September 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Sick Call (Q)
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: 9/27/2013 11:09:11 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
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: 9/27/2013 11:42:07 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Red User: Yvonne Maese Date: 9/27/2013 12:25:00 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Yvonne Maese Date: 9/27/2013 12:43:26 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01915

September 2013 EYMAN COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Records (Q))
1 Are medical records current, accurate and chronologically maintained with all documents filed in the
designated location? [NCCHC Standard P-H-01]
Level 1 Red User: Yvonne Maese Date: 9/30/2013 11:43:15 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions:
2 Are provider orders noted daily with time, date and name of person taking the orders off? [NCCHC
Standard P-H-01; HSTM Chapter 5, Section 7.0]
Level 1 Amber User: Yvonne Maese Date: 9/30/2013 11:03:06 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with nursing staff to note charts regularly. Continue to monitor.
Responsible Parties = RN/LPN
Target Date= 11/30/13
3 Does the Medication Administration Record (MAR) in the medical chart reflect dose, route, frequency,
start date and nurse’s signature? [HSTM Chapter 4, Section 1.1, Chapter 5, Section 6.4]
Level 1 Amber User: Yvonne Maese Date: 9/30/2013 12:25:58 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
4 Are medical record entries legible, and complete with time, name stamp and signature present? [HSTM
Chpt. 5, Section 6.4, CC 2.20.2.5]
Level 1 Red User: Yvonne Maese Date: 9/30/2013 10:33:43 AM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions:

PRR ADC01931

September 2013 EYMAN 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: Yvonne Maese Date: 9/30/2013 12:49:27 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce with staff to complete a refusal form to be signed by inmate. Continue to monitor.
Responsible Parties= RN/LPN
Target Date = 11/30/13
2 Are unresolved No-Shows being reported to the unit deputy warden for a written response? [DO 1101]
Level 1 Amber User: Yvonne Maese Date: 9/30/2013 12:27:58 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that unresolved No-Shows are being reported to the unit deputy warden for a written
response. Continue to monitor.
3 Are providers being notified of medication line No-Shows?
[DO 1101, HSTM Chapter 5, Section 7.1]
Level 1 Amber User: Yvonne Maese Date: 9/30/2013 12:30:01 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that providers are notified of medication line No-Shows. Continue to monitor.
4 Are No-Shows being rescheduled if medically indicated?
[DO 1101, HSTM Chapter 5, Section 7.1]
Level 1 Amber User: Yvonne Maese Date: 9/30/2013 12:57:32 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: Reinforce that No-Shows are being rescheduled if medically indicated. Continue to monitor.

PRR ADC01942

September 2013 EYMAN COMPLEX
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.
11 Are medication error reports being completed and medication errors documented?
Level 2 Amber User: Yvonne Maese Date: 9/30/2013 2:03:53 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: See above.

PRR ADC01950