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)
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.