| 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) |
| W0169 | PROFESSIONAL PROGRAM SERVICES CFR(s): 483.430(b)(4) Professional program staff must participate in on-going staff development and training in both formal and informal settings with other professional, paraprofessional, and nonprofessional staff members. This STANDARD is not met as evidenced by: Based on record review, interview, and review of the facility's policy, the facility failed to ensure direct care staff received formal training on each clients' Individual Program Plan (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 objectives not being properly implemented. Findings include: Review of the facility's undated policy titled, "Individual Program Planning," revealed, ". . . QDDP [QIDP (Qualified Intellectual Disability Professional)] The monitor is the person who sees that the program is carried out as scheduled and is responsible for seeing that a quarterly summary of progress is completed . . . The QDDP is responsible for developing a PCP for each individual participating in ROI programs. Specific goals and objectives will be established on an on-going basis and prioritized by the individual or their guardian. These will be developed in coordination with the individual, [his/her] parents/guardian - unless excluded by a legally competent individual, ROI residential staff, vocational staff, and consultants when necessary . . ." Review of the facility's "Job Title: ICF/IID QIDP-Qualified Intellectual Disability Professional (QIDP)," 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) . . . 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 . . ." 1. Review of C1's "Individual Program Plan (IPP)," provided by the facility, revealed the date of completion was 05/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 2. Review of C2's "IPP," provided by the facility, revealed the date of completion was 11/21/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 3. Review of C3's "IPP," provided by the facility, revealed the date of completion was 05/09/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 4. Review of C4's "IPP," provided by the facility, revealed the date of completion was 12/12/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 5. Review of C5's "IPP," provided by the facility, revealed the date of completion was 08/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 6. Review of C6's "IPP," provided by the facility, revealed the date of completion was 02/06/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 7. Review of C7's "IPP," provided by the facility, revealed the date of completion was 07/10/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 8. Review of C8's "IPP," provided by the facility, revealed the date of completion was 02/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. During an interview on 10/01/25 at 8:06 PM, when asked if he/she had been trained on the clients' current program objectives they are working on with the client in the home, Resident Aide (RA) 3 stated they used to receive training from the QIDP on each training objective and would have to sign a sheet for the training; however, that had not happened in some time. The RA stated it had probably been over a year. During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had not received any type of training on the clients' objectives they are working on with the clients; however, he/she could see the objectives in the facilities EMR to read how to implement. The RA stated it had been a long time since anyone has come in and actually trained them on the objectives. During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the QIDP would have completed formal training for all staff on each clients' IPP objectives. The Director stated the QIDP was the person responsible for completing the training. Based on record review, interview, and review of the facility's policy, the facility failed to ensure direct care staff received formal training on each clients' Individual Program Plan (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 objectives not being properly implemented. Findings include: Review of the facility's undated policy titled, "Individual Program Planning," revealed, ". . . QDDP [QIDP (Qualified Intellectual Disability Professional)] The monitor is the person who sees that the program is carried out as scheduled and is responsible for seeing that a quarterly summary of progress is completed . . . The QDDP is responsible for developing a PCP for each individual participating in ROI programs. Specific goals and objectives will be established on an on-going basis and prioritized by the individual or their guardian. These will be developed in coordination with the individual, [his/her] parents/guardian - unless excluded by a legally competent individual, ROI residential staff, vocational staff, and consultants when necessary . . ." Review of the facility's "Job Title: ICF/IID QIDP-Qualified Intellectual Disability Professional (QIDP)," 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) . . . 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 . . ." 1. Review of C1's "Individual Program Plan (IPP)," provided by the facility, revealed the date of completion was 05/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 2. Review of C2's "IPP," provided by the facility, revealed the date of completion was 11/21/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 3. Review of C3's "IPP," provided by the facility, revealed the date of completion was 05/09/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 4. Review of C4's "IPP," provided by the facility, revealed the date of completion was 12/12/24. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 5. Review of C5's "IPP," provided by the facility, revealed the date of completion was 08/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 6. Review of C6's "IPP," provided by the facility, revealed the date of completion was 02/06/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 7. Review of C7's "IPP," provided by the facility, revealed the date of completion was 07/10/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. 8. Review of C8's "IPP," provided by the facility, revealed the date of completion was 02/20/25. Review of the client's electronic medical record and paper medical record revealed no documented evidence the staff were formally trained on the client's IPP objectives. During an interview on 10/01/25 at 8:06 PM, when asked if he/she had been trained on the clients' current program objectives they are working on with the client in the home, Resident Aide (RA) 3 stated they used to receive training from the QIDP on each training objective and would have to sign a sheet for the training; however, that had not happened in some time. The RA stated it had probably been over a year. During an interview on 10/01/25 at 6:15 PM, RA2 stated he/she had not received any type of training on the clients' objectives they are working on with the clients; however, he/she could see the objectives in the facilities EMR to read how to implement. The RA stated it had been a long time since anyone has come in and actually trained them on the objectives. During an interview on 10/04/25 at 6:41 PM, the facility Director stated it was his/her expectation the QIDP would have completed formal training for all staff on each clients' IPP objectives. The Director stated the QIDP was the person responsible for completing the training. |