September 2013 WINSLOW COMPLEX
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: John Mitchell Date: 9/20/2013 3:01:46 PM
Corrective Plan: Charts continue to be written with out full SOAPE. I have discussed this with staff at the last nurses
meeting and they have been instructed to bring any chart back to the provider to correct if it is not in the proper
format.
Corrective Actions: See above.

PRR ADC02251

September 2013 WINSLOW 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 Amber User: John Mitchell Date: 9/12/2013 10:13:03 AM
Corrective Plan: This was discussed with the MRL and going forward all intakes that come in she will make sure
they all the charts are in correct order. She will also continue to pull random chats to check for correct order. I
documents are found in incorrect places she will try to verify who placed them there so she can retrain. The MRL
will copy documents to see where we can improve. She will attend the next Nurse meeting to advise staff of the
correct order of filing in charts and will make sure audit reference lists are available in the records room for all staff
to refer to and will continue to assist as she is able.
Corrective Actions: See above.
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: John Mitchell Date: 9/12/2013 10:28:54 AM
Corrective Plan: This issue was brought up at the last nurses meeting and is being tracked by the DON. We have
discussed spliting up the charts between staff to make sure the orders are being done same day. This will be done
for a few days to see if it works.
Corrective Actions: See above.

PRR ADC02256

September 2013 WINSLOW COMPLEX
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

PRR ADC02261