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)
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.