Meet Our Team
Meet our healthcare accreditation & regulatory compliance team – experts in the healthcare industry and collectively sharing hundreds of years of healthcare knowledge, wisdom & guidance.
Sandeep Goel
(Dual BS, MBA)
President & CEO
Sandeep Goel (President & CEO)
Sandeep Goel, President and CEO of Courtemanche & Associates, a division of SAYAS Alliance, Inc. has 30 years of global business leadership and quality management experience across multiple industries. Throughout his professional career, he has always fostered a data and information driven culture when making critical business decisions. This improved the accuracy and likelihood of a desired outcome in any legal, technical, or commercial situation. Also, over his career, Sandeep has led quality improvement programs focused on policies, standards, and processes. He has worked closely with many organizations to launch new products and services ensuring regulatory compliance. He has formed partnerships to increase industry awareness by sharing best practices through speaking events, webinars, and newsletter publications, and has been an active board member for a nationally recognized association that develops accreditation and certification guidelines.
Sandeep has dual undergraduate degrees in Biology and Engineering along with a minor degree in Psychology. In addition, he has an MBA from Carnegie Mellon University with concentrations in Strategy, Finance, Marketing, and Organizational Behavior.
Ronda Katzman
(BA)
Head of Operations
Ronda Katzman, BA (Head of Operations)
Ronda Katzman, Head of Operations at Courtemanche & Associates, is responsible for oversight and management for Finance, Budget Control, Asset Acquisition, Human Resources Management, Benefit Management, Employee Performance, and related organizational areas.
Ronda has extensive experience in business performance and operations management, implementing structures and systems to refine and maximize organizations for overall performance efficiency. She has served key roles in business and operations management in a variety of settings including property management, non-profit, independent education and small business consulting. Ronda received a Bachelor of Arts from the University of North Carolina at Charlotte and her Masters Studies in Business Management with University of Phoenix.
Ronda is based in Charlotte, NC.
Denise Smith
(RN, BS, MS, CLNC, HACP-CMS)
Head of Consulting - Senior Consultant
Denise Smith, RN, BS, MS, CLNC, HACP-CMS (Head of Consulting - Senior Consultant)
Denise Smith is Head of Consulting Services and a Senior Consultant at Courtemanche & Associates. Working in collaboration with the C&A Leaders, Denise manages Courtemanche & Associate’s business development initiatives and provides consulting services and support. With her extensive healthcare experience, Denise serves as a knowledgeable resource to new and existing clients, helping to guide them through their accreditation and regulatory needs.
Denise has more than 40 years of experience and expertise in Infection Prevention, Sterile Processing, Legal Nurse Consulting, Quality and Resource Management, Clinical Education, in acute inpatient and outpatient care settings. Clinically, Denise is a licensed Registered Nurse with an extensive background in Infection Prevention and Control for perioperative settings, sterile processing, and quality management. Additionally, she is a Certified Legal Nurse and has aided organizations for EMTALA, Medical-Surgical, and Health Care Administration areas of concern.
An avid healthcare quality educator, she has served as adjunct faculty at Saint Elizabeth College in Morristown, NJ, where she focused on issues in healthcare management, technology, the environment, and strategic planning. In her Quality Improvement roles, she has assisted organizations with regulatory readiness, plans of correction, infection control, policy development, competency development, and medical staff credentialing. Her insights and understanding of the regulations were instrumental in the development of tools and resources that enabled successful organizational adherence to regulatory standards. Other experience includes managing patient care settings and departments, such as Surgery, Endoscopy, Hemodialysis, Cardiac Cath Labs, Orthopedics, Med-Surg, and Sterile Processing, among others. She has also served on the Executive team as the Vice President of Patient Services.
Denise is a graduate of Christ Hospital School of Nursing in Jersey City, NJ, and the Jersey City State College in Jersey City, NJ where she earned a Bachelor of Science in Health Education and a Master of Science in Health Administration. She is a certified CMS Healthcare Accreditation Professional through CIHQ, is trained as a DNV Internal Auditor for Healthcare, and is a certified Legal Nurse Consultant. She is a member of the American Association of Legal Nurse Consultants, the National Alliance of Certified Legal Nurse Consultants, and The Association for Professionals in Infection Control and Epidemiology (APIC).
Christopher Pratt
(MS, BSN, HACP-CMS)
Sr. Consultant & Accredited Provider Program Dir.
Chris Pratt, MS, BSN, HACP-CMS (Senior Consultant & Accredited Provider Program Director)
Chris Pratt is a Senior Consultant with Courtemanche and Associates with more than 33 years in clinical and leadership experience working in varying healthcare positions from the bedside to the Boardroom. In this role, he is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. He is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, DNV, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. He assists organizations with post-survey activities, education, patient safety strategies, and quality improvement initiatives and has experience in various health care settings including acute care, behavioral health, and ambulatory care settings.
He retired from the military in 2016 with over 29 years of distinguished service as a U.S. Navy Nurse Corps Officer. Clinically, he is a licensed Registered Nurse with extensive experience in critical care, medical-surgical services, ambulatory care, staff development, nursing administration and quality.
Mr. Pratt’s vast Navy experiences included oversight of healthcare operations for both inpatient and ambulatory care settings, shipboard/overseas/operational nursing services, and facility/corporate staff development programs. He served as the Director for Navy Medicine Nursing Education and Education/Training Management Community providing guidance to over 60 specialty group members. He spearheaded the proposal and acquisition of an enterprise-wide Learning Management System Portal to centralize and standardize the assignment, delivery, documentation, and reliable reporting for over 63,000 employees.
Mr. Pratt graduated with a Bachelor of Science in Nursing degree from the University of South Carolina. Additionally, he earned a Master of Science in Educational Leadership from the University of Memphis in Tennessee where he was inducted into the Phi Kappa Phi Honor Society for academic achievement. He holds numerous awards and recognitions of military service. Mr. Pratt is trained in the use of Lean tools, project management and is a TeamSTEPPS instructor. He holds a certification through the CMS Healthcare Accreditation Certification Program (HACP).
Teri Reinhartsen
(RN, MS, CPHRM)
Associate Consultant
Teri Reinhartsen, RN, MS, CPHRM (Associate Consultant)
Teri Reinhartsen is an Associate Consultant with Courtemanche and Associates with 30 years of clinical and leadership experience working in varying healthcare positions from the bedside to the Boardroom. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance, and is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, DNV, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. She assists organizations with post-survey activities, education, patient safety strategies, and quality improvement initiatives and has experience in various health care settings including acute care, behavioral health, and ambulatory care settings.
Throughout her career, Teri has held a variety of Patient Safety, Risk Management and Regulatory Compliance leadership positions for several large healthcare systems. These experiences provided her with a wealth of knowledge in these areas as well as Root Cause Analysis and High Reliability Concepts. Teri has been the lead on mock surveys where she has worked and conducted educational programs related to her areas of expertise. She has also participated in and assisted in DOH/CMS investigations. Clinically, Teri has expertise in the Peri Operative area.
Ms. Reinhartsen received her Associate of Applied Science degree in Nursing from Duchess Community College, Fairview, NY. She received her Bachelor of Science degree in Legal Studies graduating Suma Cum Laude, and her Legal Nurse Consultant and Paralegal Certificates both with distinction from Mercy College, Dobbs Ferry, NY. She continued to receive her Master of Science degree in Health Care Management graduating with honors from College of St. Elizabeth, Florham Park, NJ. Teri has received Registered Professional Nurse Licenses for both the states of New York and New Jersey and has earned Certification from Certified Professional in Healthcare Risk Management (CPHRM), as well as her Organizational High Reliability Educator and Just Culture Certificates.
Pamela Davis
(RN, MSN)
Clinical Consultant
Pamela Davis, RN, MSN, (Consultant)
Pamela Davis is a Consultant with Courtemanche and Associates whose role is to assess healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. With over 30 years as a nursing professional in a variety of healthcare environments she has extensive experience as both a leader and educator. In her role as Hospital Administrator for a Texas Emergency Hospital Pamela oversaw all aspects of the facility including DNV Accreditation preparation, ongoing readiness, and compliance, and actively participating in several DNV surveys. In this role she also served as Safety Officer, managing Quality Assurance, Environment of Care, and Infection Control. During her career Ms. Davis also served as Director of Nursing for one of the first hybrid OBL Cath Lab and ASC centers in Texas leading her team to complete the first two cryoablations in an ASC in the state of Texas while consistently ensuring compliance with all regulatory standards and requirements and overseeing two TJC and COLA surveys.
In addition to her strong quality and leadership skills, Pamela has provided education and staff training throughout her healthcare career serving as a clinical instructor at Galen College of Nursing, later providing training to onboard staff and administrators in her role as Hospital Administrator, and more recently as a train the trainer style Education and Clinical Performance Specialist. She is credited with development of multiple presentations and educational videos on disease processes, coding and government regulations and use of EMR software for Tsystems.
Pamela received her BSN in Nursing as well as her Texas Teacher Certification from Midwestern State University, Wichita Falls, TX. She later received her MSN Nursing Education and Leadership Degree from Angelo State University, San Angelo, TX. Other licenses and certifications include Registered Nurse, Texas Compact.
Secondary Teacher Certification, Texas: Health/Science/Biology and AHA Certified Instructor for ACLS, PALS, and BLS.
Lena Browning Calloway
(MHS, BSN, RNC-NIC, CSHA)
Clinical Consultant
Lena Browning Calloway, MHA, BSN, RNC-NIC, CSHA (Consultant)
Lena Browning Calloway is a Consultant with Courtemanche and Associates with more than twenty years of experience as a nurse leader and accreditation specialist in acute care settings. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. She is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, Centers for Medicare and Medicaid Services (CMS) and other accrediting agencies. She assists organizations with survey readiness and post-survey activities, education, patient safety strategies, and quality improvement initiatives in various health care settings including acute care, behavioral health, and ambulatory care.
Throughout her career, Lena has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence in patient care across healthcare settings. She has also functioned as Interim Director of Accreditation and Vice President of Quality and Patient Safety with several organizations. She was responsible for restructuring Accreditation and Quality departments by successfully leading organizations to achieve better patient outcomes, continuous compliance, and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy situations with all organizations getting the Immediate Jeopardy citation lifted and no condition level findings noted on return surveys.
Lena earned her Master of Healthcare Administration from the University of Southern Indiana and her Bachelor of Science in Nursing from Murray State University. She is a Registered Nurse Certified in Neonatal Intensive Care, a Certified Specialist in Healthcare Accreditation, and holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post-resuscitation stabilization. Additionally, she is a member of the Association for Professionals in Infection Control and Epidemiology (APIC).
Kimberly Merrit
(MHA, BSN, CNOR, HACP)
Clinical Consultant
Kimberly Merritt, MHA, BSN, CNOR HACP (Clinical Consultant)
Kimberly Merritt is member of the clinical consulting team at Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. She assists organizations with post-survey activities education and follow-up, patient safety strategies, and quality improvement initiatives. Kimberly has more than 30 years of experience working in varying healthcare positions, most notably serving as a member of the Nurse Corps in the U.S. Air Force since 1994. Clinically, Kimberly is a licensed registered nurse with extensive experience ranging from home health to perioperative services, as well as leadership expertise in managing many aspects of healthcare operations. She is trained in the application, teaching, and facilitation of the requirements and recommendations of The Joint Commission, the Centers for Medicare and Medicaid Services and other regulatory and accrediting agencies.
Kimberly’s extensive Air Force experience has included administrative oversight of more than 80 personnel, managing a multi-million-dollar budget and leading OR activities. She was the lead Air Force representative for Department of Defense perioperative electronic health record development and system evaluation. Having been awarded a fellowship at the Accreditation Association for Ambulatory Healthcare (AAAHC), she reviewed standards, answered inquiries, participated in board meetings and accreditation activities, and updated electronic documentation systems.
Kimberly has a Bachelor of Science in Nursing from the University of North Carolina – Greensboro and a Master of Healthcare Administration from Seton Hall University in New Jersey. She is a certified nurse in the operating room and has healthcare accreditation and governance, risk, and compliance credentials. She has earned numerous awards and is a member of the Association of Perioperative Registered Nurses (AORN).
Tatum Parmer
(BSN, MBA, NEA-BC, FACHE)
Clinical Consultant
Tatum Parmer, BSN, MBA, NEA-BC, FACHE (Clinical Consultant)
Tatum Parmer is a clinical consultant team member with Courtemanche & Associates. In this role, she is responsible for assessing and supporting healthcare organizational readiness related to accreditation and regulatory compliance. With over 23 years of healthcare experience, she has extensive knowledge of the requirements of The Joint Commission and Centers for Medicare and Medicaid services, including knowledge of their survey process, auditing approach, and survey outcome determination. She assists organizations with survey preparation, educational needs, post-survey activities, patient safety strategies, and quality improvement initiatives.
Tatum currently is a hospital/critical access hospital Surveyor for the accrediting organization, Accreditation Commission for Health Care (ACHC). She has served in various roles at ACHC, including CMS Standards Interpretation Specialist. Her years of healthcare experience span from bedside nursing in Critical Care, Cardiac Services, and Surgical Services to Executive Leadership positions in Nursing.
Tatum earned her bachelor’s in nursing from West Virginia Wesleyan College and her Master's in Business Administration from the University of Findlay. She is a Fellow of the American College of Healthcare Executives.
Vivian Sullenberger
(BS)
Clinical Consultant
Vivian Sullenberger, BS (Clinical Consultant)
Vivian Sullenberger is a Consultant with Courtemanche and Associates. She is a seasoned Healthcare professional with 46 years of experience in a Laboratory setting. Over the course of her career, she has served in a variety of roles including Laboratory Manager, Medical Technologist as well as two decades as a Laboratory Field Representative for The Joint Commission (TJC). During her time with the Joint Commission, she served as a TJC team leader for a 250-hospital corporate laboratory system, trained TJC Laboratory cadre in the use of mobile Survey Technology and computer tablets and served as a preceptor for new TJC laboratory field representatives. Her strong leadership background has reinforced effective management and communication skills enabling her to evaluate procedures, identify problem areas in the laboratory, pro- vide education and suggest effective solutions.
Vivian received her Bachelor of Science degree from Auburn University, Auburn, AL and completed her post graduate studies at the University of Alabama, Tuscaloosa, AL. She also received her Medical Technologist Certification through the American Society of Clinical Pathologists (ASCP). She is cross trained in The Comprehensive Accreditation Manual of Hospitals and has completed RPI Yellow Belt Certification.
Jacqueline Smith
(RN, MS, CPHQ, HACP-CMS, LNC)
Clinical Consultant
Jacqueline Smith, RN, MS, CPHQ, HACP-CMS, LNC (Clinical Consultant)
Jacqueline Smith currently serves as Senior Consultant with Courtemanche and Associates. As a consultant and educator on Joint Commission (TJC) and other regulatory compliance matters, Ms. Smith assists clients with achieving and maintaining accreditation and CMS compliance. She provides technical assistance with standards and the survey process. Additionally, she conducts training, gap analysis, and mock surveys. She is experienced in developing and monitoring action plans to remedy regulatory and accreditation non-compliance.
Ms. Smith has more than 30 years of healthcare management experience and has been consulting since 2013. She most recently served as Chief Operations Officer for a two-hospital system providing inpatient, outpatient, and partial hospitalization services. Prior experience includes Director of Quality & Risk Management, with responsibility for regulatory compliance, health information management, utilization management, risk management, outcomes measurement, and performance improvement.
She has also held a variety of leadership positions in managed care including Operations Administrator, Director of Government Programs, and Director of Resource Management. Her experience also includes technology implementation assistance in the healthcare setting.
Jacqueline is a registered professional nurse receiving her degree from Sage College, Albany, NY and later a master’s degree in health systems administration from Rochester Institute of Technology. She has earned certifications in Health Care Quality (CPHQ), Healthcare Accreditation for Medicare and Medicaid Services (HACP-CMS), Behavioral Health (ACHC), Legal Nurse Consulting from Duke University and Human Resources Studies from Cornell University.
Nancy Kendrick
(MS, BSN, ADN)
Clinical Consultant
Nancy Kendrick, MS, BSN, ADN (Clinical Consultant)
Nancy Kendrick is a Clinical/Operational Home Health and Hospice Consultant with Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. Areas of expertise include Regulatory Compliance, Survey Readiness & Recovery, Risk Management, Operations Management, Program Development and Leadership/Motivation Coaching.
During Nancy’s extensive career in home care/hospice she has held a myriad of clinical, management, and executive-level positions. Additionally, she served as a home care and hospice Nurse Surveyor for The Joint Commission as well as Senior Manager/Clinical Accreditation Consultant providing services representing several healthcare consulting groups.
Nancy earned her Associate of Nursing Degree from the University of Tennessee, TN, and her Bachelor of Science Degree in Nursing and Master of Science Degree in Health Care Administration from the University of Santa Monica, CA. Training programs and certifications include The Joint Commission (TJC/JCAHO) Surveyor Certification Program, Community Health Accreditation Program (CHAP) Site Visitor Training, Accreditation Commission for Health Care (ACHC) Surveyor Training, Guest Reviewer for Marrelli and Associates, Inc. publications, Home Health/Hospice Administrator Certification, CAHSAH.
Mara Hehli
(MSN, RN, CPHQ)
Clinical Consultant
Mara Hehli, MSN, RN, CPHQ (Clinical Consultant)
Mara is a consultant with Courtemanche & Associates. Working with the C&A team, she is responsible for assessing healthcare organizational readiness for accreditation, and regulatory compliance. With over 30 years of healthcare experience, she has extensive knowledge of the requirements of The Joint Commission and Centers for Medicare and Medicaid services including knowledge of their survey process, auditing approach, and survey outcome determination. She assists organizations with survey preparation, educational needs, post-survey activities, patient safety strategies, and quality improvement initiatives.
A dedicated registered nurse, and leader in Quality, specializing in facilitation of process improvement projects to ensure high quality care to patients and families, she also serves as an expert in Patient Safety and conducting event cause, common cause, and failure mode effect analyses. Before pursuing her career in Quality work, Mara specialized in critical care, and cardiovascular critical care, House Supervision and Emergency Department Operations. Her journey into Quality included experiences in risk management, infection prevention, graduate medical education and medical staff peer review.
Mara received her bachelor’s degree in nursing from the University of Texas at Arlington where she then returned to earn her Masters degree in Nursing Administration. She holds certification as a CPHQ(Certified Professional Healthcare Quality) and a Green Belt in Lean Six Sigma.
Shanda Beilman
(MSN, RN, HACP-CMS, HACP-IC)
Clinical Consultant
Shanda Beilman, MSN, RN, HACP-CMS, HACP-IC (Clinical Consultant)
Shanda is a consultant with Courtemanche & Associates. In this role, she is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance. With over 23 years of healthcare experience, she has extensive knowledge of the requirements of The Joint Commission and Centers for Medicare and Medicaid services including knowledge of their survey process, auditing approach, and survey outcome determination. She assists organizations with survey preparation, educational needs, post-survey activities, patient safety strategies, and quality improvement initiatives.
During Shanda’s extensive career in healthcare, she has held a myriad of clinical, management, and executive-level positions such as Division Director Regulatory Readiness for Common Spirit Health, Texas Division and held several positions at St. Luke’s Sugar Land Hospital, which included, Director of Quality Assurance, House Supervisor and Emergency Room Charge Nurse. During her tenure she was instrumental in Sepsis Bundle Improvements from below 10% to over 90%.
Shanda earned her Nursing Degree from Kansas University School of Nursing, Kansas City, KS and her Master of Science Degree in Nursing from Walden University, Minneapolis, MN. She is a member of the National Association for Healthcare Quality (NAHQ) and is certified in CMS Conditions of Participation and Infection Control through CIHQ’s Healthcare Accreditation Certification Program.
Maryellen Marek
(MLT (ASCP), BA, MS, BSN, RN, CIC)
Clinical Consultant
Maryellen Marek, MLT (ASCP), BA, MS, BSN, RN, CIC (Clinical Consultant)
Maryellen Marek is a member of the clinical consulting team at Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. She assists organizations with post-survey activities education and follow-up, patient safety strategies, and quality improvement initiatives.
Ms. Marek has more than 39 years of experience working in various healthcare positions, most notably as a certified Infection Preventionist and registered nurse within several large hospital systems. Through her positions she has gained extensive experience and leadership skills in managing many aspects of healthcare operations. She is an experienced educator and is passionate about sharing her knowledge with others. She is trained in the application, teaching, and facilitation of the requirements and recommendations of The Joint Commission, the Centers for Medicare and Medicaid Services and other regulatory and accrediting agencies.
Maryellen has a Bachelor of Science in Nursing from Seton Hall University, South Orange, NJ where she graduated from the accelerated program as a member of Sigma Theta Tau Honor Society. She went on to earn her Master of Science degree in Health Care Management from the College of St. Elizabeth, Convent Station, NJ, and is currently pursuing her Doctor of Nursing Practice at the University of Medicine and Dentistry’s Hospital Administration/Nursing Leadership Program, in Newark, NJ. Maryellen is Board certified in Infection Prevention and Epidemiology and has memberships with the National APIC Association of Professionals in Infection Control, and the National SHEA Society of Healthcare and Epidemiology of America.
Kristine Smith
(RN, MSN, CPPS)
Clinical Consultant
Kristine Smith, RN, MSN, CPPS (Clinical Consultant)
Kristine Smith is a Consultant with Courtemanche and Associates whose role is to assess healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. With over 30 years of healthcare experience, working in various settings, including multi-hospital system leadership, clinical and ambulatory care, patient safety, quality, and regulatory/accreditation, she has gained extensive knowledge of regulatory standards and requirements for The Joint Commission (TJC), CMS, and DNV.
Throughout her career, Kristine has held leadership positions in Accreditation, Regulatory Compliance, Patient Safety, and Quality within several large health systems. In these roles she effectively developed and lead survey readiness activities, planning, developing, and corrective action plan implementation across departments, including Operations Excellence, Clinical Services, Quality, Risk, Infection Control, Surgical Services, Facilities, Pharmacy, Behavioral, for CMS, State, DNV, TJC, and certification surveys. She collaborated with market leaders, including hospital Presidents, Clinical, Quality, Risk, and Facility leaders, during and after on-site survey readiness visits, recommending process improvements as identified, and facilitating collaboration with corporate resources/departments. She reviewed and provided guidance for hospitals' internal audit programs, including annual EMTALA assessment, infection control and other high-risk processes.
In addition to her strong quality and leadership skills, Kristine has achieved Licensure as a Registered Nurse in the state of Florida, is a licensed Healthcare Risk Manager and has certification in Certified Professional in Patient Safety (CPPS).
Kristine received her diploma as a Registered Professional Nurse, Summa Cum Laude, from Albany Memorial School of Nursing, Albany, NY. She later earned her Master of Science in Nursing, Magna Cum Laude from Notre Dame of Maryland University, Baltimore Maryland, and Certification in the Healthcare Corporate Compliance Master’s Program from The George Washington University, Washington, D.C.
Deborah Dominick
(RN, BSN, MA, LLP)
Clinical Consultant
Deborah Dominick, RN, BSN, MA, LLP (Clinical Consultant)
Deborah Dominick is a Consultant with Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. She is trained in the survey process, auditing approach and survey outcome determination and has assisted organizations in obtaining accreditations and licensing including The Joint Commission, DNV, Centers for Medicare and Medicaid Services (CMS), AOA, COA, NCQA, CARF and other regulatory agencies. Deborah assists organizations with post-survey activities, education, patient safety strategies, and quality improvement initiatives. and has experience in various health care settings including acute care, behavioral health, and ambulatory care settings.
With more than 30 years working in various healthcare roles Deborah has gained a wealth of experience in both Clinical and Behavioral Health environments. As Director of Quality Management and Compliance she was responsible for the direction and supervision of Quality Management, Compliance and Accreditation for a managed behavioral health organization, developing policies and procedures to ensure accreditation requirements were met. As Vice President, Clinical Services for a large behavioral health system she provided clinical expertise to contracted units throughout the United States assuring that Joint Commission, CMS, and state requirements were met. Deborah is also a Legal Nurse Consultant, reviewing and analyzing cases and medical records for the state of Michigan and independent attorneys related to behavioral health programs.
Deborah graduated with a Bachelor of Science degree in Nursing from Eastern Michigan University, Ypsilanti, MI. Additionally, she earned her Master of Arts degree in Clinical Psychology from the Center for Humanistic Studies, Detroit, MI. Deborah has a Compact Registered Nurses License and holds memberships with APNA and ACHE.
Deirdre Murphy
(MBA, BBA, ADN, CPPS, LSSBB, NPSB)
Clinical Consultant
Deirdre Murphy, MBA, BBA, ADN, CPPS, LSSBB, NPSB (Clinical Consultant)
Deirdre Murphy is a Consultant with Courtemanche and Associates whose role is to assess healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. She has over 35 years of healthcare experience beginning her career bedside as a registered nurse, transitioning into leadership positions managing Healthcare Accreditation and Regulatory Compliance across the continuum. She has extensive knowledge of regulatory standards and requirements for The Joint Commission (TJC), CMS, and DNV.
In her role as System Director Safety, Accreditation and Infection Prevention Deirdre oversaw a team of professionals in a multi-hospital system, and was accountable for Patient Safety, Occupational
and Environmental Safety, Accreditation, and Infection Prevention. In addition, she served as the system’s executive leader of their HRO journey. In her previous role as Director of Accreditation Deirdre led Joint Commission (TJC) accreditation and Center for Medicare/Medicaid Services (CMS) regulatory activities
across the multi-hospital system. In this position she also oversaw the health system’s policy/procedure processes and successfully directed numerous system-wide surveys, investigations, and inspections. She was instrumental in assisting the organization with achieving their initial Disease Specific Certification
In addition to her strong quality and leadership skills, Deirdre has achieved certifications in Certified Professional in Patient Safety (CPPS), Healthcare Performance Improvement and Lean Six Sigma Black Belt (LSSBB), Breakthrough Performance Group. She is also a member of National Patient Safety Board (NPSB), American College of Healthcare Executives (ACHE), Greater Ohio Board Member and American College of Healthcare Executives (ACHE), Cincinnati LPC Chair Elect.
Deirdre received her Associate Degree in Nursing from Northern Kentucky University, Highland Heights, KY, and her Bachelor of Business Administration from Thomas More University, Englewood, KY. She later went on to earn her Master of Business Administration from Thomas More University as well.
Valentino Tesoro, MD
(BS, MBA)
Physician Consultant
Valentino Tesoro, MD, BS, MBS (Physician Consultant)
Dr. Valentino Tesoro is a Consultant with Courtemanche and Associates with over 40 years of experience in the healthcare Industry. In his role as consultant, he is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. Dr. Tesoro has extensive experience in hospital quality, patient safety and accreditation. For over 15 years he worked as a Physician Surveyor with both The Joint Commission and the California Institute of Medical Quality. In addition, he served as Team Leader for several large hospital system surveys. Other duties at The Joint Commission included serving as a preceptor for newly hired surveyors.
Prior to joining The Joint Commission, positions held by Dr. Tesoro, include Chief Quality Officer at Palomar Pomerado Health System in Escondido, California; Vice President of Medical Affairs at Bay Medical Center in Panama City, Florida; Vice President of Medical Affairs at Riverside Community Hospital in Riverside, California; Chief of Staff at Riverside Community Hospital. He also served as Major for the U.S. Army Medical Corps.
Dr. Tesoro obtained his bachelor’s degree in Chemistry from the University of Hawaii and his Doctor of Medicine degree from the University of Pennsylvania School of Medicine. He later went on to earn his MBA at the University of Tennessee School of Business.
Joseph Esch
(MBS, CHFM)
EC/LS Consultant
Joseph Esch, MBA, CHFM (EC/LS Consultant)
Joseph Esch is a Life safety surveyor and consultant. He is trained under the HFAP Acute Care and Critical Access Hospital requirements, as well as The Joint Commission accreditation requirements for the physical environment, fire safety, Life Safety Code®, and Emergency Management chapters.
Mr. Esch continually keeps up to date with the latest requirements and interpretations related to the Life Safety Code®, Environment of Care and Emergency Management issues by attending national educational conferences provided by The Joint Commission, the National Fire Protection Agency and the American Society for Healthcare Engineers. He received his Bachelor of Science from Missouri State University in 2002 and a Master of Business Administration from Drury University located in Springfield Missouri in 2012.
He currently holds a Certified Healthcare Facility Manager certification issued by the American Hospital association in 2015.
Joseph has 14 years in healthcare, his primary focus is the operations, plant and the physical environment. He has assisted in the planning and initial startup of facility programs in several acute care facilities, including the implementation of CMMS, compliance program, capital forecasting, and facility condition indexing and has been chairman of the EOC committee.
He is a member of the American Society of Healthcare Engineers and the local chapter of Chesapeake Area for Healthcare Engineers.
Michael Jones
(CHSP, CHCM, CSSGB)
EC/LS Consultant
Michael Jones, CHSP, CHCM, CSSGB (EC/LS Consultant)
Michael Jones is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives. Mike has more than 15 years of experience and expertise in Environment of Care, Life Safety and Emergency Management and is well-versed in CMS, Joint Commission, DNV, NFPA, OSHA, EPA, and DOT codes and standards.
Mike has served in multiple leadership roles throughout his career. Working in a variety of Hospitals and associated offsite Emergency Departments, Ambulatory Surgical Centers and Clinics, he conducted internal accreditation audits for Life Safety, Environment of Care and Emergency Management, provided direction & assistance to all levels of leadership in the development & application of life safety, employee safety, environmental protection and emergency management programs, and developed and implemented standardized Life Safety policies, procedures and permit forms for multiple Acute Care Hospitals.
Mike holds certifications in Certified Healthcare Safety Professional (CHSP), Certified Hazard Control, Manager (CHCM), Certified Six Sigma Green Belt (CSSGB), NFPA Life Safety Code, HVAC Fire and Life Safety Inspections Certification, Certified OSHA 30, Incident Safety Officer Certification, Incident Command System for High Rise Operations (NFA) Certification, FEMA MGT-457, NIMS 100, 200, 700, 800, SFFMA Firefighter 1, Emergency Medical Technician (2002-2014), Department of Transportation Training for Regulated Medical Waste and Hazardous Waste, Hazardous Materials (CFR 40).
Taylor Vaughn
(MBA, CHFM, CHC, CLSS-HC)
EC/LS Consultant
Taylor Vaughn, MBA, CHFM, CHC, CLSS-HC (EC/LS Consultant)
Taylor Vaughn is an EC-LS Consultant working with Courtemanche & Associates. In this role she is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. She assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives.
As a Facility Manager with Children’s Health in Dallas, TX, Taylor oversaw the system wide Environment of Care and Life Safety regulatory compliance. She has extensive knowledge of the requirements of The Joint Commission and Centers for Medicare and Medicaid services, including knowledge of their survey process, auditing approach, and survey outcome determination. She is also a Content Writer at Legacy FM, creating custom facilities-related training material for healthcare systems.
Taylor is the Region 5 Director for the Texas Association of Healthcare Facility Management (TAHFM), representing all of Dallas/Fort Worth. In 2020, she received the TAHFM Future Leader award, given to one member in the state that shows promising leadership potential within the healthcare engineering field. She is a member of the Member Tools Task Force with the American Society of Health Care Engineering (ASHE), and she is a frequent contributor to Health Facilities Management magazine. She has written four full articles over the past 3 years, covering ventilation management, recruiting, and retaining technical staff, and facility asset management. Taylor is the vice-chair of the Operational Optimization Task Force with ASHE and is currently collaborating with a team to develop an operational guideline for ASHRAE 170.
Taylor earned her Bachelor of Science Degree from Texas Tech University, Lubbock, TX and her Master of Business Administration at Amberton University, Garland TX.
Micheal, Miller
(BS, CSP, CHSP, CLSS-HC, CHSFP, LSSYB)
EC/LS Consultant
Micheal Miller, BS, CSP, CHSP, CLSS-HC, CHSFP, LSSYB (EC/LS Consultant)
Micheal Miller is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives.
For over 14 years, Micheal has held key leadership roles in healthcare safety, including serving as Executive Director overseeing Environment of Care, Life Safety, and Emergency Management at a large Level 1 county hospital. He has a proven record in regulatory compliance, safety program development, and strategic planning for healthcare facilities. During his career he launched and grew a successful consulting business focused on healthcare safety, compliance, and physical environment management. He provided expert guidance to hospitals and healthcare facilities, ensuring adherence to CMS, TJC, DNV, OSHA, EPA, and DOT regulations, and developing and implementing safety programs tailored to the specific needs of each client, improving overall safety and compliance.
Micheal earned an Associate of Science Degree in Occupational Safety and Environmental Technology from Tarrant County College, Fort Worth, TX. He earned a Bachelor of Science Degree in Occupational Health & Safety from Southeastern Oklahoma State University, Durant, OK. He is currently a member of NFPA, ASHA, TAHFM, and ASSP professional organizations.
Jason Minchew
(BS, MBA, HACP-PE, CMRT, CSSBB)
EC/LS Consultant
Jason Minchew, Bs, MBA, HACP-PE, CMRT, CSSBB (EC/LS Consultant)
David (Tony) Castrilla
(CHFM, CHOP)
EC/LS Consultant
David (Tony) Castrilla, CHFM, CHOP (EC/LS Consultant)
Tony Castrilla is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives.
Tony has over 20 years of experience in facility operations and accreditation and regulatory compliance readiness. He has provided expert guidance to hospitals and healthcare facilities, ensuring adherence to CMS, TJC, DNV, OSHA, EPA, and DOT regulations, and has developed and implemented safety programs tailored to the specific needs of each client, improving overall safety and compliance. He has successfully led multiple complex acute care hospitals and micro-hospitals through successful accreditation surveys and audits.
Tony’s leadership roles, including System Director of Quality and Compliance and Director of Engineering Support, both for national healthcare systems have equipped him with deep operational insight. In addition to his leadership experience, Tony has spent years consulting with hospitals nationwide, advising on survey preparation, regulatory compliance, and operational improvements.
Tony has earned his CHFM certification through Certified Healthcare Facility Manager and his CHOP certification through Certified Healthcare Operations Professional and is a member of the American Society of Healthcare Engineering (ASHE).
Keith Buckman
(CHFM, CHEM, CPE, CPMM)
EC/LS Consultant
Keith Buckman, CHFM, CHEM CPE, CPMM (EC/LS Consultant)
Keith Buckman is a Physical Environment/Life safety consultant specializing in Plant Operations & Maintenance, Construction & multi-service lines. He performs Regulatory Mock Surveys based on multiple Accrediting Organizations and Regulatory Agencies.
With over 40 years of facilities maintenance and construction experience, Keith began his career with the U.S. Navy Seabees holding several senior level positions. After 24 years of service, he continued his Facility Management career in the Healthcare industry overseeing several large facilities in senior level positions including serving as the Facilities Director for a Texas regional hospital district, transitioning a few years later to Vanguard’s Corporate Management Team as Plant Operations/Regulatory Compliance Specialist. In this role he has conducted extensive regulatory compliance (mock surveys), building tours, Physical Environment Tracers, and assisted with the development and implementation of action plans, correcting any noted deficiencies.
Keith is a Certified Healthcare Facility Manager, Certified Healthcare Environmental Manager, Certified Plant Engineer, Certified Plant Maintenance Manager. Mr. Buckman also has certifications in Construction Management and Construction/Quality Control.
Bart Copes
(CHSP, CHEM, HcEM-P)
EC/LS Consultant
Bart Copes, CHSP, CHEM, HcEM-P (EC/LS Consultant)
Bart Copes is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives.
Bart has over 27 years of healthcare experience as Senior Vice President of Regulatory Compliance & Support Services for thirty-nine acute care hospitals with multiple accrediting organizations. He also served as Director of Facilities/Safety Officer at multiple acute care hospitals overseeing the facility’s engineering, environmental services, laundry, dietary, security, construction, bio-medical engineering and environmental safety and emergency management departments. He also served with the 1st Calvary Division during Desert Storm as a Combat Engineer.
Bart is a Certified Healthcare Safety Professional, Certified Healthcare Environmental Manager, and a Certified Healthcare Emergency Management Professional. Bart currently holds the Manager/Security License for Texas State Board of Private Security. He is also active in the Veterans of Foreign Wars (VFW) and the First Cavalry Division Association.
Joseph A. Glaski
(MBA, FASHE, CFDAI)
EC/LS Consultant
Joseph A. Glaski, MBA, FASHE, CFDAI (EC/LS Consultant)
Joe Glaski is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives. Joe has more than 25 years of experience and expertise in Environment of Care, Life Safety and Emergency Management. Joe holds certifications as a Certified Fire Door Inspector, Certified Life Safety Specialist and Certified Healthcare Physical Environment Worker along with recognition as a Fellow Healthcare Engineer (FASHE).
Joe has served in multiple leadership roles spanning from an 1,170-bed acute care hospital to Regional Director of ASHE Region 1 and served as a Technical Committee Member on NFPA’s 1082 Building Fire and Lafe Safety Directors. Joe loves to teach and educate as represented by the many publications he has authored along with volunteering with the DHI “National Fire Door” Educator. Joe serves as a Technical Committee Member on NFPA 80 Standard for Fire Doors and other Opening Protectives & NFPA 1082 Building Life Safety Director.
Steven Cotch
(BSME, CHFM, CLSSGB)
EC/LS Consultant
Steven Cotch, BSME, CHFM, CLSSGB (EC/LS Consultant)
Steven Cotch is an EC-LS Consultant working with Courtemanche & Associates. In this role he is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance specifically related to the Environment of Care, Life Safety and Emergency Management requirements. He assists organizations with survey preparation, educational needs, post survey activities, follow-up, patient safety strategies and quality improvement initiatives.
Steven is a degreed engineer and Certified Healthcare Facility Management (CHFM) professional with over 35 years of facilities and plant operations experience in healthcare organizations, colleges, universities, and commercial buildings. He has served in various roles throughout his professional career including project engineer, mechanical engineer, director of engineering and general manager. In his consulting role, he has assisted hospitals and other healthcare facilities with interpretation and compliance with the Life Safety Code, TJC, CMS and State Department of Health regulatory requirements and provided facilities and plant operations management and expertise.
Mr. Cotch earned his Bachelor of Science in Mechanical Engineering from Union College, Schenectady, New York his Certification in Healthcare Facility Management from the American Hospital Association, Chicago, IL, and is a Certified Lean Six Sigma Greenbelt from Purdue University. Other certifications and training include Life Safety Code 101 for Healthcare, National Fire Protection Association (NFPA), The Joint Commission Environment of Care Training, American Society for Health Engineering and Certified Tool & Model Maker, International Business Machines.
Steven has professional affiliations with American Society for Healthcare Engineering (ASHE), National Fire Protection Association (NFPA) and American Society of Heating Refrigeration & Air Conditioning Engineers (ASHRAE)
Amy Goyer
(BA)
Business Enhancement & Education Coord
Amy Goyer, BA (Business Enhancement & Education Coordinator)
Amy Goyer, Business Enhancement & Education Coordinator at Courtemanche & Associates, processes expenses, works with AR & AP functions and fields calls from clients and vendors. Amy received a Bachelor of Arts in Sociology and Business. She has a background in retail management and teaching pre-school. She has also spent a bulk of her time performing volunteer work.
Amy is based in Charlotte, NC.
