April 2013 YUMA COMPLEX
Corrective Plan: At this time we are using the NETs which hopefully eliminate this deficiency. We will also research
and address the patients that are mentioned in this deficiency. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Kathy Campbell Date: 4/26/2013 6:30:04 PM
Corrective Plan: We are in the process of building our Provider Staff. When we have more than one provider, this
will ensure that our patients will be seen in accordance with the standards and in a timely fashion. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Kathy Campbell Date: 4/26/2013 6:30:25 PM
Corrective Plan: With the NETs in place, these address the nursing protocols that are in place and utilized by the
nurses during Sick Call. We will re-inforce this and document our training regarding emergency nursing care, health
maintenance and prevention at the next Nurses' Staff Meeting.
6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.

PRR ADC00650

April 2013 YUMA COMPLEX
Corrective Actions: See above.

PRR ADC00655

April 2013 YUMA 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: Kathy Campbell Date: 4/27/2013 3:57:11 PM
Corrective Plan: The Medical Records Supervisor will conduct a meeting regarding these concerns and how we can
resolve them in a timely manner. We will keep a record of the instructional meeting for the Medical Records
Departmental Staff. 6/2/2013 Cyndy Hale FHA
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: Kathy Campbell Date: 4/27/2013 3:58:36 PM
Corrective Plan: We will work with our Nursing Staff to ensure that taking orders off is done in a timely fashion.
This will be re-inforced at the next Nurse's Meeting. 6/2/2013 Cyndy Hale FHA
Corrective Actions: See above.
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: Kathy Campbell Date: 4/27/2013 4:05:07 PM
Corrective Plan: The Nursing Staff has been instructed on how to fill out the MARs appropriately. We will again
bring how important proper documentation is warranted at the next Nurse's Staff Meeting. 6/2/2013 Cyndy Hale
FHA
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: Kathy Campbell Date: 4/27/2013 4:14:22 PM
Corrective Plan: At this time, our whole staff have acquired printed name stamps. We will re-interate how important
it is to be able to read who documented the note. We will re-interate this also at the next Nurse's Staff Meeting.
6/2/2013 Cyndy Hale FHA
Corrective Actions: See above.

PRR ADC00658

April 2013 YUMA 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 10:23:42 AM
Corrective Plan: We are currently working with Ms. Christy Somner RDON and the PharmaCorr Staff on our
medication issues regarding expiring medications, refills, renewals, and non-formulary requests. We are also
educating our Nursing Staff regarding all medication policies and procedures. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.

PRR ADC00660

April 2013 YUMA 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 Amber User: Steve Bender Date: 4/25/2013 12:41:18 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
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: Steve Bender Date: 4/25/2013 12:45:16 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
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 Amber User: Steve Bender Date: 4/25/2013 12:52:03 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
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 Amber User: Steve Bender Date: 4/25/2013 12:52:35 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
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 Amber User: Steve Bender Date: 4/25/2013 12:55:12 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.
7 ***Deleted
Level 2 Amber User: Steve Bender Date: 4/25/2013 12:57:08 PM
Corrective Plan: We are in the process of building our Mental Health Staff. When we have our staff, hopefully this
will ensure our Mental Health patients are seen in a timely manner and according to standards. 6/2/2013 Cyndy
Hale, FHA
Corrective Actions: See above.

PRR ADC00665

April 2013 YUMA COMPLEX
Corrective Plan: We are currently working with our Inventory Control Staff, PharmaCorr, and Nursing Supervisors to
find a way to decrease delays in our patients receiving their medications. Again, will re-inforce with Nursing Staff
the correct documentation on the MARs and the use of the printed name stamp at the next Nurses' Staff Meeting.
6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.
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: Kathy Campbell Date: 4/27/2013 5:01:09 PM
Corrective Plan: Our Inventory Control Staff, Provider, and Nursing Staff are in the process of reviewing the
Expiration Log in a timely manner to ensure our patients' Chronic Care medications are being reviewed prior to
expiration. We are in the process of building our Provider Staff to also ensure our Continuity of Care is on track with
our patients. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Kathy Campbell Date: 4/27/2013 5:01:28 PM
Corrective Plan: Our Regional Medical Director and PharmaCorr Staff is attempting to approve and/or disapprove
the non-formulary requests within the time frame. We just received an update last week regarding the nonformulary requests that were out of sequence. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Kathy Campbell Date: 4/27/2013 5:04:06 PM
Corrective Plan: We are in the process of building our Provider Staff. When we have more than one provider, this
will hopefully take place in a timely manner. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.

PRR ADC00671

April 2013 YUMA COMPLEX
3 Are all positions filled per contractor staffing pattern?
Level 2 Amber User: Kathy Campbell Date: 4/26/2013 6:52:20 PM
Corrective Plan: At this time, we are actively recruiting for these positions. We have filled the Assistant FHA/Dental
Assistant/Dental Hygienist/two Psyche Associate/two RN Supervisor positions, they will be starting at different times
in June. We are also screening Agency/Locum Providers at this time. 6/2/2013 Cyndy Hale, FHA
Corrective Actions: See above.

PRR ADC00673