April 2013 WINSLOW COMPLEX
cleared the DOC process and it waiting clearence from the credintialing dept at Corizon. Once this has been done
he can be bagded and printed.
Corrective Actions: See above.

PRR ADC00623

April 2013 WINSLOW COMPLEX
2 Are CC inmates being seen by the provider (every three (3) to six (6) months) as specified in the inmate’s
treatment plan? [P-G-01, DO 1101, HSTM Chpt. 5, Sec. 5.1, CC 2.20.2.4]
Level 2 Amber User: Kathy Campbell Date: 4/19/2013 3:43:48 PM
Corrective Plan: Winslow and Apache currently share one mid level provider. Inmates with chronic care have been
a priority for provider appointments and continue to be so. inmate
is scheduled for 6/7/13, inmate
is also
scheduled for 6/7/13. inmate
is on the list to be seen for Hep C at Apache and inmate
was seen on 5/17/13
for his chronic. A medical director has been hired for Winslow and has passed DOC backgrounds and is waiting to
be cleared by credintaling at Corizon. When this has been completed he will be badged abd printed. I anticipate to
be caught up at both facilities in less that 2 weeks once he is on board.
Corrective Actions: See above.
4 Have disease management guidelines been developed and implemented for Chronic Disease or other
conditions not classified as CC? [P-G-01, HSTM Chpt. 5, Sec. 5.1, CC 2.20.2.4]
Level 2 Amber User: Kathy Campbell Date: 4/19/2013 3:39:25 PM
Corrective Plan: The providers being used at Winslow at this time are Locum and registry. Once this was brought to
our attention both provider were instructed to fill all areas of the Chronic Care form. Corizon has since issued an
orientation binder for providers and this standard has been added to that training for implementation.
Corrective Actions: See above.

PRR ADC00628

April 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Medical Records (Q))
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: 4/22/2013 1:17:48 PM
Corrective Plan: The majority of the above mentioned charts were noted on the same day as the writing 4/22/13.
One was noted on 4/23/13 and 3 on 4/24/13. Currently chart noting is caught up. Nursing staff have been advised
to complete the noting of charts daily.Weekend nurses have also been included in this instruction. The nursing
supervisor and the director odf nursing check on the noting of charts daily.
Corrective Actions: See above.
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 Amber User: John Mitchell Date: 4/24/2013 10:04:06 AM
Corrective Plan: Name stamps were purchased by the FHA for all nursing staff and instructions given to use them.
Locum providers have been instructed to print their name after signatures.
Corrective Actions: See above.

PRR ADC00631

April 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Prescribing Practices and Pharmacy
(Q)
2 Are pharmacy polices, procedures forms, (including non-formulary requests) being followed? [NCCHC
Standard P-D-01, CC 2.20.2.6]
Level 2 Amber User: Leslie Boothby Date: 4/26/2013 10:23:04 AM
Corrective Plan: Winslow has hired an inventory tech. She has been and is running stop date reports weekly.
Inmate med profiles on each new intake and has started a note book for all nonformularys to track them. Winslow
at present delivers meds next day after delivery. May was at 100% renewal and at present we are at 99% for June
renewal. We have also found that Pharmcor stopdate reports are not accurate, hense the weekly printouts. This is
the CAP that Winslow has taken on their own.
Corrective Actions: See above.

PRR ADC00633

April 2013 WINSLOW 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: John Mitchell Date: 4/16/2013 2:54:34 PM
Corrective Plan: Winslow does not have a medical director as of this date but does have a Locum Nurse Practioner.
At present charts are reviewed on a priority basis with most important needs first. A medical director has been
cleared for Winslow by DOC how ever he is awaiting credentialing with Corizon. Once this has been done he can
be badged and printed.
As part of the onboarding process the FHA will be training the new provider who starts on July 8th 2013, in the
standard of doing chart reviews following DOC/Corizon guide lines. This process will be monitored by the FHA.
Corrective Actions: See above.
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: John Mitchell Date: 4/16/2013 2:54:34 PM
Corrective Plan: Winslow has hired a medical director and a registry NP. The NP has been here since early May
and the MD has just recently cleared the DOC background. Winslow is caught up on Chronic care visits however
there is still a small backlog at the Apache unit. Once the MD is on board I anticipate 1 to 2 weeks to be completely
caught up. At this time the provider can begin to do the chart audits but access to care has to take priority at
present. As part of the on boarding process the FHA will be training the provider in the standard of chart reviews
and the FHA will monitor.
Corrective Actions: Approved. See above.

PRR ADC00639