Compliance Review
Services, Inc.
Consulting and Training Services for Home Health and Long-Term Care Agencies
August 2010
www.compliancereviewservices.com
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Company Background
Kimberley Kelly, RN, BSN, LNC
Founder, CEO, and Senior Consultant
• Established January 1997
• Incorporated February 1998
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www.compliancereviewservices.com
11201 Steeple Park Drive
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Mission Statement
• The mission of Compliance Review Services,
Inc. is to provide quality consulting services
at an affordable rate and help home health
agencies help themselves to stay in
compliance with State, Federal, and all other
regulatory agencies.
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CEO Credentials
Kimberley Kelly, RN, BSN, LNC
• Bachelor of Science Degree in Nursing from Ohio State University
• Licensed in Ohio, Texas, and Florida and multi-state impact licensure
• Certified Legal Nurse Consultant 1999-2005
• Legal Nurse Consultant 2005-present
– Advisor to and expert witness for law firms on nursing home abuse and neglect
lawsuits
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Administrator in home health and Supervising Nurse
Director of Nurses in long-term care
Liver transplant and GI/GU medical floor nurse and per diem visit nurse for
home health for Cleveland Clinic Foundation
Licensed vocational instructor for CNA/HCA course, both clinical and classroom
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CEO Credentials continued…
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Kimberley Kelly, RN, BSN, LNC
Enforcement monitor for Department of Aging and Disability Services 1999current for Home Health, Hospice, PAS, ICF/ MR.
External Rule Review Committee via DADS for Home Health and Hospice
Former TAHC Committee member Clinical Practice Committee
Nurse Quality Reviewer for NACES/DADS for long-term care facilities in Texas
since 2006.
Nurse Delegate Ambassador for Nursing Programs for U.S.
Regional Faculty for American Heart Association
CPR Instructor
Lead Nurse Planner for Educational Unit of company
Director of Vocational Nursing school and Educational Unit
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Services Offered
• We offer a wide range of products and services, and we’re constantly
expanding our list. If you don’t see the service you need, please let us
know—we may be able to help. Our services are categorized as follows:
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Training Center – Hepa fit testing, Live Classes, Competencies for nurses
Nurse Consulting (Home Health, Hospice, ICF/MR, ALF, and DME)
Legal Nurse Consulting
HIPAA Compliance
Agency Startups
On Line classes for Home Health, Hospice, LNC, ALF, and DME
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Services Offered (cont’d)
• Conferencing Center at the main office
or local venues used:
– Continuing education training courses
– Competency evaluations for venipuncture and
intravenous therapy
– In-service education for clock and contact hours
(our schedule of events is posted on our website)
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Services Offered (cont’d)
• Nurse Consulting
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Policy and procedure development
Mock state surveys
Chart reviews
Quality assurance programs
Staff competency evaluations
TJC/CHAP/ACHC & HQAA preparation for DME
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Note: (State of Texas only accepts TJC or CHAP for Home Health & Hospice
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Plans of correction
Staff in-services
Problem resolution
Business planning /Marketing plans
CPR classes on line and in person
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Services Offered (cont’d)
• Legal Nurse Consulting
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Medical review
Mediation/deposition preparation
Trial preparation
Expert testimony
Expertise of consulting firm
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Nursing home
Hospital
ALF
Hospice
Home health
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Services Offered (cont’d)
• HIPAA Compliance
– Customized HIPAA policies and procedures
– Organization chart review and revision
– General and administrative policy review for HIPAA
compliance
– Gap analysis to gauge overall HIPAA readiness
– HIPAA in-service
– Physical environment survey
– Required notices and forms
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Services Offered (cont’d)
• Agency Startups
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State and federally mandated policies and procedures
All required forms.
Admit packet
Human resources packet
In-service education
PAC
Governing body
Annual evaluation
Continuing education
Complaint/incident/accident binders
Accreditation specific policies, procedures, forms and binders
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Services Offered (cont’d)
• ALF Consulting Services
– Policies and Procedures
– Monthly RN visits on-site for medication
compliance
– On line classes for ALF Managers including:
* Part I 8 hour class *Part II 16 hour class
* Part III 12 hour class
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Services Offered (continued)
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DME Consulting Services
On site accreditation preparation
State, CMS, NPI, Accreditation applications
On line classes inclusive of all areas pertinent
to DME companies from the ground up
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Consultant Credentials
• Registered Nurses or Licensed Vocational Nurses
• Experience as Administrators, Director of Nurses, or Quality
Assurance Nurses
• Minimum of four years in home health care field
• Demonstrated proficiency with Home Health and Hospice
State surveys with TJC and CHAP.
• Demonstrated proficiency with DME surveys with
TJC/CHAP/ACHC/ and HQAA accreditation process
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How Do We Stay Current?
• The Home Health, Hospice, ALF, and DME
fields are constantly changing: new
regulations, updates to the regulations,
updates to the updates… it’s never ending.
We understand the demands of the industry,
and we’re committed to being your up-todate resource.
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How Do We Stay Current? (cont’d)
• Memberships and Positions
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Member of TAHC since 1998
CEO is an invited member of the Rule Review Committee for the 2005-2007 regulations
CEO is a State of Texas Consultant Enforcement Monitor and BNE Monitor since 1999
CEO was a member of the State OBQI Committee for over one year
CEO is a member of the Rule Review Stakeholder Committee 2005-2007
CEO is independent contractor for DADS LTC Quality Review Project 2007
Membership with HARCH (Houston Area Residential Care Homes Association)
Compliance Review Services, Inc. is a Member of the following Chambers of Commerce:
• Cy-Fair Houston
• Houston North West
• Greater Tomball Area
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How Do We Stay Current? (cont’d)
• Resources and Networking
– On multiple regulatory mailing lists (both State, Medicare, and
Accrediting bodies) for regulation and policy updates
– Current in-house resources, such as coding books, nurse practice acts,
and clinical skills manuals
– We have a good rapport with the State and accrediting bodies and can
call anytime to ask questions or get clarification on issues.
– We work closely with attorneys and CPAs who have expertise in home
health and related health fields
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How Do We Stay Current? (cont’d)
• Ongoing Education
– We hold regular staff training events to ensure
consistency and share informational updates
– We attend seminars sponsored by TAHC, DADS,
and other authoritative sponsors
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Associations
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Can You Afford a Consultant?
• Can you afford not to have a nurse
consultant?
• The cost of the consultant may be less than
possible fines owed for noncompliance
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Consultant vs. Employee
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No payroll taxes (savings of 16% to your agency)
No worker’s compensation costs
No unemployment taxes
No employee benefits
Short-term investment for a big return—COMPLIANCE!
Avoidance of State and Federal regulatory fines
Agency can put consultative education on its cost report
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Financial Considerations
• Our goal is to try and work with our clients;
however, like you, we are running a business,
and we need to make sure that our financial
side fulfills our CEO expectations.
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Cost of Consultant
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The cost of the nurse consultant visits are $100.00-$120.00 per hour. It may be adjusted
based on the following criteria:
– Size of the agency
– Services to be provided
– Distance traveled and mileage considerations
– How many years the agency has been in business
For out-of-town consulting or distances greater than 50 miles from the consulting firm’s
office; the client is responsible for additional expenses (e.g., hotel accommodations and
mileage). This is negotiated during contract signing.
Our pricing is posted for the general public to see on our website under the pricing button.
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Billing Procedures
• Invoicing schedule – we produce weekly invoices to
go out to our clients
• We receive payments the day of service for on-site
consulting; our consultants will collect the payment
• We receive payments for plans of correction upon
pick up from our office or via USPS, UPS, Fedex
• We will work with large corporations on receiving
payments issued by a corporate entity.
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Scheduling
• We offer scheduling on line at
www.compliancereviewservices.com
or
• You can call the office to schedule a
consultant to visit with your company.
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Department of Aging and Disability Services
Licensing Agency
Hospice
Licensed and Certified Home
Health (LCHH)
Licensed Home Health (LHH)
Personal Assistance
Services (PAS) License
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Medicare
Medicaid
Private pay
Private insurance
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No Medicare involvement
No Medicaid involvement
Private pay
Private insurance
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Medicare
Medicaid
Private pay
Private insurance
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No Medicare involvement
Medicaid
Private pay
Private insurance
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Federal regulations
State regulations
Medicaid rules
Private insurance guidelines
§ State regulations
§ Private insurance guidelines
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Federal regulations
State regulations
Medicaid rules
Private insurance guidelines
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Federal regulations
State regulations
Medicaid rules if PHC
Private insurance guidelines
Skilled and nonskilled services
provided: SN, volunteer, MSW, CNA,
pastor, bereavement, equipment, meds
Skilled and nonskilled services
provided: SN, PT, OT, SLP, MSW,
CNA, psych, pediatric
§ Supervision of staff per policies
§ Plans of care done q 2 weeks
§ Medicare eligible 90-90-60-60-60
§ Supervision of staff per policies
§ Plans of care done q 6 months
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LHH can do PHC
Skilled and nonskilled services
provided: SN, PT, OT, SLP, MSW,
CNA, psych, pediatric, private
§ Palmetto states supervision of
aides q 2 weeks by RN
§ Supervision of RN, LVN per policies
§ Plans of care done q 60 days
LCHH can do PHC
Only nonskilled services provided:
providers, companions, sitters,
attendants
§ Supervision per policies (not
required by RN) usually q 60 days
§ If patient on respite, q 14 days
PAS license (no other license
required) can do PHC
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Medicare Initial Survey Process
Request
Prepare
Receive
• Request initial
application packet
from State office
• Request CMS 855A to
Palmetto
• Request CLIA
application
• Complete pre-survey
on-line through
DADS
• Submit applications
• Obtain NPI #
• Finalize policies and
procedures
• Conduct PAC and
Governing Body
meetings to approve
p/p and appoint
Administrator,
Alternate and
Supervising Nurse
and Alternate
• Receive initial
license from State
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Medicare Initial Survey Process, cont’d
Patient Care
Request
Survey
• Admit and provide
skilled services to
10 clients (7 active
for survey)
• Request in writing
temporary OASIS
user ID and
password
• Conduct OASIS
test submission
• Request initial
survey in writing to
TJC using their
form when ready
• Apply for TJC/CHAP
password and
complete application
for TJC/CHAP to
conduct initial survey
once State license is
received from DADS
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Continued 
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Medicare Initial Survey Process, cont’d
Patient Care
• Do a new SOC
assessment on
all patients at
next visit once
you have passed
the survey
• Collect OASIS
at all time
points
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Receive
• HHA and State
Agency receive
Medicare
provider
number from
CMS
• Permanent
OASIS user ID
issued by State
agency
Request
• Request MDCN
account
Begin monthly
submissions to
the State
Complete!
www.compliancereviewservices.com
Our Staff
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Kimberley Kelly, RN, BSN, LNC – CEO & Senior Consultant
Michael Bradshaw, RN – Assistant Senior Consultant
Janice M. Johnson-Umezulike, RN, BSN, MN, CNS, DNS – Education Coordinator
Marie Luque – General/Office Manager
Jayne Jessop - Referral Coordinator
Barbara Rodriguez -- Assistant to Referral Coordinator/Administrative Assistant
Jacob Gallegos IV – Administrative Assistant
Nurse Consultants
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Kimberley Kelly, CEO and Senior Consultant
Michael Bradshaw RN-former DADS Surveyor and Assistant Senior Consultant
Paula Frate RN-Nurse Consultant
Denise Garcia RN-Nurse Consultant
Linda Henslee LVN, Certified OASIS Specialist, Nurse Consultant
Joyce May RN-former DADS Surveyor and ESRD Surveyor, Nurse Consultant
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Kimberley Kelly, RN, BSN, LNC
CEO & Senior Consultant
Kimberley graduated from Ohio State University with a Bachelor of
Science in Nursing in 1986. She has 20+ years of experience in the
healthcare field, ranging from Administrator, to Director of Nurses, to
home health agency owner. She has worked in multiple medical
environments, taught at a vocational college, and developed and taught
numerous educational offerings. Kimberley is a member of the Home
Health Alliance Team, Texas Association for Health Care, and Better
Business Bureau. She is a Texas Department of Human Services
Consultant-Monitor and currently sits on the Texas Outcome Based
Quality Management coalition team. Since receiving her Certified Legal
Nurse Consultant certification in 1999 and maintained it through 2005,
she is a consulting nurse expert and testifying nurse expert witness in
both plaintiff and defense cases. In addition, Kimberley was inducted
into the Business Who’s Who in March of 2004 for her
accomplishments as a small business owner.
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Michael Bradshaw, RN
Assistant Senior Consultant
•Michael earned an Associate degree in Nursing in 1977 from
Angelina College in Lufkin, Texas.
•His nursing career began in a hospital setting including:
Medical/Surgical Staff Nurse, Shift Supervisor, Assistant Charge
Nurse, Intensive Care Staff Nurse, Intensive Care Manager; Home
Health and Nursing Home which included Administrator,
Supervising Nurse, QA Nurse, Assistant Director of Clinical Services,
Home Health Aide Supervisor, and Field Nurse.
•Michael worked as a HCSSA Nurse Surveyor for the Department of
Aging & Disability Services in Houston, Texas for 5 years before
joining the Compliance Review Services, Inc. team in 2005.
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Janice M. Johnson-Umezulike, RN, BSN,
MN, CNS, DNS – Education Coordinator
Janice received her Bachelor of Science in Nursing from
McNeese State University in Lake Charles, Louisiana, in 1984.
She received both her Masters in Nursing and Doctor of Nursing
Science from Louisiana State University Medical Center in New
Orleans, Louisiana in 1989 and 1997, respectively. Since 1990,
she has been a member of Sigma Theta Tau, International Honor
Society of Nursing. Janice is currently a professor and
continuing education instructor at Lee College in Baytown,
Texas, as well as an educational consultant for a home health
and medical staff employment agency.
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Marie Luque, Office/General Manager
• Marie worked for many years in human resources for the
State of New York before marrying into the oil business and
traveling the globe. She lived overseas for 15 years in Asia
and South America, with two daughters, Joline and Jessica,
born in Bolivia and Chile, respectively. After she returned to
the U.S., Marie worked in real estate marketing for several
years from her home office. She joined the Compliance
Review Services, Inc. team in April 2004.
• As a frustrated English major, Marie has been writing for
some time and has had a short story published. Her goal is
to have one of her two novels in shape to submit for
publication within her lifetime. Marie is also devoted to
soccer and plays in two competitive leagues. Her other
hobbies include golf, squash, tennis, and volleyball.
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Jayne Jessop
Referral Coordinator
• Jayne Jessop joined the Compliance Review
Services, Inc. Administrative Team in July 2006.
Ms. Jessop has over 15 years of sales and
diversified administrative experience, and has
wasted no time becoming an integral part of the
Compliance Review Services, Inc. family. Ms.
Jessop comes to us via England, and has put her
experience both here and abroad to work in
helping Compliance Review Services, Inc. acquire
new business as well as give our existing clients,
managers, and consultants the highest level of
service and support.
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Barbara Rodriguez
Assistant to Referral Coordinator
• Barbara joined the Compliance Review Services
team in October of 2006. She comes to us with an
impressive customer service background which
includes extensive experience with computers and
account maintenance. Barbara is also a veteran who
served our country in the military for 12 years.
Barbara assists the Referral Coordinator with new
business projects, maintains the company
databases, and heads up production of marketing
material.
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Jacob Gallegos IV
Administrative Assistant
• Jacob joined the Compliance Review team in August
2010. With a strong administrative and computer
background gained while serving in the United States
Marine Corps, Jacob is putting that experience to work
for us and our clients. He is currently attending college
courses at the University Of Houston (Main Campus) to
Major in English and Minor in Criminal Justice. His
long term goal is to get into and complete Law School.
In his free time he enjoys outdoor sports and reading
History books.
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Paula Frate, RN Consultant
•Paula began her nursing career in 1978 with an Associate Degree of Applied Science in
Nursing from a small college in northern Ohio. She relocated to Houston, Texas in 1981
and comes to Compliance Review Services with a broad background in both business
and healthcare.
Her clinical experience spans the continuum of healthcare including intensive care,
emergency room, rehabilitation, home health and hospice. In 2000 she became certified
as a holistic nurse to better address the needs of dying patients and their families.
Paula’s business experience began in 1984 as a consultant to insurance companies and
large corporations implementing case management and health promotion programs.
Over the past ten years she has worked with a large county hospital system to improve
charge capture and revenue management for medical research and as an Education and
Performance Improvement Coordinator with a large home health and hospice agency.
She is an experienced home health and hospice software trainer and is currently pursuing
certification as a business coach.
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Denise Garcia, RN Consultant
• Denise Garcia, RN earned her BS in Nursing from Mercy
College of Detroit, in Michigan and continued with an MS
in Health Services Administration from St. Joseph's
College in Standish, Maine. Denise has 20 years of
experience ranging from Director of Operations for a
multimillion dollar non-profit home health agency, to
Administrator of two home health care operations, and
including positions as Patient Care Administrator, Director
of Clinical Services and Director of Nursing in the area of
Hospice. We are proud to have Denise bring her expertise
to our nurse consultant staff as of August 1, 2007.
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Linda Henslee,
Educational Consultant/Trainer
Field Consultant, COS
• Linda Henslee comes to Compliance Review Services,
Inc. with many years of Home Health experience, as an
Administrator, Alternate Administrator, QA
Coordinator, and as a Nurse Consultant. Ms. Henslee
attended nursing school and received her degree in
Arkansas. In addition to her years of experience as a
staff nurse, Ms. Henslee joined our consultant team in
July 2006, and has proven uniquely qualified to give our
clients the best possible consulting services. Linda is
also a Certified Oasis Specialist.
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Joyce May, RN, BSN
Nurse Consultant
•Joyce began her nursing career in 1972 at the first NICU in the Dallas area. After helping to
open the unit and serving as Assistant Head Nurse, Joyce moved to Big Spring, Texas, in
1974 and was Charge Nurse PACU/Staff Nurse OR in a hospital. From 1976 to 1984, Joyce
wore multiple hats at an Andrews, Texas, hospital, and served as Charge Nurse/Assistant
Director OR/PACU, Staff Nurse OR/PACU, and Director of Material Management
Department. She developed the procedure manual for the department, was the quality
assurance representative for OR/PACU, and was active on the Safety and Infection Control
committee. After two other hospital staff nurse positions, Joyce became a Nursing Specialist
for the Texas Department of Health/Department of State Health Services. From 1990 to
2004, she conducted initial and recertification surveys, evaluated healthcare agencies for
compliance with Medicare Conditions of Participation and State License Rules, and provided
educational and consultative assistance to all provider types. In 2005, Joyce joined the
Compliance Review Services, Inc., team.
•Joyce obtained her Associate in Applied Science from El Central College in Dallas, Texas, in
1972 and her Bachelor of Science in Nursing from Texas Tech University in Lubbock, Texas,
in 1989. She received nine months of training in the Texas Department of Health Continuous
Quality Improvement process in 2001 and her CLEAR Certification for Complaint
Investigation in 2003.
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Why Choose Our Consulting Firm over
Our Competitors?
Our Top Ten List
10. Customer service is our primary focus.
9. We offer free phone and e-mail consultative support.
8. We have over 10+ years of proven success with our clients.
7. We have over 150 years of nursing experience within our
staff.
6. We have several former state surveyors and a DADS
enforcement monitor on our staff.
We .Care .Campaign
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Why Choose Our Consulting Firm over
Our Competitors? cont’d
5. We stay current with regulations and alert our clients to any
changes. We are active with TAHC and BNE, are involved with
DADS workgroups, and network with state regulators.
4. We offer comprehensive start-up packages, manuals, forms, and
other printed materials that are done professionally, accurately,
and completed timely. We have done TJC successfully for years.
3. We offer educational and training sessions with contact hours
and are a TNA-approved educational provider unit.
2. We provide a free newsletter to our clients several times a year.
We .Care .Campaign
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Why Choose Our Consulting Firm over
Our Competitors? cont’d
And the number one reason is…
We Care about Our Clients and
Are Dedicated to Their Success.
Your Success Is Our Success!
We .Care .Campaign
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Take a Step in the Right Direction
We’ve been helping home health and long-term care
agencies help themselves to stay in compliance since
1997. We’re looking forward to working with you.
—Kimberley Kelly, RN, BSN, LNC, and staff
Compliance Review Services, Inc.
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