Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01G011 (X3) Date Survey Completed 03/19/2021
Name of Provider or Supplier Rainbow Omega, Inc, Street Address, City, State 202 Hope Drive, Eastaboga, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
W0000 A recertification survey and focused infection control surveys were conducted by Healthcare Management Solutions, LLC on behalf of the Alabama Department of Public Health (ADPH), Division of Health Care Facilities.

An unannounced on-site Recertification survey (2EZHI1) was conducted at the Davis/Orman Intermediate Care Facility from March 16, 2021 to March 19, 2021. There were no citations at the Condition Level. This facility is not in substantial compliance with 42 CFR 483, Subpart I, Requirements for Intermediate Care Facilities for Individuals with Intellectual Disabilities as evidenced by Standard level deficiencies being cited.
W0336 NURSING SERVICES
CFR(s): 483.460(c)(3)(iii)

Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.


This STANDARD is not met as evidenced by:
Based on interview and record review, the facility failed to ensure client's health monitoring by nursing staff was documented on a quarterly basis. This failure had the potential to result in inadequate health monitoring and effected 12 of 14 client identifiers (CI) (CI #1, CI #2, CI #3, CI #4, CI #6, CI #8, CI #9, CI #10, CI #11, CI #12, CI #13, CI #14).

Findings include:

On 03/19/21 at 10:45 AM interview with Employee Identifier (EI) #1, Director of Nursing/Registered Nurse (DON) revealed the nursing quarterly health reviews had not been completed on a quarterly basis. EI #1 stated that some of the training she received was inaccurate in that she was told she only had to complete one quarterly assessment per client for a 12-month period.

On 03/19/21 at 12:30 PM EI #2, Director of ICF/IID Services/Qualified Intellectual Disabilities Professional (QIDP) provided the nursing health reviews for the most recently completed four quarters of the year, January 2020 through December 2020 titled, "Search Health Care Report" which documented:

CI #1 did not have quarterly nursing assessments for the quarters beginning in April 2020 and October 2020;

CI #2 did not have a quarterly nursing assessment for the quarter beginning in April 2020;

CI #3 did not have a quarterly nursing assessment for the quarter beginning in April 2020;

CI #4 did not have quarterly nursing assessments for the quarters beginning in January 2020, April 2020 and October 2020;

CI #6 did not have quarterly nursing assessments for the quarters beginning in January 2020, April 2020 and October 2020;

CI #8 did not have quarterly nursing assessment for the quarters beginning in January 2020, April 2020 and October 2020;

CI #9 did not have quarterly nursing assessments for the quarters beginning in January 2020 and July 2020;

CI #10 did not have a quarterly nursing assessment for the quarter beginning in April 2020;

CI #11 did not have quarterly nursing assessments for the quarters beginning in January and April 2020;

CI #12 did not have a quarterly nursing assessment for the quarter beginning in April 2020;

CI #13 did not have quarterly nursing assessments for the quarters beginning in January 2020 and April 2020;

CI #14 did not have quarterly nursing assessments for the quarters beginning in January and March 2020 and October 2020.

On 03/19/21 at 1:00 PM, EI #1 confirmed that quarterly nursing assessments were missing for the above identified clients.
W0341 NURSING SERVICES
CFR(s): 483.460(c)(5)(ii)

Nursing services must include implementing with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to control of communicable diseases and infections, including the instruction of other personnel imethods of infection control.


This STANDARD is not met as evidenced by:
Based on observation, interview, and policy review, the facility failed to follow their agency's Infection Control Policy regarding the screening for COVID prior to the start of the employee's shift for one of one employee identifier (EI) #3. The COVID screening consisted of answering a questionnaire, checking the employee's temperature and signing the questionnaire. The employee failed to perform hand hygiene. This deficient practice had the potential to affect all 14 of 14 clients at the agency.

Findings include:

Review of the agency's policy titled, "Infection Control and Universal Precautions" updated 03/16/21 indicated, "To prevent the possible spread of infections and communicable diseases, all staff are to be trained on techniques for universal precautions and preventing cross-contamination and will be required to follow the established procedures ...Screening protocol ...All employees will be screened before beginning their job responsibilities by ...answering a questionnaire concerning any possible exposure to the named disease or virus. Checking temperature and recording result on questionnaire. Signing questionnaire ...the importance of proper hand hygiene and proper handwashing techniques."

Observation on 03/17/21 at 5:59 AM, EI #3/ Resident Aide (RA) arrived at the facility, picked up a disposable mask from the screening station located on a table on the right side of the main entrance and put it on as she passed quickly through the common area down a hallway. EI #3 did not sanitize her hands, complete the screening questions sheet available on at the screening station and did not take and record her temperature.

Continued observation on 03/17/21 at 6:05 AM revealed EI #3 carried a large bundle of laundry down the center hallway, passed clients as she moved to the end of the hallway and deposited the bundle outside for pickup. On 03/17/21 at 6:11 AM, EI #3 returned to the screening station where she sanitized her hands, checked her temperature, and filled out the screening form reviewing exposure to others with known or suspected COVID-19.

During an interview on 03/17/21 at 6:14 AM, EI #3 verified that she did not check her temperature, sanitize her hands, and complete the screening questions sheet when she entered the facility. She explained she "just forgot," because she was rushing to get clocked in by 6:00 a.m. when her shift began. She said she had been trained on the requirement to be responsible for self-screening every time she comes into the building."

During an interview on 03/17/21 at 6:25 AM, EI #4, Licensed Practical Nurse (LPN), who also served as the Team Leader for the Resident Aide staff, verified that all staff had been trained and were aware of the requirement to complete the steps at the screening station before proceeding further throughout the residence. EI #4 confirmed it was not an acceptable practice for staff to proceed into the building without completing screening.

During an interview on 03/17/21 at 9:55 AM, EI #1, Director of Nursing/Registered Nurse (DON) confirmed that all staff, including EI #3 received training on the screening process for staff to complete upon arrival in the building for their shifts. She added staff compliance was monitored by the nursing staff, including herself, however staff were expected to be responsible to engage in all infection control practices.

Review of EI #3's training records revealed, "Acknowledgment of Training on Infection Control and Universal Precautions Policy and Procedures" including the statement, "I acknowledge that I have received Rainbow Omega's policy and procedures on Infection Control and Universal Precautions and was trained on this policy and procedure and I understand and agree to abide by this policy and procedure." The training records documented EI #3 had been most recently trained and signed the acknowledgment documents on 11/09/20 and 03/05/21.
W0371 DRUG ADMINISTRATION
CFR(s): 483.460(k)(4)

The system for drug administration must assure that clients are taught to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective, and if the physician does not specify otherwise.


This STANDARD is not met as evidenced by:
Based on observation, interview, and record review the facility failed to fully assess the self-administration of medication training needs and consider development of training plans resulting from actual assessments for 14 of 14 clients, Client Identifiers (CI) (CI #1, CI #2, CI #3, CI#4, CI #5, CI #6, CI #7, CI #8, CI #9, CI #10, CI #11, CI #12, CI #13, and CI #14).

Findings include:

During a medication pass observation on 03/16/21 at 2:10 AM, CI #4 and CI #7 received medications from Employee Identifier (EI) #5, Licensed Practical Nurse (LPN). No self administration of medication training was provided to CI #4 and CI #7 during the medication pass.

During a medication pass observation on 03/17/21 at 6:22 AM, CI #8 received medications from EI #4. No self administration of medication training was provided to CI #8 during the medication pass.

On 03/18/21 at 9:35 AM, an interview with EI #1, Director of Nursing/Registered Nurse (DON) revealed she completed an annual "Client Self-Administration Assessment Form" for each client. EI #1 provided copies of these documents for CI #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14. Each "Client Self-Administration Assessment Form" indicated:

"1. The consumer has not effectively verbalized understanding of the purpose for the medication(s),

2. The consumer has not effectively verbalized common possible side effects,

Including I. What to do if dose is missed, II. What to do if extra dose(s) taken, III. What to do if adverse reactions occur.

3. The consumer cannot recognize the medication(s).

4. The consumer cannot perform return demonstrations of self administration of medication(s) to include appropriate documentation."

The "Client Self-Administration Assessment Form" included a determination section, including fields to check yes or no. All sections of these documents were completed the same for each client as follows: "Cannot self-medicate independently and needs assistance with medications by nurse."

Each "Client Self-Administration Assessment Form" for the clients listed above included a section for individualized notes from the Registered Nurse evaluator. Each assessment documented the same hand-written notes, as follows, "Is a dependent medicator as she cannot recognize her medications and does not know purpose of medications or what to do in the event of a missed dose. She does not know the potential common side effects of medications either." The only individualization in the "Client Self-Administration Assessment Forms" was making the gender of the pronoun used (he or she) match the gender of the client and the client's name in the heading of the "Client Self-Administration Assessment Forms".

During an interview on 03/18/21 at 2:10 PM, EI #1 stated that she was previously instructed that clients living in an ICF/IID were not eligible for self-administration of medication training. EI #1 state she was required to complete annual assessments to document all clients lack of ability to receive training in self administration of medication. She stated she followed the format and documentation of previous assessors and that was why all 14 clients' "Client Self-Administration Assessment Form" were exactly the same except that she changed the gender of the pronoun.