October 21, 2025 - 8:15 AM - October 22, 2025 2:15 PM

2025 Pennsylvania Continuous Service Readiness Fall Conference

Location: Online

Registration Deadline: October 23, 2025

Overview

The Pennsylvania Continuous Service Readiness Program (CSRP) is a joint effort between Joint Commission Resources (JCR) and The Hospital and Healthsystem Association of Pennsylvania (HAP) to structure and implement a program by which hospitals can receive education, consultation, and feedback on an ongoing basis from JCR and The Joint Commission (TJC) staff. This program will be presented virtually.

This meeting is limited to participants from CSR hospitals. Not a member? If you are interested in participating in the CSR Program, please contact Daneen Schroder.


*Save the date for the CSR Spring 2026 Conference (April 16-17 2026)*

Agenda

10/21/2025

8:15 AM

Welcome and Opening Comments

Penny Hoover, MSN, RN, CJCP, CPPS, Nurse Paralegal, Continuous Service Readiness (CSR), RPI® Certified Yellow Belt
Joint Commission Resources, inc. ®
 

8:30 AM

Hot Button” Topics in Behavioral Health

Suzanne D. Harrison, MPH, Consultant/Behavioral Health Specialist, Continuous Service Readiness (CSR), RPI® Certified Yellow Belt
Joint Commission Resources, Inc. ®
 

10:00 AM

Break
 

10:15 AM

Hot Button” Topics in Behavioral Health 

Suzanne D. Harrison, MPH, Consultant/Behavioral Health Specialist, Continuous Service Readiness (CSR), RPI® Certified Yellow Belt
Joint Commission Resources, Inc. ®
 

11:45 AM

Lunch
 

12:30 PM

Clinical Documentation – Hot Topics

Shannon Haltom, DNP, RN, Continuous Service Readiness (CSR) for the Texas Region
Joint Commission Resources, Inc. ®
 

1:45 PM

Wrap up and Closing Comments

Penny Hoover, MSN, RN, CJCP, CPPS, Nurse Paralegal, Continuous Service Readiness (CSR), RPI® Certified Yellow Belt
Joint Commission Resources, Inc. ®
 


10/22/2025

8:15 AM

Welcome & Opening Comments

Penny Hoover, MSN, RN, CJCP, CPPS, Nurse Paralegal, Continuous Service Readiness (CSR), RPI® Certified Yellow Belt
Joint Commission Resources, inc. ®
 

8:30 AM

Accreditation 360: The New Physical Environment Chapter, Emergency Management and Life Safety Survey Updates

Robert N. Neil, MBA-HA, CHFM, CHSP, Specialist Principal Consultant/Practice Leader, Global Consulting, Lean Six Sigma Certified Black Belt
Joint Commission Resources, Inc. ®
 

10:00 AM

Break
 

10:15 AM

Accreditation 360: The New Physical Environment Chapter, Emergency Management and Life Safety Survey Updates

Robert N. Neil, MBA-HA, CHFM, CHSP, Specialist Principal Consultant/Practice Leader, Global Consulting, Lean Six Sigma Certified Black Belt
Joint Commission Resources, Inc. ®
 

11:45 AM

Lunch
 

12:30 PM

High Reliability in the Physical Environment

Richard Boor, PE, PhD, Consultant
Joint Commission Resources, Inc. ®
                   and
Dawn Allbee, MA, CCMP, Executive Director- High Reliability Services
Joint Commission
 

2:00 PM

Wrap up and Closing Comments

Objectives

At the conclusion of this program, participants will be able to:

  1. Describe the structure, content, and intent of the new Physical Environment (PE) Chapter and explain key changes from the former Environment of Care (EOC) and Life Safety (LS) chapters
  2.  Discuss the clinically appropriate use and monitoring of chemical restraints
  3. Explain the use of high reliability to connect Planning, Design, and Construction into Operations—the PDCO
  4. Understand basic documentation requirements for pain assessment, restraints, and medication titration

Session-specific objectives:

"Hot Button” Topics in Behavioral Health

  1. Discuss the clinically appropriate use and monitoring of chemical restraint
  2. Describe best practices for behavioral health discharges of patients identified as at risk for suicide (NPG.08.01.01, EP 6)
  3. Understand the content and requirements for the CMS mandated Psychiatric Inpatient Experience (PIX) survey
  4. Describe recommended practices to reduce workplace violence and how they apply to a behavioral health population

Clinical Documentation – Hot Topics

  1. Understand basic documentation requirements for Pain Assessment, Restraints and Medication Titration
  2. Describe the basic requirements for an interdisciplinary plan of care
  3. Recall the elements of a complete medical record

Accreditation 360: The New Physical Environment Chapter, Emergency Management and Life Safety Survey Updates

  1. Describe the structure, content, and intent of the new Physical Environment (PE) Chapter and explain key changes from the former EC and LS chapters
  2. Utilize the PE documentation tool effectively to organize evidence, track compliance, and prepare for survey readiness
  3. Apply the updated workplace violence prevention requirements under the National Performance Goals (NPG) to improve policies, staff training, and annual worksite analyses
  4. Prepare inpatient and outpatient locations for the expanded Life Safety Code® surveyor role by identifying readiness gaps and implementing corrective actions
  5. Evaluate physical environment and life safety compliance by identifying deficiencies in “What’s Wrong with This Picture?” scenarios and recommending appropriate remediation
  6. Integrate updated Emergency Management guidance into organizational plans, including hazard vulnerability assessments and continuity of operations strategies

High Reliability in the Physical Environment

  1. Learn the basics of High Reliability
  2. Be able to apply High Reliability principles to the Physical Environment documentation
  3. Use High Reliability to connect Planning, Design, and Construction into Operations—the PDCO

Continuing Education

The Pennsylvania FALL 2025 CSR Conference on October 21 amd 22, 2025, will award 9.0 Continuing Education contact hours for the following: ANCC & ACHE 

Full attendance at every session and completion of a post-engagement survey are prerequisites for receiving continuing education credits.

In support of improving patient care, this activity has been planned and implemented by Joint Commission Resources.  Joint Commission Resources is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. 

By attending the Pennsylvania Fall 2025 CSR Conference offered by Joint Commission Resources, participants may earn up to 9.0 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

For additional information on continuing education credit, please visit our Continuing Education page at https://www.jointcommission.org/resources/continuing-education-credit-information/.

Registration Information

This conference is available to CSR members only. Although there is no charge, you must register to attend.

Questions? Contact HAP Education Services at 717-561-5270.

Have an idea for an Education Topic?

We'd love to hear from our members. Simply fill out our brief form to share your ideas with us.

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