| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
| 6400.22(d)(2) | -At the time of the inspection on 8/20/26, Individual #1's financial ledger was documented that they had $34.37 in petty cash, however, there was only $34.12 in petty cash and $0.15 was unaccounted for.
-Individual #1's cash logs are inconsistent. The individual's October, November, and December 2025 logs were not "up-to-date," with frequent blank spaces and "hash marks." There are no logs for June, July, and August 2026. Additionally, the logs do not include details on what withdrawals/deposits were made. | (2) Disbursements made to or for the individual.
| Tranquil Hearts LLC will reconcile Individual #1's petty cash and financial records. The $0.25 discrepancy will be investigated and documented. Available financial records, receipts, and supporting documentation for October, November, and December 2025 and June, July, and August 2026 will be reviewed, and records will be completed or corrected where supporting documentation is available. Going forward, each deposit and withdrawal will include the date, amount, purpose of the transaction, updated balance, and staff initials. Blank spaces and hash marks will not be used in place of required financial documentation. Staff responsible for handling individual funds will be retrained on Tranquil Hearts LLC's financial documentation and money-management procedures. |
08/31/2026
| Implemented |
| 6400.22(e)(3) | Between 10/1/25 and 5/31/26, there were 17 purchases logged that were over $15. There are only 9 receipts of purchases over $15 present in Individual #1's record, and most of them are slips written by staff with few details. | 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. | Tranquil Hearts LLC will review Individual #1's financial records for the period of 10/1/2025 through 5/31/2026 and identify the purchases exceeding $15 that do not have adequate supporting documentation. The Supervisor will review the available receipts and expense records and ensure that all documentation that can be verified is placed in the individual's financial record. Staff responsible for assisting individuals with purchases will be retrained that every single purchase exceeding $15 made on behalf of or in conjunction with an individual must be supported by an actual receipt or sufficiently detailed expense record. Handwritten slips with limited information will not be used as a substitute for appropriate purchase documentation. |
09/01/2026
| Implemented |
| 6400.106 | The furnace was cleaned on 7/9/25 and not again until 8/13/26, which is outside of the annual time frame. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Tranquil Hearts LLC will ensure that the furnace is inspected and cleaned by a professional furnace cleaning company. The most recent inspection and cleaning was completed on 8/13/2026, and written documentation of the service will be maintained in the home's records. Management will review the furnace maintenance records to ensure that documentation of the completed service is present and available for inspection. |
09/01/2026
| Implemented |
| 6400.112(c) | -The 10/17/26 fire drill paperwork did not identify the amount of time it took for evacuation.
-The 11/21/25 and 12/29/25 fire drill paperwork did not identify what time the fire drill took place.
-The 3/29/26 fire drill paperwork did not identify if the fire alarm was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Tranquil Hearts LLC will review the identified fire drill records and correct the documentation where the required information can be verified. Staff responsible for conducting and documenting fire drills will be retrained on completing the fire drill form in its entirety. Each fire drill record must include the date, time of the drill, amount of time required for evacuation, exit route used, any problems encountered, and whether the fire alarm or smoke detector was operative. The Supervisor will review completed fire drill documentation to ensure all required information is present. |
09/02/2026
| Implemented |
| 6400.112(e) | (repeat from the 9/22/25 inspection)
A sleep drill was completed on 1/10/26 and one has not been completed since, which is outside of the 6-month time frame that a sleep drill is to be completed. | A fire drill shall be held during sleeping hours at least every 6 months. | Tranquil Hearts LLC will immediately schedule and complete a fire drill during sleeping hours to correct the overdue requirement. Staff responsible for conducting fire drills will be retrained on the requirement that a sleeping-hours fire drill must be completed at least once every six months. The Supervisor will review the fire drill schedule and documentation to ensure the sleeping-hours drill is completed and properly recorded. |
08/31/2026
| Implemented |
| 6400.112(h) | The 1/10/25 and 3/29/26 fire drill paperwork did not identify if the individuals had evacuated to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | In accordance with 55 Pa. Code Chapter 6400.112(h), Tranquil Hearts LLC will ensure that individuals evacuate to the designated meeting place outside of the building or within the approved fire-safe area during every fire drill. The fire drill form will be revised to clearly document whether each individual evacuated to the designated meeting place. Staff responsible for conducting fire drills will be retrained on the requirement and on completing all sections of the fire drill record. The Supervisor will review the 1/10/25 and 3/29/26 fire drill records and ensure that future fire drill documentation clearly identifies that individuals evacuated to the designated meeting place. The regulation states: "Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. |
08/31/2026
| Implemented |
| 6400.141(a) | Individual #1 had a physical on 5/9/25 and not again until 6/5/26. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | In accordance with 55 Pa. Code § 6400.141(a), Tranquil Hearts LLC will ensure that each individual receives a physical examination annually. Individual #1's most recent physical examination was completed on 6/5/2026. Tranquil Hearts will review the physical examination dates for all individuals currently receiving residential services to ensure that no other annual physical examinations are overdue. Staff responsible for coordinating medical appointments will be reminded of the requirement that annual physical examinations must be completed within the required annual timeframe. |
09/03/2026
| Implemented |
| 6400.141(c)(4) | Individual #1's date of admission was 7/7/25. Individual #1 has not had a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | In accordance with 55 Pa. Code § 6400.141(c)(4), Tranquil Hearts LLC will ensure that Individual #1 receives the required hearing screening as recommended by the physician. Individual #1 has an appointment scheduled with the PCP on 9/9/2026 to obtain a referral for a hearing evaluation. Tranquil Hearts LLC will follow through with scheduling and completing the hearing screening after the referral is received. Documentation of the PCP recommendation, referral, hearing appointment, and completed screening will be maintained in the individual's medical record. |
08/31/2026
| Implemented |
| 6400.141(c)(6) | Individual #1's date of admission was 7/7/25. The individual does not have a tuberculin test on file. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | In accordance with 55 Pa. Code § 6400.141(c)(6), Tranquil Hearts LLC will correct this noncompliance by addressing Individual #1's missing tuberculin screening. Individual #1 has a PCP appointment scheduled for 9/9/2026. At that appointment, Tranquil Hearts LLC will request that the required tuberculin skin test by Mantoux method be ordered or completed. Documentation of the test date and results will be obtained and placed in the individual's medical record. If the tuberculin test is positive, Tranquil Hearts LLC will follow the physician's recommendations and obtain documentation of the required chest X-ray results |
09/02/2026
| Implemented |
| 6400.141(c)(13) | Individual #1's 6/5/26 physical does not include the individual's allergy to dairy. | The physical examination shall include: Allergies or contraindicated medications. | In accordance with 55 Pa. Code § 6400.141(c)(13), Tranquil Hearts LLC will ensure that Individual #1's allergy to dairy is accurately documented on the physical examination. Tranquil Hearts LLC will contact the individual's PCP and request that the 6/5/2026 physical examination be updated or supplemented to include the documented dairy allergy. The updated documentation will be placed in the individual's medical record. |
09/03/2026
| Implemented |
| 6400.141(c)(14) | (Repeat Violation from the 9/22/25 inspection)
The medical information pertinent to diagnosis and treatment section of Individual #1's 6/5/26 physical states, "contact office of primary care or refer to this document." | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | In accordance with 55 Pa. Code § 6400.141(c)(14), Tranquil Hearts LLC will contact Individual #1's primary care provider and request that the 6/5/2026 physical examination be updated or supplemented with specific medical information that would be pertinent to diagnosis and treatment in the event of an emergency. The statement "contact office of primary care or refer to this document" will not be relied upon as the required emergency medical information. The completed or corrected documentation will be maintained in the individual's medical record. |
09/04/2026
| Implemented |
| 6400.141(c)(15) | The special diet information section of Individual #1's 6/5/26 physical is blank. | The physical examination shall include:Special instructions for the individual's diet. | In accordance with 55 Pa. Code § 6400.141(c)(15), Tranquil Hearts LLC will contact Individual #1's primary care provider and request that the 6/5/2026 physical examination be updated or supplemented to include any special dietary instructions applicable to the individual. The completed documentation will be placed in the individual's medical record. If there are no special dietary instructions, the medical provider will be asked to clearly document that rather than leaving the section blank. |
09/03/2026
| Implemented |
| 6400.181(a) | (Repeat Violation from the 9/22/25 inspection)
Individual #1's date of admission was 7/7/25. There is not a completed assessment on file until 3/26/26. | 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. | In accordance with 55 Pa. Code § 6400.181(a), Tranquil Hearts LLC will ensure that each individual has an initial assessment completed within the required timeframe and an updated assessment annually thereafter. Tranquil Hearts LLC located an assessment for Individual #1 that had been completed in October 2025; however, the assessment was not maintained in the individual's residential record. Individual #1's current assessment dated 3/26/2026 will be maintained in the individual's home and agency record. The Program Specialist will review the records of all individuals served to verify that a current assessment is completed and available in each individual's residential record. |
09/03/2026
| Implemented |
| 6400.181(d) | Individual #1's 3/26/26 assessment was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | In accordance with 55 Pa. Code § 6400.181(f), Tranquil Hearts LLC will ensure that Individual #1's 3/26/2026 assessment is reviewed, signed, and dated by the Program Specialist. The completed signed assessment will be maintained in the individual's residential record. |
09/03/2026
| Implemented |
| 6400.181(e)(9) | Individual #1's 3/26/26 assessment does not document the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | In accordance with 55 Pa. Code § 6400.181(e)(1), Tranquil Hearts LLC will have the Program Specialist review and update Individual #1's 3/26/2026 assessment to include documentation of the individual's disability, including the individual's functional and medical limitations. The updated assessment will be signed and dated by the Program Specialist and maintained in the individual's residential record. |
09/03/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's 3/26/26 assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | In accordance with 55 Pa. Code § 6400.181(e)(2), Tranquil Hearts LLC will obtain and document a complete lifetime medical history for Individual #1. The Program Specialist will update the 3/26/2026 assessment to include the individual's lifetime medical history. The updated assessment will be signed and dated by the Program Specialist and maintained in the individual's residential record. |
09/04/2026
| Implemented |
| 6400.181(e)(11) | Individual #1's 3/26/26 assessment does not include a psychological evaluation or confirmation that one has not been completed. | The assessment must include the following information: Psychological evaluations, if applicable. | In accordance with 55 Pa. Code § 6400.181(e)(11), the Program Specialist will review Individual #1's records to determine whether a psychological evaluation has been completed. If an evaluation exists, a copy will be obtained and the information will be incorporated into or referenced in the individual's assessment. If no psychological evaluation has been completed or is applicable, the assessment will be updated to clearly document this. The updated assessment will be signed and dated by the Program Specialist and maintained in the individual's residential record. |
09/04/2026
| Implemented |
| 6400.211(b)(3) | (Repeat Violation from the 9/22/25 inspection)
Individual #1's demographic information does not include the name and contact information for the person who can give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| In accordance with 55 Pa. Code § 6400.211(b)(3), Tranquil Hearts program specialist will update Individual #1's demographic and emergency information to include the name, address, and telephone number of the person authorized to give consent for emergency medical treatment, if applicable. The updated information will be placed in the individual's residential record and made easily accessible to staff in the home. |
09/04/2026
| Implemented |
| 6400.214(b) | At the time of the inspection on 8/20/26, Individual #1 and #2's assessment was not available in the home. | The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home. | In accordance with 55 Pa. Code § 6400.214(b), Tranquil Hearts LLC will ensure that the most current assessments for Individual #1 and Individual #2 are placed in their respective residential home records and are readily available for review. The Program Specialist will verify that the current assessment for each individual is present in the home and that outdated copies are replaced when a new assessment is completed |
08/24/2026
| Implemented |
| 6400.34(a) | Individual #1's date of admission was 7/7/25. There was no documentation verifying that Individual #1 was informed of their rights until 7/1/26. A CYS worker signed the individual's admission rights document on 5/12/25. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | In accordance with 55 Pa. Code § 6400.34(a), Tranquil Hearts LLC will ensure that Individual #1 is informed of their individual rights and the process for reporting a rights violation. Although a CYS worker signed the rights document on 5/12/2025, Tranquil Hearts LLC recognizes that documentation must verify that the individual was informed of and had their rights explained upon admission to the residential home. The current rights documentation will be reviewed and maintained in the individual's record, and staff responsible for admissions will be retrained on completing rights documentation at the time of admission. |
08/29/2026
| Implemented |
| 6400.165(a) | In February 2026, PRN Acetaminophen and Ibuprofen were added to Individual #1's Medication Administration Record. There is not a doctor's order for these medications. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Tranquil Hearts LLC will ensure that no prescription or PRN medication is added to an individual's Medication Administration Record unless a current written order from an authorized prescriber is available. When a new medication is ordered, changed, or discontinued, the written order will be obtained and compared with the MAR before staff administer the medication. The Supervisor will review medication orders and MARs monthly and whenever medication changes occur to verify that all medications listed on the MAR are supported by a current written prescriber's order. Any discrepancy will be reported and corrected immediately, and the physician or pharmacy will be contacted for clarification when needed. Staff will be retrained as necessary to maintain compliance with 55 Pa. Code § 6400.165(a). |
08/25/2026
| Implemented |
| 6400.165(e) | -Individual #1 was prescribed hydrocortisone butyrate on 10/15/25. This medication was discontinued on 11/15/25 without a doctor's order.
-Individual #1 was prescribed Loratadine on 10/7/25. This medication was discontinued on 10/14/25 without a doctor's order.
-Individual #1's Olanzapine was increased from 10mg twice daily to 15mg in the morning and 10mg in the evening on 6/1/26. There is no doctor's order for this change in dosage. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | In accordance with 55 Pa. Code § 6400.165(e), Tranquil Hearts LLC will contact the prescribing providers to obtain written documentation for the discontinuation of Hydrocortisone Butyrate dated 11/15/2025, the discontinuation of Loratadine dated 10/14/2025, and the Olanzapine dosage increase effective 6/1/2026. Tranquil Hearts LLC will continue to follow up with the prescribing offices until the written orders or clarification are received. Once received, the written orders will be placed in Individual #1's medication record and the MAR will be reviewed to ensure that it accurately reflects the prescriber's written instructions. |
08/25/2026
| Implemented |
| 6400.165(g) | Individual #1 had psychiatric medication reviews on 11/17/25, 4/30/26, and 8/13/26. Additionally, the 8/13/26 medication review did not include the necessary dosage of medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | In accordance with 55 Pa. Code § 6400.169(a), Tranquil Hearts LLC will ensure that Individual #1 receives psychiatric medication reviews at least every three months. Tranquil Hearts LLC will contact the psychiatric provider regarding the 8/13/2026 medication review and request that the documentation be completed or supplemented to include the necessary medication dosage. The corrected documentation will be placed in Individual #1's medical record. Tranquil Hearts LLC will also review the dates of prior psychiatric medication reviews and ensure future reviews are scheduled within the required three-month timeframe. |
08/31/2026
| Implemented |
| 6400.166(a)(11) | (Repeat Violation from the 9/22/25 and 5/20/26 inspections)
Individual #1's August 2026 Medication Administration Record does not include the diagnosis or purpose for the following medications: Aquaphor, DDAVP, Lithium, Prozac, Zyprexa, Orajel, Amoxicillin. | 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. | In accordance with 55 Pa. Code § 6400.166(a)(11), Tranquil Hearts LLC will update Individual #1's August 2026 Medication Administration Record to include the diagnosis or purpose for Aquaphor, DDAVP, Lithium, Prozac, Zyprexa, Orajel, and Amoxicillin. The medication purposes will be verified against the physician's orders, pharmacy information, and medical record before being entered on the MAR. Staff responsible for medication documentation will be retrained on the requirement that the diagnosis or purpose must be documented for every prescription medication, including PRN medications. |
08/27/2026
| Implemented |
| 6400.181(f) | There is no verification that Individual #1's 3/26/26 assessment was sent to the team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | In accordance with 55 Pa. Code § 6400.181(f), Tranquil Hearts LLC will ensure that the Program Specialist provides each completed assessment to all members of the individual's plan team at least 30 calendar days prior to the individual plan meeting. For Individual #1, the Program Specialist will document that the current assessment has been provided to the appropriate team members. Documentation of distribution, such as email confirmation, fax confirmation, or other written verification, will be maintained in the individual's record. |
08/31/2026
| Implemented |
| 6400.186 | An update was made to Individual #1's Individual Support Plan indicating that a recommendation was made to request a communication specialist evaluation on 6/23/26. While a request for evaluation was typed up, there is no verification that the request was actually sent. | The home shall implement the individual plan, including revisions. | In accordance with 55 Pa. Code § 6400.186, Tranquil Hearts LLC will ensure that all recommendations and revisions contained in the Individual Support Plan are implemented and documented. For Individual #1, the Program Specialist will follow up on the 6/23/2026 recommendation for a communication specialist evaluation and ensure that the request is actually sent to the appropriate provider. Verification that the referral or request was sent, such as email confirmation, fax confirmation, or other written documentation, will be maintained in the individual's record. The Program Specialist will continue to follow up until the evaluation is scheduled or a response is received. |
08/31/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic information does not include their religion. The individual's face sheet says, "N/A." | Each individual's record must include the following information: Religion | In accordance with 55 Pa. Code § 6400.213(1)(iv), Tranquil Hearts LLC updated Individual #1's demographic information to accurately reflect the individual's religious affiliation. The updated information has been placed in the individual's record. |
08/28/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic information does not include a next of kin. | Each individual's record must include the following information: Next of kin | In accordance with 55 Pa. Code § 6400.213(1)(v), Tranquil Hearts LLC updated Individual #1's demographic information to include the individual's next of kin. The corrected demographic information has been placed in the individual's record. |
08/26/2026
| Implemented |