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)
W0164 PROFESSIONAL PROGRAM SERVICES
CFR(s): 483.430(b)(1)

Each client must receive the professional program services needed to implement the active treatment program defined by each client's individual program plan.


This STANDARD is not met as evidenced by:
Based on interview, record review, and review of the facility's policy, the facility failed to ensure a Qualified Intellectual Disability Professional (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 (CFA) included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and be implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in Self-Injurious Behavior (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.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 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 [individual Program Plans]) -Manage a training binder with signatures . . . Respond to all t-logs related to behaviors and major/minor incidents . . . Participates in guidance and educational programs to obtain a working knowledge of all policies, standards, and regulations to maintain compliance. Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans. 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) . . . Presents new and revised IPP ' s and BSP ' s with rights restrictions to HRC for review and approval . . . Reviews all rules and regulations of the licensing and certifying agencies regarding ICF/IID resident care, staffing requirements and all other applicable standards and assists the ICF/IID Program Director with ensuring that the ICF/IID ' s are in compliance . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

1. Review of C1's "Comprehensive Functional Assessment (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). Continued review of C1's CFA revealed, ". . . Vocational Skills: There are no plans for [C1's Name] to participate in the vocational program. [C1's Name] enjoys doing things like answering the phone and helping with paperwork. We will be asking and assisting [him/her] in things that [he/she] can do to be involved in the process in the ICF. [C1's Name] would love to make bracelets and sell them to others. [His/Her] dream is to make enough that [he/she] can donate bracelets to the Cancer floor at the children's hospital . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional.

During an interview on 10/01/25 at 12:25 PM, C1 stated he/she would love to have a job on the facility's campus. C1 stated currently he/she bought materials with his/her own money to make bracelets and tried to sell them on his/her own. C1 stated he/she could see himself/herself working in the community as a door greeter at a department store such as Walmart. C1 further stated it was very important to him/her to have and live an independent life as he/she could.

During an interview on 09/30/25 at 1:45 PM, when asked about the facility's vocational program, the QIDP stated the facility did not have or focus on "vocational training." The QIDP stated they just try and keep the clients involved in activities and games. The QIDP stated a lot of the clients who resided at the facility wanted to work. When asked why the clients were not given the opportunity to work, the QIDP stated the reason he/she was given was because the residential work location staff would not be able to provide the clients with toileting assistance. When asked about C1, the QIDP stated C1 really wanted a job in the community, and he/she would love to be able to just have a job. The QIDP further stated independence was very important to C1 and that his/her independence is not restricted.

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. Continued review of C2's CFA revealed, ". . . Vocational Skills: [C2's] name no longer attends the workshop due to [his/her] behavioral issues and [his/her] desire to go to the Wellness Center instead. [He/She] was not able to concentrate on the work-short attention span and had stopped being productive in workshop setting. [He/She] attends the [Facility Name] activities center every afternoon Monday-Friday. At the Activity Center, [he/she] receives training in the informal areas of gross motor, fine motor, social skills, cognitive and sensory skills, and money skills . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff; and did not identify any behavioral supports to assist the client in a vocational setting.

Continued review of C2's "CFA," revealed the CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB).

Review of C2's EMR and paper medical record revealed no documented evidence of an active plan for behavior supports.

During an interview on 10/01/25 at 3:50 PM, when asked about C2's BSP, the QIDP stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge. The QIDP further stated he/she was not aware that the QIDP position was the person responsible for ensuring clients receive all of the services they needed including behavior support services.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C3's Individual Program Plan (IPP) was completed on 05/09/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C3. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

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. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C5's IPP was completed on 08/20/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C5. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

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. Continued review of the CFA revealed, ". . . Vocational Skills. [C6's Name] has not shown an interest in attending the workshop and when afforded the opportunity to do so, [he/she] did not focus on the tasks at hand. Due to [C6's name] lack of interest in a workshop, [his/her] inability to focus on tasks, and [his/her] need of constant supervision, [he/she] is more suited for the ICF/IID Health and Wellness setting. At the ICF and HWC [Health and Wellness Center] [he/she] is able to engage in activities [he/she] enjoys but also serves to improve [his/her] current functional limitations. [He/She] attends Health and Wellness Center generally 2-3 days per week ..." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated C6 was afforded the opportunity to attend a "workshop;" however, the facility did not have a workshop in place.

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. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked here at the facility, C7 stated "No." When asked if he/she had ever worked at the facility doing a job, C7 stated he/she stated "yes," that he/she answered phones at the Wellness Center. When asked why he/she no longer did that job, C7 stated "I don ' t know." The client stated he/she missed working. When asked why he/she missed it, C7 stated because he/she made money.

9. 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. Continued review of the CFA revealed, ". . . Vocational Skills. [C8's Name] is unable to perform work tasks available at the sheltered workshop. Due to [his/her] physical limitations, placement in the vocational setting is not recommended at this time. [He/She] attends the activity center at he Health and Wellness Center where [he/she] is able to engage in activities [he/she] enjoys, do physical/ROM [range of motion] exercises, and work on skills to improve [his/her] current level of functioning . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated the facility had a sheltered workshop; however, it had been verified there were no workshops or vocational programs at the facility.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed by the facility for five years. RA3 stated the facility at one time had different programming which included vocational training and jobs for the clients. RA3 stated he/she believed C7 used to have a job in a vocational setting at the facility at one time. RA3 also stated C1 wanted to have a job where he/she could make money. The RA stated being independent and making his/her own money was very important to C1.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a Qualified Intellectual Disability Professional (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 (CFA) included an appropriate vocational assessment which identified skills or needed skills to maintain or obtain and be implemented in a day training program. Additionally, the QIDP was aware of C2's high frequency in Self-Injurious Behavior (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.

Findings include:

Review of the facility's job description titled, "ICF/IID QIDP-Qualified Intellectual Disability Professional," dated 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 [individual Program Plans]) -Manage a training binder with signatures . . . Respond to all t-logs related to behaviors and major/minor incidents . . . Participates in guidance and educational programs to obtain a working knowledge of all policies, standards, and regulations to maintain compliance. Conducts in-service trainings for all ICF/IID direct care staff on each resident ' s active care plans; works with ICF/IID staff on methods of collecting data and achieving goals as outlined in care plans. 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) . . . Presents new and revised IPP ' s and BSP ' s with rights restrictions to HRC for review and approval . . . Reviews all rules and regulations of the licensing and certifying agencies regarding ICF/IID resident care, staffing requirements and all other applicable standards and assists the ICF/IID Program Director with ensuring that the ICF/IID ' s are in compliance . . . Coordinates all other support systems and related services for residents on assigned caseload . . ."

1. Review of C1's "Comprehensive Functional Assessment (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). Continued review of C1's CFA revealed, ". . . Vocational Skills: There are no plans for [C1's Name] to participate in the vocational program. [C1's Name] enjoys doing things like answering the phone and helping with paperwork. We will be asking and assisting [him/her] in things that [he/she] can do to be involved in the process in the ICF. [C1's Name] would love to make bracelets and sell them to others. [His/Her] dream is to make enough that [he/she] can donate bracelets to the Cancer floor at the children's hospital . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional.

During an interview on 10/01/25 at 12:25 PM, C1 stated he/she would love to have a job on the facility's campus. C1 stated currently he/she bought materials with his/her own money to make bracelets and tried to sell them on his/her own. C1 stated he/she could see himself/herself working in the community as a door greeter at a department store such as Walmart. C1 further stated it was very important to him/her to have and live an independent life as he/she could.

During an interview on 09/30/25 at 1:45 PM, when asked about the facility's vocational program, the QIDP stated the facility did not have or focus on "vocational training." The QIDP stated they just try and keep the clients involved in activities and games. The QIDP stated a lot of the clients who resided at the facility wanted to work. When asked why the clients were not given the opportunity to work, the QIDP stated the reason he/she was given was because the residential work location staff would not be able to provide the clients with toileting assistance. When asked about C1, the QIDP stated C1 really wanted a job in the community, and he/she would love to be able to just have a job. The QIDP further stated independence was very important to C1 and that his/her independence is not restricted.

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. Continued review of C2's CFA revealed, ". . . Vocational Skills: [C2's] name no longer attends the workshop due to [his/her] behavioral issues and [his/her] desire to go to the Wellness Center instead. [He/She] was not able to concentrate on the work-short attention span and had stopped being productive in workshop setting. [He/She] attends the [Facility Name] activities center every afternoon Monday-Friday. At the Activity Center, [he/she] receives training in the informal areas of gross motor, fine motor, social skills, cognitive and sensory skills, and money skills . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff; and did not identify any behavioral supports to assist the client in a vocational setting.

Continued review of C2's "CFA," revealed the CFA identified the client had a behavior support plan (BSP) and identified target behaviors of physical aggression, verbal aggression, and self-injurious behavior (SIB).

Review of C2's EMR and paper medical record revealed no documented evidence of an active plan for behavior supports.

During an interview on 10/01/25 at 3:50 PM, when asked about C2's BSP, the QIDP stated the client did not have any type of behavior plan at this time. The QIDP stated there should have been a BSP a long time ago. The QIDP also confirmed there had not been any behavior functional assessments completed to his/her knowledge. The QIDP further stated he/she was not aware that the QIDP position was the person responsible for ensuring clients receive all of the services they needed including behavior support services.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C3's Individual Program Plan (IPP) was completed on 05/09/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C3. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

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. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

5. Review of C5's EMR and paper medical record revealed no documented evidence that the QIDP completed or ensured that a CFA had been completed on the client in the past year. C5's IPP was completed on 08/20/25.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed he/she could not locate an up to date CFA for C5. The Director stated QIDP was on vacation; however, he/she communicated with the QIDP and still could not locate the CFA.

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. Continued review of the CFA revealed, ". . . Vocational Skills. [C6's Name] has not shown an interest in attending the workshop and when afforded the opportunity to do so, [he/she] did not focus on the tasks at hand. Due to [C6's name] lack of interest in a workshop, [his/her] inability to focus on tasks, and [his/her] need of constant supervision, [he/she] is more suited for the ICF/IID Health and Wellness setting. At the ICF and HWC [Health and Wellness Center] [he/she] is able to engage in activities [he/she] enjoys but also serves to improve [his/her] current functional limitations. [He/She] attends Health and Wellness Center generally 2-3 days per week ..." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated C6 was afforded the opportunity to attend a "workshop;" however, the facility did not have a workshop in place.

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. Continued review of the CFA revealed the QIDP failed to complete the vocational assessment section of the client's CFA.

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked here at the facility, C7 stated "No." When asked if he/she had ever worked at the facility doing a job, C7 stated he/she stated "yes," that he/she answered phones at the Wellness Center. When asked why he/she no longer did that job, C7 stated "I don ' t know." The client stated he/she missed working. When asked why he/she missed it, C7 stated because he/she made money.

9. 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. Continued review of the CFA revealed, ". . . Vocational Skills. [C8's Name] is unable to perform work tasks available at the sheltered workshop. Due to [his/her] physical limitations, placement in the vocational setting is not recommended at this time. [He/She] attends the activity center at he Health and Wellness Center where [he/she] is able to engage in activities [he/she] enjoys, do physical/ROM [range of motion] exercises, and work on skills to improve [his/her] current level of functioning . . ." The CFA's vocational assessment did not indicate an evidence-based assessment completed by the appropriate professional staff. Additionally, the vocational assessment indicated the facility had a sheltered workshop; however, it had been verified there were no workshops or vocational programs at the facility.

During an interview on 10/01/25 at 8:06 AM, RA3 stated he/she had been employed by the facility for five years. RA3 stated the facility at one time had different programming which included vocational training and jobs for the clients. RA3 stated he/she believed C7 used to have a job in a vocational setting at the facility at one time. RA3 also stated C1 wanted to have a job where he/she could make money. The RA stated being independent and making his/her own money was very important to C1.