| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | At the time of the inspection, on 9/24/25 the water temperature in the bathtub was 128F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water thermostat was adjusted on September 24, 2025, to maintain water temperatures below 120 degrees Fahrenheit. |
10/20/2025
| Implemented |
| 6400.77(b) | During the inspection of the home on 9/24/25 the following items were missing from the first aid kit the is kept in the home- Thermometer, scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new thermometer and scissors have been purchased and placed in the first aid kit. The kit now contains all required items in accordance with 6400.77(b) |
09/25/2025
| Implemented |
| 6400.103 | The Evacuation Plan- does not indicate the relocation address where staff and Individuals are to relocate. The document was blank. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. | Tranquil Hearts has revised the Emergency Disaster Evacuation Response Plan to include the designated relocation address for all individuals and staff in the event of an evacuation. The plan now specifies the primary relocation site: Tru Hilton Hotel and a secondary relocation site: Residence Inn by Marrott in case the primary location is unavailable.
All staff have been trained on the updated evacuation procedures, relocation sites, and individual/staff responsibilities, including transportation assignments. Training was conducted on 10/10/2025, and documentation is maintained in the staff training files. The revised plan has been reviewed and signed by the Program Specialist and Facility Director, and a copy is now located in the facility's Emergency Preparedness Binder and within each individual's home binder. |
10/10/2025
| Implemented |
| 6400.141(c)(12) | REPEAT- 12/16/24- This section was left blank on the 5/20/25 annual physical examination form for Individual #1 | The physical examination shall include: Physical limitations of the individual. | The individual's physician was contacted, and an updated annual physical examination form with the physical limitations section completed was obtained and placed in the individual's record. |
10/14/2025
| Implemented |
| 6400.141(c)(14) | REPEAT 12/16/24-This section was left blank on the 5/20/25 annual physical examination form for Individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physician was contacted and provided the missing medical information. |
10/17/2025
| Implemented |
| 6400.145(1) | REPEAT 12/16/24-The emergency medical plan document for Individual #1 does not include the hospital or source of health care that will be used in emergencies. | 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. | The emergency medical plan for Individual #1 was updated to include Lancaster General Hospital as the designated hospital in the event of an emergency. The plan also specify that the primary care physician (PCP) will provide follow-up care if needed after the emergency |
10/19/2025
| Implemented |
| 6400.181(a) | Repeat 12/16/25-Assessment- Individual #1's date of admission was 5/23/25 the agency did not complete the initial assessment. | 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. | Tranquil Hearts has completed a new, comprehensive annual assessment for Individual #1, ensuring all required regulatory components under 6400.181(a)--(f) are included. The updated assessment now contains all mandatory sections such as adaptive behavior, level of skills, communication, socialization, mobility, personal needs, medical information, and interests. The assessment has been reviewed, signed, and dated by the Program Specialist and placed in the individual's record. Copies have been distributed to the team, including the Supports Coordinator and family, as required. The Program Specialist has received additional training on the completion, content, and timeliness of annual assessments to prevent reoccurrence. |
10/10/2025
| Implemented |
| 6400.211(b)(1) | REPEAT- 12/16/24- 211b1· The name, address, and telephone number of a designated person to be contacted in case of emergency was missing from Individual #1's documentation. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| The program specialist made the necessary correction to reflect the person who is to be contacted incase of an emergency . This includes the name, address, telephone number, and relationship of the person to be contacted. |
10/17/2025
| Implemented |
| 6400.211(b)(3) | The name, address, and telephone number of the person able to give consent for emergency medical treatment was missing from Individual #1's documentation. | 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.
| The program specialist made the necessary correction to reflect the person who is able to give consent for emergency medical treatment. This includes the name, address, telephone number, and relationship of the person to be contacted in the case of an emergency medical treatment. |
09/25/2025
| Implemented |
| 6400.166(a)(4) | Individual #1 was prescribed Nicotine transdermal patches 21mg PRN on 8/5/25. The full box has 14 nicotine patches, during the inspection on 9/24/25 there were only 5 Nicotine patches left in the box. The Transdermal Nicotine patches were not on the medication administration record; there are no staff initials or date when the Nicotine patches were applied. None of the required information is on the MAR for this medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Nicotine transdermal patches were added to the individuals MAR. All staff members who are medication administration trained were given a refresher course on medication documentation. |
10/06/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's MAR's May 2025- Albuterol Sulfate inhalation 90 mcg- Does not have the reason why the medication was prescribed. Aug 2025- The following medications do not indicate on the MAR's the reason why the medications were prescribed- Risperidone 3mg 2xs daily, Divalproex ER 250mg1 tab 2xs daily, Amoxicillin 500mg 1 cap 3xs daily until gone, Trazodone 50mg 1 tab nightly. | 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. | The purpose of Albuterol sulfate inhalation 90 mcg was added on to the MAR, all staff who administer medication were given a refresher course on medication documentation. |
10/06/2025
| Implemented |
| 6400.167(a)(1) | Individual #1's 8/20/25 MAR's -Trazodone 50mg tab take nightly - was left blank. There is no documentation on the MARs to explain why it was not administered.
Famotidine 20mg was left blank 8/27/25. There is no documentation on the MARs to explain why this medication was not administered. | Medication errors include the following: Failure to administer a medication. | Due to the severity of improper documentation all staff members who administer medication were trained on medication documentation. |
10/06/2025
| Implemented |