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 07/13/2023
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)
W0252 PROGRAM DOCUMENTATION
CFR(s): 483.440(e)(1)

Data relative to accomplishment of the criteria specified in client individual program plan objectives must be documented in measurable terms.


This STANDARD is not met as evidenced by:
Based on facility document review, clinical record reviews, and interviews, the facility failed to document 3 (Clients #1, #2, and #3) of 3 sampled clients' active treatment objectives data per the required frequency of the clients' plans. This failure resulted in three clients not having the required amount of data to assess their progress accurately.

Findings included:

A review of a facility document titled, "Job Title: ICF/IID [Intermediate Care Facilities for Individuals with Intellectual Disabilities] Resident Aide," dated 04/20/2021, indicated, "Works closely with and takes direction from the "on duty" ICF/IID LPN [Licensed Practical Nurse] (Team Lead) regarding all aspects of ICF/IID resident care and nursing support." The document further indicated, "Completes documentation for CPAs [Care Program Approaches], IPPs [Individual Program Plans] or BSPs [Behavior Support Plans], and prepares reports, as required by licensing and certifying agencies and ROI [release of information] policy."

A review of Client #1's "Data Collection Monthly- Individual Summary Sheet," for April 2023, May 2023, and June 2023, revealed the client had an Individual Support Plan for "Independent Living," "Healthcare Management - Physical Exercise," and "Money Management." Per the documents, the staff were directed to document the client's progress in meeting the established goals three times a week for "Independent Living," two times a week for "Healthcare Management - Physical Exercise," and one time a week for "Money Management." Documentation revealed data was not collected at the frequency set in the objective for April 2023, May 2023, and June 2023.

A review of Client #2's "Data Collection Monthly- Individual Summary Sheet," for April 2023, May 2023, and June 2023, revealed the client had an Individual Support Plan for "Money Management," "Social/Communication," and "Health Education." Per the documents, the staff were directed to document the client's progress in meeting the established goals one time a week for "Money Management," two times a week for "Social/Communication," and three times a week for "Health Education." Documentation revealed data was not collected at the frequency set in the objective for April 2023, May 2023, and June 2023.

A review of Client #3's "Data Collection Monthly- Individual Summary Sheet," for April 2023, May 2023, and June 2023, revealed the client had an Individual Support Plan for "Sensory," "Stimulation," and "Community Safety." Per the documents, the staff were directed to document the client's progress in meeting the established goals two times a week for Sensory, Stimulation, and Community Safety. Documentation revealed data was not collected at the frequency set in the objective for April 2023, May 2023, and June 2023.

During an interview on 07/13/2023 at 2:32 PM, the Qualified Intellectual Disability Professional (QIDP) stated it was the responsibility of the QIDP to ensure the client's active treatment was provided. Per the QIDP, the collection of the active treatment data was important in the active treatment of the clients as it helped the QIDP assess the clients' progress in their treatment. The QIDP acknowledged the facility failed to ensure active treatment objective data was collected per the required frequency of the clients' plans for Clients #1, #2, and #3.

During an interview on 07/13/2023 at 2:49 PM, the Program Director stated that upper management was aware resident aides were not documenting data as written on the client's Data Collection Monthly- Individual Summary Sheet. According to the Program Director, the resident aides were observed conducting the clients' active treatment objectives; however, the staff had been trying to figure out how to improve the resident aides' documentation. The Program Director explained, the facility understood the importance of the collection of data as it helped the facility track the client's progress." The Program Director acknowledged the facility failed to ensure active treatment objective data was collected per the required frequency of the clients' plans for Clients #1, #2, and #3.