Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00293440 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
6400.77(b)At the time of the inspection on 8/20/26, there were no scissors in the first aid kit. 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. In accordance with 55 Pa. Code § 6400.77(b), Tranquil Hearts LLC corrected the noncompliance by purchasing and placing scissors in the first aid kit. The Supervisor will inspect the first aid kit to verify that all required items are present, including antiseptic, adhesive bandages, sterile gauze pads, thermometer, tweezers, tape, and scissors. 08/22/2026 Implemented
6400.106The furnace was cleaned on 5/12/25 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. In accordance with 55 Pa. Code § 6400.106, Tranquil Hearts LLC had the furnace inspected and cleaned by a professional furnace cleaning company on 8/13/2026. Written documentation of the completed inspection and cleaning will be maintained in the residential home's maintenance records and made available for review. 08/31/2026 Implemented
6400.112(e)(repeat from the 9/22/25 inspection) A sleep drill was completed on 10/7/25 and not again until 6/24/26, 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 correct this noncompliance by ensuring that sleeping-hours fire drills are completed within the required six-month timeframe. Although a sleeping-hours drill was completed on 6/24/2026, staff responsible for fire drill scheduling will be retrained on the requirement that a fire drill during sleeping hours must occur at least every six months. The Supervisor will review the fire drill schedule for each residential home and verify that the next sleeping-hours drill is scheduled before the six-month deadline. 09/01/2026 Implemented
6400.214(b)At the time of the inspection on 8/20/26, Individual #1's assessment and current ISP were 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 corrected the noncompliance by placing Individual #1's most current assessment and current ISP in the individual's residential home record. The Program Specialist will verify that both documents are current, complete, and readily available in the home for staff and regulatory review. 08/24/2026 Implemented
SIN-00274160 Renewal 09/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The 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