Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293436 Renewal 08/17/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for this 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.Tranquil Hearts determined that the required Chapter 6400 self-assessment had not been completed within the applicable timeframe because an incorrect self-assessment form had been used. Following the licensing inspection, Tranquil Hearts obtained and completed the correct Chapter 6400 Community Homes Self-Assessment Tool for the home. Any areas identified during the self-assessment requiring correction were addressed accordingly. We also reviewed the self-assessment requirements for its other Chapter 6400 homes to verify that the correct form is being used and that future self-assessments are completed within the required timeframe. 09/28/2026 Implemented
6400.21(a)Staff person #2 was hired on 3/29/26. A PSP background check was not conducted until 8/18/26.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. On 8/18/2026, the Pennsylvania State Police criminal history record check for Staff Person #2 was completed and placed in the staff person's personnel record. Tranquil Hearts also reviewed the personnel files of current employees who have direct contact with individuals to verify that required Pennsylvania criminal history record checks were completed and maintained in accordance with regulatory requirements. Any identified missing documentation will be obtained and placed in the applicable personnel file. The deficiency occurred because the required criminal history check was not completed within the required timeframe following Staff Person #2's date of hire. The administrative staff responsible for employee onboarding will be retrained regarding required pre-employment and post-hire clearance timelines. 08/18/2026 Implemented
6400.22(d)(2)-Individual #1's financial ledger was recorded that the individual's petty cash balance was $224.08 on 12/6/25, however, after a $20 debit on their financial ledger on 12/6/25, the balance was recorded as being $194.08 when it should have been $204.08. -Individual #1's financial ledger was recorded that the individual's petty cash balance was $230.59 on 5/19/26, and on 6/11/26, the balance was then $225.53 with no debits having been recorded.(2) Disbursements made to or for the individual. Tranquil Hearts reviewed Individual #1's petty cash ledger and supporting receipts/disbursement documentation for the cited period. The mathematical and documentation discrepancies identified by Licensing were reconciled, and the financial record was corrected to accurately reflect the individual's disbursements and running balance. We also reviewed financial records for other individuals whose funds are managed or assisted with by Tranquil Hearts to determine whether similar discrepancies existed. Any discrepancies identified were reconciled and corrected. To address the cause of the deficiency, Tranquil Hearts implemented an additional supervisory review process. House Supervisors now review individual financial records weekly so discrepancies can be identified and corrected promptly. Completed financial sheets are collected monthly and submitted to Administration for secondary review and retention. 08/26/2026 Implemented
6400.151(a)Staff person #6 had a physical on 8/18/24. As of 8/19/26, this staff member hasn't had a physical since that date. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff Person #6 has been directed to obtain the required physical examination no later than 09/18/2026. Upon completion, the physical examination documentation will be placed in the employee's personnel record. We reviewed the personnel records of all current staff who are subject to §6400.151(a) to verify that required physical examinations were completed within the required timeframe. Any employee found to have an overdue or missing physical examination was scheduled for completion and will not continue duties inconsistent with regulatory requirements until the required documentation is obtained. The deficiency occurred because the employee's bi-annual physical due date was not identified and acted upon before expiration. 09/18/2026 Implemented
6400.151(c)(2)Staff person #6 was hired on 9/4/24. There is not a tuberculin test on file for this staff person. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff Person #6 had completed a tuberculosis test and physical examination at the time of hire; however, the documentation was not available in the personnel file at the time of inspection. Tranquil Hearts has since reviewed the employee's personnel record and obtained/re-established the required health documentation as applicable. We also reviewed the personnel files of current employees to verify that required physical examination and tuberculosis testing documentation is present and maintained in the appropriate personnel record. Any missing documentation identified through this review will be obtained and filed. The deficiency occurred because, during the agency's early period of operation, personnel records were not consistently maintained and some required documents were misplaced. Tranquil Hearts has since strengthened its administrative structure and assigned responsibility for maintaining employee personnel and health records to designated administrative staff. 09/02/2026 Implemented
6400.46(a)-Staff person #2 was hired on 3/29/26. This staff person has not received fire safety training. - Staff person #4 was hired on 1/9/26 and first worked with individuals on 1/18/26. This staff person did not receive fire safety training until 1/19/26. -Staff person #6 was hired on 9/4/24. There is no record that this staff completed fire safety training before 9/15/25.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.At the time of inspection, Tranquil Hearts understood that the Program Specialist was not required to complete the fire safety training identified under §6400.46(a) because they did not work alone with individuals and was present in the homes in a supervisory or programmatic capacity while direct support staff were also present. During the inspection, Licensing clarified that the fire safety training requirement applies to the Program Specialist regardless of whether they work independently with individuals. Following that clarification, the Program Specialist completed the required fire safety training, and documentation of completion was placed in their training record. Tranquil Hearts also reviewed the training records of applicable program specialists and direct service workers to verify that required fire safety training was completed and documented. 08/24/2026 Implemented
6400.51(a)(1)Staff person #2 was hired on 3/29/26. This staff person did not complete their trainings on the subjects covered in 6400.51b1 until 6/29/26, subjects covered in 6400.51b2 until 5/1/26, subjects covered in 6400.51b3 until 5/15/26, and subjects covered in 6400.51b4 until 5/4/26. There is no documentation verifying that this staff person completed trainings in the subjects covered in 6400.51b5. This staff person is the program specialist for all individuals served.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Tranquil Hearts reviewed the orientation and training record for Staff Person #2 and identified the required orientation subjects that were either completed outside of the required timeframe or lacked documentation. Any outstanding orientation subject was completed, and documentation of the completed training was placed in the employee's training file. We also reviewed orientation records for current program specialists and direct service workers to verify that required orientation topics were completed and documented within the applicable regulatory timeframe. The deficiency resulted from inadequate tracking of orientation requirements and due dates during the agency's earlier onboarding process. Tranquil Hearts has since assigned designated administrative staff responsibility for monitoring employee onboarding, orientation completion, and required documentation. 09/14/2026 Implemented
6400.51(b)(5)-Staff person #3 was hired on 5/4/26 and began working with individuals on 6/16/26. This staff person has not been trained in the subjects covered by this regulation. -Staff person #4 was hired on 1/9/26 and began working with individuals on 1/18/26. This staff person has not been trained in the subjects covered by this regulation.The orientation must encompass the following areas: Job-related knowledge and skills.Tranquil Hearts reviewed the orientation and training records for Staff Persons #3 and #4 and confirmed that the required job-related knowledge and skills component under §6400.51(b)(5) had not been properly completed and documented prior to the employees beginning work with individuals. Following the licensing inspection, Tranquil Hearts developed and implemented an individualized Job-Related Knowledge and Skills training and competency process. Staff Persons #3 and #4 completed the required training using this process. The training included review of job responsibilities, the specific needs and supports of the individuals assigned to the staff person, supervision requirements, communication needs, health and safety considerations, and other job-related skills necessary for the employee's assigned duties. The training also included an in-person field component so each staff person could demonstrate understanding and competency while working in the residential setting. Completion was documented through staff and trainer signatures and competency verification, and the completed documentation was placed in each employee's training record. We also reviewed applicable orientation and training records for other direct service staff to identify whether similar gaps existed. Any identified deficiencies were corrected through completion of the required Job-Related Knowledge and Skills training and competency documentation. 08/26/2026 Implemented
6400.52(a)(1)Staff person # 6 completed 13.5 hours of training in training year 2025. Additionally, there was no training completed on the areas covered in 6400.52c1 through 6400.52c4.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Tranquil Hearts reviewed Staff Person #6's annual training record and identified the deficit in required annual training hours and required training subjects. Staff Person #6 will complete training addressing the outstanding required job-related subjects, and documentation of completion will be maintained in the employee's training file. We also reviewed the annual training records of all current direct service workers to verify completion of at least 24 hours of annual training and inclusion of required training subjects. Any deficiencies identified through this review will be corrected through additional training. The deficiency occurred because annual training hours and required subject areas were not being monitored consistently throughout the training year, which allowed the employee to reach the end of the training year without completing all required training. 09/21/2026 Implemented
6400.166(a)(11)(repeat from the 9/22/25 inspection and the 5/20/26 investigation) For Individual #1, the August 2026 MAR does not identify the diagnosis or purpose for the medication Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.During the licensing inspection, Tranquil Hearts identified that the August 2026 MAR for Individual #1 did not contain the diagnosis or purpose for the medication as required by §6400.166(a)(11). The provider had received updated prescription information containing the correct medication directions and diagnosis and retained the corresponding pharmacy label documentation; however, staff were unsure whether the diagnosis or purpose could be manually added to the MAR prior to receipt of a newly generated MAR. During the inspection exit process, Licensing clarified that the diagnosis or purpose may be added directly to the MAR when supported by the current physician order, prescription, pharmacy label, or other appropriate medication documentation. Following that clarification, the diagnosis/purpose information was added to Individual #1's MAR. Tranquil Hearts also reviewed current MARs for other individuals receiving medication administration services to verify that each medication entry contained the required diagnosis or purpose. Any missing information identified during the review was corrected using current medication orders, prescription information, or pharmacy documentation. 08/25/2026 Implemented
6400.167(a)(1)(repeat from the 9/22/25 inspection) Individual #1 was not administered their 8am dose of Vitamin D3 on 11/3/25.Medication errors include the following: Failure to administer a medication.Tranquil Hearts reviewed the medication administration record for Individual #1 for 11/3/2025. The 8:00 a.m. dose of Vitamin D3 was administered; however, the staff person failed to initial the corresponding MAR entry after administration. Other medications administered during the same medication pass were initialed appropriately. The deficiency resulted from a documentation error during the medication pass. The staff person did not complete the required MAR documentation for the Vitamin D3 dose after administering the medication. In addition, the missing MAR entry was not identified during the subsequent supervisory review of the monthly medication documentation. Following identification of the deficiency, medication administration staff were reminded/retrained that each medication must be documented on the MAR immediately following administration in accordance with medication administration procedures. Tranquil Hearts also reviewed applicable medication records to identify any additional missing or incomplete administration documentation and addressed any deficiencies identified. 09/01/2026 Implemented
SIN-00256857 Renewal 12/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
6400.144For 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
SIN-00274155 Renewal 09/22/2025 Compliant - Finalized
SIN-00237691 Renewal 01/19/2024 Compliant - Finalized