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 08/10/2022
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)
E0000 The facility was in substantial compliance with the Condition of Participation at 42 CFR 483.475 Emergency Preparedness.
W0000 An unannounced on-site Recertification survey was conducted at the Davis/Orman Intermediate Care Facility from 8/8/22 to 8/10/22. 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.
W0331 NURSING SERVICES
CFR(s): 483.460(c)

The facility must provide clients with nursing services in accordance with their needs.


This STANDARD is not met as evidenced by:
Based on record review, interviews, and review of a facility policy titled, "ROI [Rainbow Omega, Incorporated] AIMS [Abnormal Involuntary Movement Scale] Policy," the Intermediate Care Facility (ICF) failed to ensure nursing services were provided to meet the needs of Client Identifier (CI) #2. Specifically, the facility failed to ensure AIMS testing was conducted to monitor for potential side effects of antipsychotic medications for 1 (CI #2) of three sampled clients reviewed for psychotropic medication use. The failed practice had the potential to result in failure to promptly identify signs of tardive dyskinesia for CI #2.

Findings include:

Review of an undated facility policy titled, "ROI AIMS Policy" revealed, "The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. ... Purpose ... The AIMS test is given every three to six months to monitor the patient for the development of TD. ...".

Review of a "Behavior Support/Medication Reduction Plan," dated 04/26/2022, revealed CI #2 had diagnoses that included Moderate Intellectual Disability (a disorder characterized as having impaired thinking and learning disabilities), Cerebral Palsy (a disorder that affects movement, muscle tone, balance, and posture), and Depression. The plan indicated CI #2's behavior support medications included Celexa (an antidepressant medication) 40 milligrams (mg) daily and quetiapine (an antipsychotic medication) 150 mg.

Review on 08/09/2022 at 10:22 AM of CI #2's July 2022 and August 2022 "MAR [Medication Administration Record] Data Forms" revealed CI #2 received citalopram (Celexa) 40 mg daily at 7:00 AM and quetiapine extended-release (ER) 150 mg, one tablet daily at 7:00 PM.

As of 08/09/2022 at 10:22 AM, there was no documentation available for review in the clinical record to indicate the facility had conducted AIMS testing for Client #2.

In an interview on 08/09/2022 at 4:00 PM, Employee Identifier (EI) #1, Contract Pharmacist, stated the facility contracted her pharmacy company to conduct pharmacy reviews for the residents at the Intermediate Care Facility (ICF). EI #1 further stated that they did not conduct AIMS test monitoring for the clients.

During an interview on 08/10/2022 at 12:45 PM, EI #2, Psychiatrist, stated CI #2 was prescribed the two psychotropic medications for Depression. EI #2 stated she was currently not conducting AIMS testing, the facility nursing department usually did that. EI #2 further stated Registered Nurses (RN) conducted the AIMS testing and that it should be conducted every 90 days.

During an interview on 08/10/2022 at 1:44 PM, EI #3, Registered Nurse Supervisor, stated the AIMS testing should be conducted for clients who were taking psychotropic medications every 90 days. EI #3 acknowledged the ICF nursing staff had not been conducting the AIMS testing for CI #2 and were not following the facility's policy.