan: Advent of a portable dental chair at the Lumley unit, will allow for expanded function and quicker
more efficient delivery of care onsite at the Lumley unit. The Santa Maria unit clinic is now open full-time with DAII
Inga Popin dedicated solely to service of Santa Maria/Piestewa and Santa Rosa units.
Corrective Actions: See above.
4 Are 911's seen within 24 hours of HNR submission? [NCCHC Standard P-E-06]
Level 1 Amber User: Mark Haldane Date: 10/24/2013 11:54:16 AM
Corrective Plan: Advent of a portable dental chair at the Lumley unit, will allow for expanded function and quicker
more efficient delivery of care onsite at the Lumley unit. The Santa Maria unit clinic is now open full-time with DAII
Inga Popin dedicated solely to service of Santa Maria/Piestewa and Santa Rosa units.
Corrective Actions: See above.
15 Are dental entries complete with military time and signature over name stamp?
Level 1 Amber User: Mark Haldane Date: 10/4/2013 1:09:49 PM
Corrective Plan: This was placed into effect on 10/18/13, this is now a mandatory practice in this area
Corrective Actions: See above.

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October 2013 PERRYVILLE COMPLEX
Corrective Action Plans for PerformanceMeasure: Emergency Response Plan
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: Mark Haldane Date: 10/21/2013 12:46:32 PM
Corrective Plan: Corizon has not been here a year as of yet. There is a mass disaster drill scheduled for Perryville in
the future in which medical is scheduled to participate.
Corrective Actions: Approved by Mark Haldane-See above.
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: Mark Haldane Date: 10/21/2013 12:47:48 PM
Corrective Plan: Going forward, at each unit, on all shifts drills will be scheduled, conducted and reviewed /ICS
actual in order to meet and or exceed these requirements.
Corrective Actions: This will be addressed on November MGAR if not in compliance.
5 Are mass disaster and man down drills critiqued and shared with all health staff? [NCCHC Standard P-A07]
Level 1 Amber User: Mark Haldane Date: 10/21/2013 12:48:31 PM
Corrective Plan: Corizon has not been here a year as of yet. There is a mass disaster drill scheduled for Perryville in
the future in which medical is scheduled to participate. In the case of “man down” drills / ICS (actual) we will direct
staff that when an After Action Review (AAR) is conducted of an incident in which medical staff participated, they
should attend that review and request a copy of the incident reports for medical records.
Corrective Actions: This will be addressed in November MGAR if negative findings.

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October 2013 PERRYVILLE COMPLEX
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: 10/24/2013 12:20:49 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.

PRR ADC02541