| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed for the home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | December 17,2024- The self assessment was not completed in the correct amount of time which is 3 to 6 months prior to the expiration date of our compliance. We have put on all calendars (electronic and physical) to submit self inspection in the correct time. |
12/18/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's financial record was not accurate, as the balance on 6/1/24 was $221.76 and after the individual spent $10, the financial record was recorded as $201.76, when it should have been $211.76. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | We have tracked the individuals financial log and money bag to account for the missing 10$. Seems as though when the individual came back from church, they did not give staff the 10$ which then led staff to count for the money wrong. The money was placed back into the individual's money bag and the itemized financial log has been updated. |
12/19/2024
| Implemented |
| 6400.22(e)(3) | The following receipts were missing for Individual #1 for haircuts: $20 on 3/29/24, $20 on 5/23/24, $20 on 7/27/24, and $20 on 10/13/24. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | December 19,2024- Receipts for all purchases over $15 dollars will be accounted for. If the merchant cannot provide receipts Tranquil Hearts will keep a receipt book and make receipts for each needed purchase. We have then made receipts for the missing hair cut receipts. |
12/19/2024
| Implemented |
| 6400.141(c)(10) | The form from Individual #1's 11/11/24 physical appointment did not indicate if the individual is free of communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | December 19, 2024- A new physical form has been established that includes a section indicating if the individuals is free of communicable diseases. The program specialist / CEO will look over the physical form or documents and make sure that this information is filled out completely. We have had the doctor fill out a part for any communicable diseases. |
12/19/2024
| Implemented |
| 6400.141(c)(12) | The form from Individual #1's 11/11/24 physical appointment did not indicate if the individual had any physical limitations. | The physical examination shall include: Physical limitations of the individual. | December 19, 2024- A new physical form has been established that includes a section indicating if the individual has any physical limitations. The program specialist / CEO will look over the physical/ documents and make sure that this information is filled out completely. We have had the physician fill out the portion for physical limitations. |
12/19/2024
| Implemented |
| 6400.141(c)(14) | The form from Individual #1's 11/11/24 physical appointment did not indicate information pertinent to diagnosis in the case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | December 19, 2024- A new physical form has been established that includes a section indicating if there are any pertinent information associated with the diagnosis in case of an emergency. The program specialist / CEO will look over the physical/ documents and make sure that this information is filled out completely. We have had the physician fill out if there is pertinent information to diagnosis. |
12/19/2024
| Implemented |
| 6400.141(c)(15) | The form from Individual #1's 11/11/24 physical appointment did not indicate if there were special diet instructions for the individual. | The physical examination shall include:Special instructions for the individual's diet. | December 19, 2024- A new physical form has been established that includes a section indicating if the individual is on or has a special diet that needs to followed. The program specialist / CEO will look over the physical/ documents and make sure that this information is filled out completely. We have had the physician fill out if there is any information for special diet. |
12/19/2024
| Implemented |
| 6400.144 | For individual #1's 10/8/24 Primary Care appointment, it was ordered that the individual needs to have lab work completed. At the time of the inspection on 12/18/24, the lab work had not yet been scheduled.
For individual #1's 12/12/24 follow-up foot care appointment, it was ordered that the individual was to soak their right foot with Epsom salt for three days; this was only completed on 12/13/24. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| December 20, 2024- The individual who needed labs done has been completed. |
12/23/2024
| Implemented |
| 6400.145(1) | The medical plan for Individual #1 and #2 did not have the hospital or source of health care that will be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | December 19, 20204- For individual #1 and #2 and updated emergency medical plan has been set in place and has their preferred hospital, the nearest hospital and states if the preferred is not available is the nearest okay. |
12/19/2024
| Implemented |
| 6400.151(b) | MD/CNP/PA-C did not sign and date the 2/13/24 physical for Staff #1 and the 3/7/24 physical form for Staff #2. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | December 21, 2024- I have an updated physical form for both individual #1 and individual #2 with the doctors signatures. |
12/21/2024
| Implemented |
| 6400.151(c)(3) | The physical forms from Staff #1's physical on 2/13/24, Staff #2's physical on 3/7/24, and Staff #4's physical on 11/3/24 do not indicate if the staff are free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | December 21,2024- We have received updated staff physical forms from Satff #1, #2, #4 stating that they are all communicable disease free. They filled out the appropriate section in the staff physical forms. |
12/21/2024
| Implemented |
| 6400.181(a) | For individual #1, the new admission assessment was completed on 5/23/24, which was not completed within 60 days of the individual's 3/23/24 date of admission. While the provider completed an assessment, it did not address many of the areas required by 6400.181e1-14 and was largely incomplete. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | For Individual #1 the new admission assessment was completed but because the individual was admitted 3/23/24 and the assessment was completed 5/23/24 it was technically 61 days. We were prompted now to count the days because it could be different then the admit date. |
12/23/2024
| Implemented |
| 6400.166(a)(2) | For Individual #1, the prescriber was not labeled for the Tamsulosin HCL on the March MAR's and for the Vitamin D3 on the April MAR's. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | December 20, 2024- We have now updated the MAR for March to show the prescribing physician for the Tamsulosin HCL and Vitamin D3 on the April MAR for individual #1. |
12/20/2024
| Implemented |
| 6400.181(f) | Individual #1's assessment was not provided to the SC and team 30 days prior to the 11/20/24 ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | December 20, 2024- When we receive a letter in the email or by email letting us know that the individuals ISP meeting will be coming up, we will make sure to agree for a date at least 30 days within the meeting to send over the assessment. The SC did give us ample amount of time but we did not know we had to do the prior. We not understand that the assessment is used in guiding the ISP meeting. |
12/20/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not indicate the individual's eye color, identifying marks and religion affiliation. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, Social Security number, eye color, identifying marks, and religion affiliation. | December 20, 2024- Individual #1 records have been updated with eye color, hair color, identifying marks, and religion. |
12/20/2024
| Implemented |