Kirsten Taylor Billups, JD., RN

**** ******* ****.,

Cleveland, Ohio 44121

216-***-****(Cell)/216-***-****(Home)

Objective: Utilize my extensive experience in quality assurance and

compliance to enhance a healthcare corporation's compliance program.

EDUCATION

Cleveland Marshall College of Law (1994) Juris Doctorate Degree-JD

Ursuline College (1990) Baccalaureate of Science Degree-RN

EXPERIENCE

HCR Manorcare-Toledo, Ohio (Corporate Office)

Clinical Services Consultant/Quality Assurance Consultant (August 2005-

present)

>Responsibilities: Manage the regulatory compliance of multiple acute

care/rehab facilities in preparation of annual surveys, survey revisits and

during complaint surveys. Assist the centers to improve their quality

outcomes of their quality measures, reduce rehospitalizations, and enhance

census. Develop performance improvement plans for areas of high risk for

resolution. Write plan of corrections, informal dispute resolutions and

participate in survey readiness. Provide education on point click care and

Abaqis. Manage acute high risk events/reportable to the Ohio Department of

Health and utilize the corporate quality assurance and performance

improvement plan to develop action plan for problem resolution. Conduct

corporate compliance assessments and response to hotline call on reported

incidence of corporate noncompliance.

>Accomplishments: Achieved several deficiency free surveys and stay below

the state average number of deficiencies, wrote several successful informal

dispute resolutions and achieve the lowest number of citation within the

region of 11 centers. Assisted several centers to become restraints free

Clinical Risk Manager (April 2003-August 2005)

>Responsibilities: Provide risk management services to 40 acute and rehab

facilities in Ohio and Illnois. Prioritize the high risk centers and

initiated the process of risk identification, risk assessment and risk

resolution to resolve incident and accidents that results in patient

injuries. Initiated the corporations quality assurance programs on a multi

level bases from facility to regional to corporate levels and provided

education on the investigation process for state reportable events. Conduct

environmental and clinical risk assessments identify regulatory or legal

areas of noncompliance.

>Accomplishments: Assisted in the abatement of an immediate jeopardy and

provided the initial education to 40 centers on the role out of the company

quality assurance program and the how to conduct effective investigations

on adverse accidents and incidents.

Care Services-Euclid, Ohio

Director of Nursing, (June 2002-April 2003)

>Responsibilities: Plan, organize, coordinate, evaluate and direct the

overall operation of our nursing service department, in accordance with all

federal, state, and local standards, guidelines and regulations. Ultimately

to ensure that the highest degree of quality care is delivered at all

times.

>Accomplishments: Write policies and procedures and conduct comprehensive

investigations for reporting to Ohio Department of Health.

Director of Quality Assurance, (September 1998-June 2002)

>Responsibilities: Conduct audits of clinical records for compliance,

organize the facility quality assurance programs to develop action plans

for resolution of high risk issues.

>Accomplishments: Achieve full compliance with clinical records.

Nursing Supervisor, (January 1995-September 1998)

>Responsibilities: Management the daily clinical services of the facility

during specific shifts, obtained clinical reports on changes of condition,

verify actual staffing numbers, conduct physical assessments and educate

the direct care staff on new orders for implementation. Writing reports to

promote care consistency.

>Accomplishments: Assist the direct care staff of RNs, LPNs and CNAs to

manage their staff duties when excessive staffing challenges took place.

Medicare Nursing Center-Euclid Ave., Ohio

Risk Manager (December 1993-December 1994)

Responsibilities: Provide 50-bed long-term care facility risk management

and patient safety intervention. Risk identification through clinical

record reviews and patient rounds, risk analysis of incidence and accidents

with trending and tracking of data collected. Develop risk interventions

and implementation through quality assurance and staff training.

Accomplishments: Assisted the center staff to provide quality patient care

and maintain full clinical compliance.

University Hospitals of Cleveland-Cleveland, Ohio

Clinical Nurse (June 1988- December 1993)

Responsibilities: Provides direct nursing care in accordance with

established policies, procedures and protocols of the healthcare

organization. Implements and monitors patient care plans. Monitors,

records and communicates patient condition as appropriate. Evaluate,

updates and revises plan of care to facilitate achievement of planned and

expected outcomes with experience in Med-Surgical and Post-partum care.

Accomplishments: Transition from a as needed nursing student to a full time

clinical staff nurse.

Associations and Recreational Activities

Member of Esprit Ski and Sports Club

Golf Director for Wedgewood Golf Association

Co-Founder of a Local Book Club

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