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)
W0158 FACILITY STAFFING
CFR(s): 483.430

The facility must ensure that specific facility staffing requirements are met.


This CONDITION is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure qualified staff were employed or contracted by the facility when they failed to have a Qualified Intellectual and Disability Professional (QIDP) who met all regulatory requirements of the position and who ensured clients received the provision of services to meet each clients' needs, which included continuous and aggressive active treatment and behavior health supports. The failure to have an effective QIDP negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the QIDP constituted Immediate Jeopardy. It was determined the Immediate Jeopardy existed on 03/18/25 when an unqualified QIDP was placed in the QIDP position.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to complete a comprehensive behavior assessment on C2.

Through observation, interview, and record review, the survey team validated all components of the removal plan were implemented, and the Immediate Jeopardy was removed effective 10/04/25 at 6:15 PM.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression, including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W159.

2. The facility failed to ensure they employed a QIDP who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life. Cross Reference: W160.

3. The facility failed to ensure the QIDP ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in SIB; however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible. Cross Reference: W164.

4. The facility failed to ensure direct care staff received formal training on each clients' IPP objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objective not being properly implemented. Cross Reference: W169.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure qualified staff were employed or contracted by the facility when they failed to have a Qualified Intellectual and Disability Professional (QIDP) who met all regulatory requirements of the position and who ensured clients received the provision of services to meet each clients' needs, which included continuous and aggressive active treatment and behavior health supports. The failure to have an effective QIDP negatively impacted all 15 clients who resided at the facility.

On 10/02/25 at 8:15 PM, the facility's Director was notified that the failures related to the QIDP constituted Immediate Jeopardy. It was determined the Immediate Jeopardy began on 03/18/25 when an unqualified QIDP was placed in the QIDP position.

Findings include:

1. The Qualified Intellectual Disability Professional (QIDP), who was not qualified for the position, failed to ensure clients' Individual Program Plans (IPPs) were monitored quarterly with data to support progression or regression, including documented observation of clients during program implementation for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). Additionally, the QIDP failed to promote competent interactions of residential staff when he/she received notification of C2 engaging in high frequency episodes of self-injurious behavior (SIB) and did not ensure the client had the needed behavior supports. C2 sustained harm for SIBs. These failures placed all 15 clients of the home at risk for not receiving the services needed for their active treatment program. Cross Reference: W159.

2. The facility failed to ensure they employed a QIDP who had at least one year of experience working with persons with intellectual disability or other development disabilities. This failure placed all 15 clients of the facility at risk of not receiving the programs and supports for aggressive active treatment to retain skills or obtain new skills for a meaningful and independent quality of life. Cross Reference: W160.

3. The facility failed to ensure the QIDP ensured clients received coordinated program services and supports for aggressive active treatment and adaptive behaviors for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). Also, the facility failed to ensure the Comprehensive Functional Assessment included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in SIB; however, the QIDP failed to ensure the client received behavioral services to reduce the client's behavior and the client sustained actual harm. These failures placed all 15 clients at risk of regression in skills and impeded their ability to obtain new skills for a meaningful and independent quality of life as possible. Cross Reference: W164.

4. The facility failed to ensure direct care staff received formal training on each clients' IPP objectives for eight of eight clients (Client (C) 1, C2, C3, C4, C5, C6, C7, C8). The failure to receive formal training by the author of each clients' written objective placed the clients at risk of the program objective not being properly implemented. Cross Reference: W169.

The facility presented an acceptable plan of removal on 10/04/25 at 2:35 PM.

The facility's removal plan included:

1. The facility Director and a part-time Qualified Intellectual and Disability Professional (QIDP) will cover the functions of a QIDP until a candidate who meets the minimum requirements is hired.

2. The facility Director and part-time QIDP will complete an updated Comprehensive Functional Assessment (CFA), including having the vocational section completed by a qualified individual on all 15 clients who reside at the facility.

3. The facility is in the process of developing a day treatment program to fit each clients' need based on the CFA to ensure all 15 clients who reside at the facility receive continuous active treatment.

4. The facility Director has consulted with a Board-Certified Behavior Analyst (BCBA) to complete a comprehensive behavior assessment on C2.

Through observation, interview, and record review, the survey team validated all components of the removal plan were implemented, and the Immediate Jeopardy was removed effective 10/04/25.