Empowering Angels Group, LLC

Three of four foster home records reviewed did not have any unannounced quarterly visits in file.

Caregiver's medication was observed on top of the night stand in the master bedrooms, with additional medications found inside the same night stand drawer, which was unlocked.

Review of Backgrounds showed an employee was no longer employed as of 2/7/25 and the background check was not inactivated.

It was observed that a foster home screening was approved however did not have an evaluation of the information obtained to make a recommendation pertaining to the capacity # the home should be licensed for.

In 2 child files reviewed the medication logs were not filled out to their entirety and ommited the prescribing health care preofessional's name. One of the medication logs also did not have the strength of the medication.

In one of the files in which a child was placed as an emergency admission placement there was no documentation regarding the circumstances necessitating the emergency admission.

In a discharge summary there is no documentation regarding the medication the child is taking.

Pre-placement visits are not taking place with non-emergency placements.

The operation's EBI policy does not allow the use of EBI however a caregiver used EBI on a child in care.

It was observed that not all trainings conducted had a demonstration of knowledge and competency in writing.

There was no documentation that the required debriefing took place with its required components.

The incident report does not detail what caregiver was involved in the EBI or what circumstances led to the EBI, it does not describe what took place and only states that a short personal hold was done for 1 min. 30 seconds.

The home study reviewed indicated that there was an additional caregiver however the agency informed and confirmed with the foster parent that the individual listed in the home study is not a caregiver.

A contractor file was observed to not be meeting the same requirements as an employee of the operation such as trainings were not filed, an affidavit was not notarized, no job description and no drug screening was observed.

The suicide policy is missing information addressing suicide deaths.

The operational policies indicate that if intending to provide treatment services for a child with ID, the admission assessment must include a psychological evaluation completed within 14 months of the date of admission. However, at the time of admission the admission assessment must include a written, dated, and signed Psychological evaluation with psychometric testing, including the child?s diagnosis. Another psychological evaluation must take place within 14 months of admission.

In 2 out of 2 files reviewed multiple training completion certificates did not indicate the trainer's qualifications.

The subchapter for reporting serious incidents is not addressed through policy in detail to include time frames. There is mention in several different locations that serious incidents and ANE should be reported to the hotline.

The operational policies do not include anything in the policies to ensure that the items necessary for diaper changing are kept out of the reach of children.

The operational policies do not include for at least one of the current caregivers in the planning or indicate that at least one of the professional service providers will be involved as indicated in 749.1363(a)(2).

There?s no consideration in the budget for required identified staff such as child placement staff and child placement management staff salaries.

The operational policies regarding temporary verifications are not specific to all the information required in 749.2521 - 749.2539.

The operational policy states that the admission assessment for all children no matter what level of care will be completed with full participation of the treatment team within 30 days of admission..

The child rights subchapter only details the child right?s form; there is no mention of all child right?s.

The operational policies does not address 749.1807(a)(4)-749.1807(a)(8) which is regarding specifics pertaining to cribs.

In the operational polices a lot of the standards related to infants sleeping and cribs are not included.

There is no indication in the operational policies for when the service plan is to be reviewed or updated for children receiving treatment services for ID. The policy states "For a child receiving treatment services the plan must be reviewed at least 90 days from the date of the last plan." which is only applicable for children receiving treatment services for ED and Autism Spectrum Disorder.

The operational policies do not include anything regarding 749.1373 pertaining to what information will be provided to the next placement or caregiver.

The admissions & placement operational policies for this subchapter does not include the information required for the children?s files and several other components.

The operational policies regarding admission assessment requirements for children receiving treatment services references children with autism and ED however does not mention ID which is inconsistent with what the operation is applying for.

In the operational policies there is no indication of when the service plan is to be implemented.