fall Edition
october 2022 • Volume II
Yuma Clinic Passes ADHS Unannounced Site Inspection
On August 24, 2022, the Arizona Department of Health Services (ADHS) stopped by our Yuma Clinic (1185 S Redondo Center Dr.) for an unannounced site inspection. A Healthcare Compliance Surveyor from their Phoenix Licensing Department began the inspection process. The surveyor conducted an on-site inspection to ensure our Yuma Clinic promotes quality care and safety, and meets their performance standards.
On-Site Inspection Process
The whole site inspection process took about three hours. Here are some of the items that the Healthcare Compliance Surveyor reviewed during the tour of the Yuma Clinic.
- Treatment plans/notes
- Patient files
- Staff files
- Staff paperwork
- Safety, calibration and expiration of medical equipment
- Clinical supervision records
It Takes a Team Effort
The Yuma Outpatient Team did a fantastic job at handling this unannounced visit from the ADHS Licensing Department. They immediately contacted all relevant departments to pull the requested information together and were able to present it to the investigator in a timely and efficient manner to meet the needs of the inspection. The following people worked together as a team to ensure this inspection went seamlessly.
- Dawn Murphy, Senior Director of Clinical Services – Southern Region
- Wendy Lugo-Hanson, Clinical Program Director
- Kristin Parrish, Clinical Coordinator
- Arlene Gallardo, Site Administrator
- Wendy Brandt, Chief Human Resources Officer
- Amy Palermo, Human Resources Benefits and Compensation Manager
- Jessica Colvin, Director, Quality Management/Compliance
- Marsha Ashcroft, Director of Risk Management
- Billie Holliday, Chief Operating Officer
Successful Results
No deficiencies were cited during the unannounced, on-site State Compliance Survey. On August 26, 2022, Horizon received a letter and a “Compliance Statement of Deficiency form, which constitutes the inspection report and indicates that no deficiencies were cited at the time of the inspection.” A copy of the form will become a part of the Department’s public file for the facility.
Best Practices
It is always best practice for all of our facilities to be prepared for an unannounced inspection. The best recommendations for other facilities to follow are to always greet investigators with a calm and professional demeanor. Have the Healthcare Compliance Surveyor wait in a clean and quiet room or conference room. After they are settled in a room, contact the following support team for instructions:
- Pam Brotman
- Chief Quality & Compliance Officer
- (480) 888-5048 (cell)
- Jessica Colvin
- Director, Quality Management/Compliance
- (480) 825-3829 (cell)
Pam or Jessica will walk you through the process and help to coordinate whatever is needed to be successful.
Again, congratulations to the Yuma Clinic Team for being prepared and pulling together for a successful compliance inspection.
If you have any questions or comments, contact Jessica Colvin at jessica.colvin@hhwaz.org.