| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01G011 | (X3) Date Survey Completed 10/04/2025 |
| 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) |
| W0102 | GOVERNING BODY AND MANAGEMENT CFR(s): 483.410 The facility must ensure that specific governing body and management requirements are met. This CONDITION is not met as evidenced by: Based on observation, interview, record review, and review of facility policies, the Governing Body failed to provide operating direction and management to ensure regulatory compliance was met for Conditions of Participation (CoPs) in Medicare and Medicaid. Immediate Jeopardy was identified at five CoPs. The facility's failures impacted all 15 clients who resided at the facility. On 10/02/25 at 8:15 PM, the Facility Director was notified the failures constituted Immediate Jeopardy at 483.410 Governing Body and Management. On 10/04/25 at 2:35 PM, the facility presented an acceptable plan of removal. The facility's removal plan included: 1. The facility revised their abuse policy to include peer to peer aggression as abuse. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. 2. The facility developed the required written policy and procedure governing the management of inappropriate client behavior. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. 3. The facility identified that the Facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) would share the QIDP functions until a qualified candidate was hired. 4. The facility started planning for their development of a day training program to ensure clients receive continuous and aggressive active treatment. 5. The facility began educating staff that by not intervening when a client was engaging in self-injurious behavior (SIB) can constitute neglect. 6. The facility consulted with a Board-Certified Behavior Analys (BCBA) who will complete a comprehensive behavior assessment on Client (C) 2 and develop the appropriate behavior plan based on the assessment. The BCBA will educate staff on the developed plan. 7. The facility developed a policy and procedure regarding appropriate notification during incidents of abuse and clients engaging in SIB. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. Through interview and record review, the survey team was able to validate the facility had begun implementation of the plan of removal, and the Immediate Jeopardy was lifted on 10/04/25 at 6:15 PM. Findings include: Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8; and placed all clients of the facility (15 total clients) at risk for negative outcomes. Cross Reference: W104. Based on observation, interview, record review, and review of facility policies, the Governing Body failed to provide operating direction and management to ensure regulatory compliance was met for Conditions of Participation (CoPs) in Medicare and Medicaid. Immediate Jeopardy was identified at five CoPs. The facility's failures impacted all 15 clients who resided at the facility. On 10/02/25 at 8:15 PM, the Facility Director was notified the failures constituted Immediate Jeopardy at 483.410 Governing Body and Management. Findings include: Based on interview, record review, review of the employee job description, and review of the facility's policy, the Governing Body failed to provide operating direction and management to ensure clients were protected from abuse and neglect, that a Qualified Intellectual Disability Professional (QIDP) was employed, that the facility had the required day training program that provided continuous and aggressive active treatment, that families were notified of client abuse, and that a policy for the management of client behavior was developed and implemented. These failures negatively impacted or had the potential to negatively impact eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8; and placed all clients of the facility (15 total clients) at risk for negative outcomes. Cross Reference: W104. ********************************** On 10/04/25 at 2:35 PM, the facility presented an acceptable plan of removal. The facility's removal plan included: 1. The facility revised their abuse policy to include peer to peer aggression as abuse. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. 2. The facility developed the required written policy and procedure governing the management of inappropriate client behavior. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. 3. The facility identified that the Facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) would share the QIDP functions until a qualified candidate was hired. 4. The facility started planning for their development of a day training program to ensure clients receive continuous and aggressive active treatment. 5. The facility began educating staff that by not intervening when a client was engaging in self-injurious behavior (SIB) can constitute neglect. 6. The facility consulted with a Board-Certified Behavior Analys (BCBA) who will complete a comprehensive behavior assessment on Client (C) 2 and develop the appropriate behavior plan based on the assessment. The BCBA will educate staff on the developed plan. 7. The facility developed a policy and procedure regarding appropriate notification during incidents of abuse and clients engaging in SIB. The facility immediately started educating their staff on the policy and all staff will be trained prior to the start of their next shift. Through interview and record review, the survey team was able to validate the facility had begun implementation of the plan of removal, and the Immediate Jeopardy was lifted on 10/04/25. |