| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The Emergency Disaster Response/Evacuation Plan does not indicate the relocation address where staff and Individuals are to relocate. This was left blank on the document signed by the Individual on 5/10/25. | 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 Marriott 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 |
| 6400.111(c) | During the inspection on 9/24/25 the fire extinguisher in the kitchen was rated 1A-10BC, this does not meet the minimum requirement of 2A-10BC. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | During the inspection on 9/24/25, it was identified that the kitchen fire extinguisher was rated 1A-10BC and did not meet the minimum requirement of 2A-10BC. Tranquil Hearts has immediately corrected this issue by purchasing and installing new fire extinguishers rated 2A-10BC in the kitchen and throughout the home, ensuring compliance with 6400.112(b). The new extinguishers were installed and verified by the Directors and supervisor on 10/6/2025, and all staff were notified and trained on the proper use and location of the new equipment. Documentation of purchase, installation, and staff acknowledgment has been added to the facility's fire safety file. |
10/06/2025
| Implemented |
| 6400.145(1) | The emergency medical plan document for Individual #1 does not include the hospital or source of health care that will be used in 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. | 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 specifies that the primary care physician (PCP) will provide follow-up care if needed after the emergency. |
09/25/2025
| Implemented |
| 6400.181(a) | 181a- Repeat 12/16/24- Assessment- The initial assessment for Individual #1 did not have all of the required information to have a complete assessment. The assessment in the record was not sent to team members and was not signed by the program specialist. | 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 |
| 6400.167(a)(1) | Individual #1's MAR on 9/15/25 at 8am for Doxycycl HYR 100mg was left blank. 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. | Staff was given a corrective action and retrained on proper documentation on the MAR. |
10/06/2025
| Implemented |