October 2013 WINSLOW COMPLEX
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.

PRR ADC02867

October 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Mental Health (Q)
1 Are HNRs for Mental Health services triaged within 24 hours of receipt by a qualified Mental Health
Professional, to include nursing staff? [CC 2.20.2.10]
Level 2 Amber User: John Mitchell Date: 10/22/2013 12:43:16 PM
Corrective Plan: The night nurses have been counciled about making sure the HNR are time stamped and dated.
The time stamp machines no longer work so this is done by hand untill the new ones that have been ordered come
in. Staff have been made aware that this is imperative in order for the compliance dates to me meet. Since this is
the first notification made to staff and action moving away from this policy will incounter written disipline.
Corrective Actions: See above.
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: John Mitchell Date: 10/24/2013 8:49:39 AM
Corrective Plan: Please see MGAR response of 9/26/13. Addendum to this note is that when inmate is moved with
in the 7 days an email is being sent to the receiving facility to inform them of the need for imediate appointment with
Psychiatrist.
Corrective Actions: See above.

PRR ADC02871

October 2013 WINSLOW COMPLEX
Corrective Action Plans for PerformanceMeasure: Oral Care (Dental)
4 Are 911's seen within 24 hours of HNR submission? [NCCHC Standard P-E-06]
Level 1 Amber User: John Mitchell Date: 10/10/2013 4:01:56 PM
Corrective Plan: This was given to dental. As of October they now have dental coverage Mon thru Fri. They will
make sure that HNRs are picked up daily and they have discussed with dental staff what constitutes a true dental
emergency. IR's will be completed if dental emergencies called for are not brought up.
Corrective Actions: See above.
16 Is treatment plan section C and priority section D of the dental chart completed?
Level 2 Amber User: John Mitchell Date: 10/22/2013 8:01:51 AM
Corrective Plan: This was given to the dentist and he said he discussed this with staff. They will update section C
annually or if treatment changes and will continue to write in dates of service in section D.
Corrective Actions: See above.

PRR ADC02879