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 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)
W0104 GOVERNING BODY
CFR(s): 483.410(a)(1)

The governing body must exercise general policy, budget, and operating direction over the facility.


This STANDARD is not met as evidenced by:
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 15 clients of the facility at risk for negative outcomes.

Findings include:

1. Review of the facility's policy titled "Continuous Quality Improvement," revised in 2020 revealed, ". . . The entity has a current Continuous Quality Improvement (CQI) Plan approved by the board of directors. ROI will develop a plan of accountability that will improve its success in carrying out the goal of meeting the needs of developmentally handicapped adults through a measurable increase in staff productivity in designated areas over a specified period of time . . . ROI will develop and implement a Continuous Quality Improvement Plan for the purpose of improving the quality of life for those served. 1. The CQI Plan of ROI will be initiated by approval of the board of directors and will be available for review by designated DMR staff.

2. The CQI Plan of ROI will include mechanisms for: a. Problem identification/opportunity for improvement. B. Assessment/analysis of identified performance problems. c. Documentation of problem resolution/improvements. d. Follow-up assessment to evaluate corrective action . . ."

Cross Reference: W122, W149, W158, W160, W195, W196, and W274

2. Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/28/22, revealed the policy failed to identify that aggression from one peer to another peer was abuse. Cross Reference: W149

3. Review of the facility's QIDP's employee file revealed the QIDP lacked the regulatory required one year experience working directly with persons with intellectual disability or other developmental disabilities in setting that served persons with intellectual disabilities. Cross Reference: W160.

4. Review of the facility's undated policy titled, "Individual Programming Plan," revealed, ". . . II. Vocational Program. Individual and vocational day trainees are provided prevocational job training and work experience in [facility' name] vocational workshop, which opened in 1995 . . . Day Habilitation. Day-Hab Program provides services to adults with developmental disabilities which results in substantial functioning limitations in 3 or more major areas: self-care, language, learning, mobility, self-direction, and the capacity for independent living and economic self-sufficiency. Our main goal is to incorporate social, recreational, and community activity skills. Our training program emphasizes on maximizing a person ' s independence in areas of: Daily living skills, Safety Mobility, Money management, Human Rights, Spirituality Growth, Interpersonal relationships, Volunteerism, Self-Advocacy, Recreational & Community activities.

Goals are developed based on deficits in skill sets that can be worked on throughout the year in an array of settings. Goals are typically worked on in classroom settings, community settings, and social settings . . ." Through observation, interview, and record review, it was determined the facility failed to have a vocational program. Cross Reference: W195 and W196

5. Review of the facility's undated policy titled, "Emergencies (Section from the facility's Emergency Preparedness Plan)," revealed, ". . . EMERGENCY PROCEDURES FOR SEVERE BEHAVIORAL PROBLEMS IN ALL ROI PROGRAMS - (i.e., residential and workplace violence involving residents and staff or between residents). Policy: [Facility Name] is committed to the safety and well being of all residents, staff, and visitors. Crisis Prevention Intervention (CPI) procedures are to be practiced at all times . . ." The facility's policy did not address the use of a functional behavior assessment, a hierarchy of least to most intrusive measures, or the incorporation of behavior management programs in clients' IPPs. Cross Reference: W266 and W274.

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 15 clients of the facility at risk for negative outcomes.

Findings include:

1. Review of the facility's policy titled "Continuous Quality Improvement," revised in 2020 revealed, ". . . The entity has a current Continuous Quality Improvement (CQI) Plan approved by the board of directors. ROI will develop a plan of accountability that will improve its success in carrying out the goal of meeting the needs of developmentally handicapped adults through a measurable increase in staff productivity in designated areas over a specified period of time . . . ROI will develop and implement a Continuous Quality Improvement Plan for the purpose of improving the quality of life for those served.

1. The CQI Plan of ROI will be initiated by approval of the board of directors and will be available for review by designated DMR staff.

2. The CQI Plan of ROI will include mechanisms for: a. Problem identification/opportunity for improvement. B. Assessment/analysis of identified performance problems. c. Documentation of problem resolution/improvements. d. Follow-up assessment to evaluate corrective action . . ."

Cross Reference: W122, W149, W158, W160, W195, W196, and W274

2. Review of the facility's policy titled, "Procedures for Reporting & Investigating Abuse, Neglect, and Mistreatment," revised 03/28/22, revealed the policy failed to identify that aggression from one peer to another peer was abuse. Cross Reference: W149

3. Review of the facility's QIDP's employee file revealed the QIDP lacked the regulatory required one year experience working directly with persons with intellectual disability or other developmental disabilities in setting that served persons with intellectual disabilities. Cross Reference: W160.

4. Review of the facility's undated policy titled, "Individual Programming Plan," revealed, ". . . II. Vocational Program. Individual and vocational day trainees are provided prevocational job training and work experience in [facility' name] vocational workshop, which opened in 1995 . . . Day Habilitation. Day-Hab Program provides services to adults with developmental disabilities which results in substantial functioning limitations in 3 or more major areas: self-care, language, learning, mobility, self-direction, and the capacity for independent living and economic self-sufficiency. Our main goal is to incorporate social, recreational, and community activity skills. Our training program emphasizes on maximizing a person ' s independence in areas of: Daily living skills, Safety Mobility, Money management, Human Rights, Spirituality Growth, Interpersonal relationships, Volunteerism, Self-Advocacy, Recreational & Community activities.

Goals are developed based on deficits in skill sets that can be worked on throughout the year in an array of settings. Goals are typically worked on in classroom settings, community settings, and social settings . . ." Through observation, interview, and record review, it was determined the facility failed to have a vocational program. Cross Reference: W195 and W196

5. Review of the facility's undated policy titled, "Emergencies (Section from the facility's Emergency Preparedness Plan)," revealed, ". . . EMERGENCY PROCEDURES FOR SEVERE BEHAVIORAL PROBLEMS IN ALL ROI PROGRAMS - (i.e., residential and workplace violence involving residents and staff or between residents). Policy: [Facility Name] is committed to the safety and well being of all residents, staff, and visitors. Crisis Prevention Intervention (CPI) procedures are to be practiced at all times . . ." The facility's policy did not address the use of a functional behavior assessment, a hierarchy of least to most intrusive measures, or the incorporation of behavior management programs in clients' IPPs. Cross Reference: W266 and W274.