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)
W0159 QIDP
CFR(s): 483.430(a)

Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, 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.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Respond to all t-logs related to behaviors and major/minor incidents. Complete quarterly summaries of each individual's overall progress to review with families/program director. Maintain a binder with Quarterly Information for each individual . . . Conducts monitoring of direct care staff to ensure correct methods are followed for achieving goals as outlined in all resident ' s treatment plan . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD).

Review of C1's annual "IPP," provided by the facility revealed it was completed on 05/2025. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's interdisciplinary team (IDT).

Review of C1's "QIDP Binder" and C1's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C1's electronic medical record (EMR) revealed no documented evidence of quarterly progress notes completed by the QIDP.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's annual "IPP," provided by the facility, revealed the annual IPP was completed on 11/21/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT. Additionally, there were no special team meeting notes or quarterly progress notes of C2's increase of behaviors including the high frequency of SIB episodes.

Review of C2's "QIDP Binder" and C2's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C2's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

3. Review of C3's annual "IPP," provided by the facility, revealed the annual IPP was completed on 05/09/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C3's "QIDP Binder" and C3's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C3's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's annual "IPP," provided by the facility, revealed the annual IPP was completed on 12/12/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C4's "QIDP Binder" and C4's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C4's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

5. Review of C5's annual "IPP," provided by the facility, revealed the annual IPP was completed on 08/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C5's "QIDP Binder" and C5's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C5's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's annual "IPP," provided by the facility revealed the annual IPP was completed on 02/06/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C6's "QIDP Binder" and C6's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C6's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," provided by the facility, revealed the annual IPP was completed on 07/10/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C7's "QIDP Binder" and C7s program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C7's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," provided by the facility, revealed the annual IPP was completed on 02/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C8's "QIDP Binder" and C8's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C8's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

During an interview on 10/01/25 at 9:47 AM, when asked where the monthly and/or quarterly meeting progress notes could be found, the QIDP stated he/she had been working on the binders and that was why all the clients' binders were in his/her office. The QIDP stated he/she would be off the rest of the week on vacation; however, the surveyor would be able to access the binders in his/her office and all the information needed would be in the binders. The QIDP stated he/she was working on getting the binders caught up before he/she left for the day.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation that the IPP trainings to staff and monitoring of the implementation would have been completed by the QIDP. The Director confirmed the binders containing the monitoring notes were not up to date.

Based on observation, interview, record review, and review of the facility's policy, 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.

Findings include:

Review of the facility's job description for the QIDP titled, "ICF/IID QIDP- Qualified Intellectual Disability Professional," revised 02/17/25, revealed, "Serves as a QIDP in both Intermediate Care Facilities (ICF/IID) by performing the following: Duties. Responsible for integrating, coordinating, and monitoring active treatment plans (IPPS). This includes the following responsibilities: Train all staff on active treatment plans (IPPs), Manage a training binder with signatures, Monitoring staff implementation of active treatment plans . . . Respond to all t-logs related to behaviors and major/minor incidents. Complete quarterly summaries of each individual's overall progress to review with families/program director. Maintain a binder with Quarterly Information for each individual . . . Conducts monitoring of direct care staff to ensure correct methods are followed for achieving goals as outlined in all resident ' s treatment plan . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) as well as any behavior support plan (BSP), psychotropic medication plan, or other support systems (e.g., educational opportunities, employment services, activity programs, meal programs, safety programs, and transportation services) . . ."

1. Review of C1's "CFA," dated 05/011/25 and provided by the facility, revealed the client was admitted to the facility on 04/01/21 with diagnoses which included cerebral palsy, mild intellectual disability, and post traumatic stress disorder (PTSD).

Review of C1's annual "IPP," provided by the facility revealed it was completed on 05/2025. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's interdisciplinary team (IDT).

Review of C1's "QIDP Binder" and C1's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C1's electronic medical record (EMR) revealed no documented evidence of quarterly progress notes completed by the QIDP.

2. Review of C2's "CFA," dated 11/15/24 and provided by the facility, revealed the client was admitted to the facility on 10/24/17 with diagnoses which included severe intellectual disabilities, autism, schizoaffective disorder, bipolar type, and impulse disorder.

Review of C2's annual "IPP," provided by the facility, revealed the annual IPP was completed on 11/21/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT. Additionally, there were no special team meeting notes or quarterly progress notes of C2's increase of behaviors including the high frequency of SIB episodes.

Review of C2's "QIDP Binder" and C2's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C2's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

3. Review of C3's annual "IPP," provided by the facility, revealed the annual IPP was completed on 05/09/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C3's "QIDP Binder" and C3's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C3's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

4. Review of C4's "CFA," dated 12/12/24 and provided by the facility, revealed the client was a 54 year old client admitted to the facility on 11/08/16 with diagnoses which included down syndrome and moderate intellectual disabilities.

Review of C4's annual "IPP," provided by the facility, revealed the annual IPP was completed on 12/12/24. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C4's "QIDP Binder" and C4's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C4's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

5. Review of C5's annual "IPP," provided by the facility, revealed the annual IPP was completed on 08/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C5's "QIDP Binder" and C5's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C5's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

6. Review of C6's "CFA," dated 02/04/25 and provided by the facility, revealed the client was admitted to the facility on 03/06/07 with diagnoses which included profound intellectual disabilities and mood disorder.

Review of C6's annual "IPP," provided by the facility revealed the annual IPP was completed on 02/06/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C6's "QIDP Binder" and C6's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C6's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

7. Review of C7's "CFA," dated 07/02/25 and provided by the facility, revealed the client was admitted to the facility on 07/06/10 with diagnoses which included moderate intellectual disabilities.

Review of C7's "IPP," provided by the facility, revealed the annual IPP was completed on 07/10/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C7's "QIDP Binder" and C7s program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C7's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

8. Review of C8's "CFA," dated 04/10/24 and provided by the facility, revealed the client was admitted to the facility on 12/08/11 with diagnoses which included cerebral palsy and mild intellectual disabilities.

Review of C8's "IPP," provided by the facility, revealed the annual IPP was completed on 02/20/25. The IPP did not include any monthly or quarterly progress notes completed by the QIDP or other disciplines of the client's IDT.

Review of C8's "QIDP Binder" and C8's program binder, both located in the QIDP's office, revealed no documented evidence of quarterly progress notes.

Review of C8's EMR revealed no documented evidence of quarterly progress notes completed by the QIDP.

During an interview on 10/01/25 at 9:47 AM, when asked where the monthly and/or quarterly meeting progress notes could be found, the QIDP stated he/she had been working on the binders and that was why all the clients' binders were in his/her office. The QIDP stated he/she would be off the rest of the week on vacation; however, the surveyor would be able to access the binders in his/her office and all the information needed would be in the binders. The QIDP stated he/she was working on getting the binders caught up before he/she left for the day.

During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation that the IPP trainings to staff and monitoring of the implementation would have been completed by the QIDP. The Director confirmed the binders containing the monitoring notes were not up to date.