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)
W0196 ACTIVE TREATMENT
CFR(s): 483.440(a)(1)

Each client must receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this subpart, that is directed toward: (i) The acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible; and (ii) The prevention or deceleration of regression or loss of current optimal functional status.


This STANDARD is not met as evidenced by:
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility.

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 . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . . 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 05/01/25 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). The CFA documented C1's desire to be independent as possible including working to make money and to be able to exercise his/her independence to socialize and independently visit with friends who live on campus; however, the facility's lack of programing that was meaningful to C1 impeded the client from self-determination.

Review of C1's "Individual Program Plan (IPP)," dated 05/01/25 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed. 7:30-breakfast, brush teeth, take a shower, 8:00-take meds, 9:00-11:30- HWC [Health and Wellness Center], 11:30-1:30 [pm]- lunch. Afternoon: 1:30-HWC for activities and goal training, 3:30-return to house . . ." The IPP did not incorporate in C1's schedule a day training program where goals and objectives meaningful to him/her were implemented.

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. The CFA documented under the "Vocational Skills" section that C2 no longer participated in the workshop due to the client's behavioral issues. The CFA documented the client was no longer able to concentrate and had short attention span; however, it did not identify other alternatives attempted or other work areas such as a less stimulating environment to complete his/her task.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed, 7:00-shower, 730-breakfast, chores, meds, 9:00-11:00 HWC, 10:30-hydration/snack, 11:00 home for lunch. Afternoon: 12:00 [pm]- brush teeth, 1:30-3:30 HWC for activities, 2:30-hydration break, 3:30-return home . . ."

During an observation on 09/30/25 at 1:35 PM of the HWC, C2 was sitting in a chair at table with several peers. C2 had his/her hands over his/her ears. Staff attempted to get C2 to engage in writing something on a paper fan. C2 appeared to become over stimulated and began engaging in SIB. The QIDP asked C2 if he/she wanted to go home. The QIDP did not attempt to assist the client to a less stimulating environment to work on any task. The HWC was one open room and there were approximately 20 clients from both ICF facilities. The clients were not engaged in any meaningful active treatment or programing.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that a CFA had been completed in the past year.

Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . What are [his/her] daily routines? Morning: 6:00 wake up, toilet, get dressed, 7:30-breakfast, brush teeth, meds, 900-Health and Wellness Activities, 10:30-Hydration, 11:30-Lunch. Afternoon: 1:00-return to HWC (activities and goal training), 3:00-retun home, 4:30-dinner, watch television/movies/leisure time . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] employment history: [C2's Name] worked on Honda parts . . . Past years vocational progress: Vocational goals prior to moving into ICF . . . Counting 30 e-lids, setting up/using and replacing [his/her] foot stool, increasing [his/her] earning by 5% and navigating to employment site on computer . . . Employment goals: No Vocational goals as [he/she] now attends Health and Wellness Center . . ." There is no opportunity for the client to work or other vocational opportunities as the facility no longer has a day training program.

During an observation on 09/30/25 at 1:33 PM at the HWC, C3 was sitting at a table with several of his/her peers. C3 stated he/she was waiting on a fan so he/she could sign his/her name. The client's schedule had him/her arriving at the HWC at 1:00 PM indicating the client had not been engaged in meaningful active treatment since arriving.

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 "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-wake, shower, 7:30-breakfast, meds, brush teeth, 10:00-break, 11:00 lunch. Afternoon: 1:00 go to HWC, 3:00-return home . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] educational history: Pre-vocational program, Competitive employment part time at Auburn Hotel and Dixon Conference, and sheltered workshop at [facility name] . . . Past year's vocational progress: Discharged from the Vocational Program 04/30/21 . . ." The IPP indicated the client was very independent with most daily tasks and activities of daily living (ADLs); however, the client is not receiving any type of skills training or afforded the opportunity to use his/her strength of independence in an aggressive active treatment program.

,

5. Review of C5's EMR and paper medical record revealed no documented evidence a CFA had been completed in the past year.

Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . F. What are [his/her] daily routines? Morning: 7:15AM- Get up cleanup/bath, dressed, 8:00AM-First Feeding-peg tube (take meds with feeding); brush teeth during waiting intervals. 10:15-10:30 AM-return to bed and check brief, 11:30-Second feeding-peg tube (take meds with feeding); check brief. Afternoon: 1:00 PM-Health and Wellness Center, 2:30PM-Lie Down, 4:00 PM-third feeding-peg tube and check brief . . ." The schedule did not include any type of meaningful active treatment or other type of training program.

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 "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00 AM-Wake up, shower and get dresses, 7:30-breakfast, 8:00-take meds, 9:00-go to HWC, 11:30-Return to [facility home name] for lunch. Afternoon: 12:30-brush teeth, 1:00 Go to HWC center, 4:00 return to house . . ."

During an interview on 10/03/25 at 1:11 PM, Family Member (F) 6 stated the facility used to have better programs than what they do now. F6 stated this morning he/she went to the HWC with C6. F6 stated there were several clients in the building from both facilities and they played one game of bingo with the clients and then all the clients sat there doing nothing while staff talked to each other. F6 stated C6 did not even like bingo. When asked if C6 would be interested in learning a new skill for vocational or work, F6 stated C6 could not work a real job. When asked if C6 could complete tasks independently or even with staff help of something like stringing a bead on a string, or moving items from one place to another, F6 stated "Yes, that would be good for [him/her]." F6 stated C6 did help with laundry in the home by pushing the laundry cart to the laundry room door. F6 stated he/she wished the facility would bring back the programming like they once had.

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," dated 07/10/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-Wake up, shower, dress, 7:30-breakfast, ears cleaned, medications, 9:00 -Go to HWC, 11"30-lunch, brush teeth. Afternoon: 1:00 go to HWC, 4:00-return to [home name] for dinner . . ."

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked or had a job at the facility, C7 stated "No." When asked if he/she had ever worked since he/she had been at the facility, C7 stated "Yes." C7 stated he/she answered phones for the wellness center at one time. When asked why he/she did not work there anymore, C7 stated "I don ' t know." When asked if he/she missed working, C7 stated "Yes." C7 stated he/she missed working because he/she made money.

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," dated 02/20/25 and provided by the facility, revealed, ". . .F. What are [his/her] daily routines? Morning: 6:00-wake up, shower, and get dressed. 7:30-breakfast, brush teeth, meds, 9:00-Health and Wellness Activities, 10:30 Hydration, 11:30/12:00-lunch and meds, and personal grooming. Afternoon: 1:00-return to HWC for activities and goal training, 3:00 return to house, 4:30-dinner, watch tv/movies, leisure . . ." C8's activity schedule did not include any training programing due to facility not having a day training program.

The facility did not have a day training program and only activities and games were offered to the clients each day.

During an interview on 09/30/25 at 1:45 PM, the QIDP stated the facility did not focus on any type of vocational training for the clients. The QIDP stated the facility just tried to keep the clients involved in games and activities. The QIDP also stated that a lot of the clients wanted to work.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day program for the clients.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each client received a continuous and aggressive active treatment program to acquire behaviors and skills to live an independent life as possible that mirrored a normal living experience as possible for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility failed to have a Qualified Intellectual Disability Professional (QIDP) to ensure the facility had a day training program for the clients to obtain or maintain vocational skills and promote vocational readiness with an on the job training program, and/or other program bases on a Comprehensive Functional Assessment (CFA) completed by a person or persons with the competency needed to complete all sections of the CFA including the Vocational section. Thes failures negatively impacted all 15 clients of the facility.

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 . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . . 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 05/01/25 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). The CFA documented C1's desire to be independent as possible including working to make money and to be able to exercise his/her independence to socialize and independently visit with friends who live on campus; however, the facility's lack of programing that was meaningful to C1 impeded the client from self-determination.

Review of C1's "Individual Program Plan (IPP)," dated 05/01/25 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed. 7:30-breakfast, brush teeth, take a shower, 8:00-take meds, 9:00-11:30- HWC [Health and Wellness Center], 11:30-1:30 [pm]- lunch. Afternoon: 1:30-HWC for activities and goal training, 3:30-return to house . . ." The IPP did not incorporate in C1's schedule a day training program where goals and objectives meaningful to him/her were implemented.

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. The CFA documented under the "Vocational Skills" section that C2 no longer participated in the workshop due to the client's behavioral issues. The CFA documented the client was no longer able to concentrate and had short attention span; however, it did not identify other alternatives attempted or other work areas such as a less stimulating environment to complete his/her task.

Review of C2's "IPP," dated 11/21/24 and provided by the facility, revealed, ". . . What are [his/her] daily routines? Morning: 6:30 [am]-wake up, get dressed, 7:00-shower, 730-breakfast, chores, meds, 9:00-11:00 HWC, 10:30-hydration/snack, 11:00 home for lunch. Afternoon: 12:00 [pm]- brush teeth, 1:30-3:30 HWC for activities, 2:30-hydration break, 3:30-return home . . ."

During an observation on 09/30/25 at 1:35 PM of the HWC, C2 was sitting in a chair at table with several peers. C2 had his/her hands over his/her ears. Staff attempted to get C2 to engage in writing something on a paper fan. C2 appeared to become over stimulated and began engaging in SIB. The QIDP asked C2 if he/she wanted to go home. The QIDP did not attempt to assist the client to a less stimulating environment to work on any task. The HWC was one open room and there were approximately 20 clients from both ICF facilities. The clients were not engaged in any meaningful active treatment or programing.

3. Review of C3's electronic medical record (EMR) and paper medical record revealed no documented evidence that a CFA had been completed in the past year.

Review of C3's "IPP," dated 05/09/25 and provided by the facility, revealed the client was a 71 year old client who was admitted to the facility 07/12/10 with diagnoses which included cerebral palsy and moderate intellectual disabilities. The IPP also revealed, ". . . What are [his/her] daily routines? Morning: 6:00 wake up, toilet, get dressed, 7:30-breakfast, brush teeth, meds, 900-Health and Wellness Activities, 10:30-Hydration, 11:30-Lunch. Afternoon: 1:00-return to HWC (activities and goal training), 3:00-retun home, 4:30-dinner, watch television/movies/leisure time . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] employment history: [C2's Name] worked on Honda parts . . . Past years vocational progress: Vocational goals prior to moving into ICF . . . Counting 30 e-lids, setting up/using and replacing [his/her] foot stool, increasing [his/her] earning by 5% and navigating to employment site on computer . . . Employment goals: No Vocational goals as [he/she] now attends Health and Wellness Center . . ." There is no opportunity for the client to work or other vocational opportunities as the facility no longer has a day training program.

During an observation on 09/30/25 at 1:33 PM at the HWC, C3 was sitting at a table with several of his/her peers. C3 stated he/she was waiting on a fan so he/she could sign his/her name. The client's schedule had him/her arriving at the HWC at 1:00 PM indicating the client had not been engaged in meaningful active treatment since arriving.

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 "IPP," dated 12/12/24 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-wake, shower, 7:30-breakfast, meds, brush teeth, 10:00-break, 11:00 lunch. Afternoon: 1:00 go to HWC, 3:00-return home . . . Summary of Employment and Educational Background/Vocational History . . . Describe [his/her] educational history: Pre-vocational program, Competitive employment part time at Auburn Hotel and Dixon Conference, and sheltered workshop at [facility name] . . . Past year's vocational progress: Discharged from the Vocational Program 04/30/21 . . ." The IPP indicated the client was very independent with most daily tasks and activities of daily living (ADLs); however, the client is not receiving any type of skills training or afforded the opportunity to use his/her strength of independence in an aggressive active treatment program.

,

5. Review of C5's EMR and paper medical record revealed no documented evidence a CFA had been completed in the past year.

Review of C5's "IPP," dated 08/20/25 and provided by the facility, revealed the client was a 44 year old client who was admitted to the facility on 08/06/14 with diagnoses which included Wolf-Hirschhorn Syndrome, profound intellectual disabilities, and epilepsy. The IPP also revealed, ". . . F. What are [his/her] daily routines? Morning: 7:15AM- Get up cleanup/bath, dressed, 8:00AM-First Feeding-peg tube (take meds with feeding); brush teeth during waiting intervals. 10:15-10:30 AM-return to bed and check brief, 11:30-Second feeding-peg tube (take meds with feeding); check brief. Afternoon: 1:00 PM-Health and Wellness Center, 2:30PM-Lie Down, 4:00 PM-third feeding-peg tube and check brief . . ." The schedule did not include any type of meaningful active treatment or other type of training program.

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 "IPP," dated 02/06/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00 AM-Wake up, shower and get dresses, 7:30-breakfast, 8:00-take meds, 9:00-go to HWC, 11:30-Return to [facility home name] for lunch. Afternoon: 12:30-brush teeth, 1:00 Go to HWC center, 4:00 return to house . . ."

During an interview on 10/03/25 at 1:11 PM, Family Member (F) 6 stated the facility used to have better programs than what they do now. F6 stated this morning he/she went to the HWC with C6. F6 stated there were several clients in the building from both facilities and they played one game of bingo with the clients and then all the clients sat there doing nothing while staff talked to each other. F6 stated C6 did not even like bingo. When asked if C6 would be interested in learning a new skill for vocational or work, F6 stated C6 could not work a real job. When asked if C6 could complete tasks independently or even with staff help of something like stringing a bead on a string, or moving items from one place to another, F6 stated "Yes, that would be good for [him/her]." F6 stated C6 did help with laundry in the home by pushing the laundry cart to the laundry room door. F6 stated he/she wished the facility would bring back the programming like they once had.

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," dated 07/10/25 and provided by the facility, revealed, ". . . F. What are [his/her] daily routines? Morning: 6:00-Wake up, shower, dress, 7:30-breakfast, ears cleaned, medications, 9:00 -Go to HWC, 11"30-lunch, brush teeth. Afternoon: 1:00 go to HWC, 4:00-return to [home name] for dinner . . ."

During an interview on 09/30/25 at 5:02 PM, when asked if he/she worked or had a job at the facility, C7 stated "No." When asked if he/she had ever worked since he/she had been at the facility, C7 stated "Yes." C7 stated he/she answered phones for the wellness center at one time. When asked why he/she did not work there anymore, C7 stated "I don ' t know." When asked if he/she missed working, C7 stated "Yes." C7 stated he/she missed working because he/she made money.

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," dated 02/20/25 and provided by the facility, revealed, ". . .F. What are [his/her] daily routines? Morning: 6:00-wake up, shower, and get dressed. 7:30-breakfast, brush teeth, meds, 9:00-Health and Wellness Activities, 10:30 Hydration, 11:30/12:00-lunch and meds, and personal grooming. Afternoon: 1:00-return to HWC for activities and goal training, 3:00 return to house, 4:30-dinner, watch tv/movies, leisure . . ." C8's activity schedule did not include any training programing due to facility not having a day training program.

The facility did not have a day training program and only activities and games were offered to the clients each day.

During an interview on 09/30/25 at 1:45 PM, the QIDP stated the facility did not focus on any type of vocational training for the clients. The QIDP stated the facility just tried to keep the clients involved in games and activities. The QIDP also stated that a lot of the clients wanted to work.

During an interview on 10/01/25 at 3:50 PM, when asked how often the CFA was to be completed or updated, the QIDP stated he/she thought the CFA was to be completed annually. When asked again about the Vocational section of the CFA, the QIDP stated he/she did not complete or ensure a vocational assessment was completed because even though at least 50 percent of the clients of the facility wanted to work or learn skills, the facility did not have a day program to teach these skills or jobs the clients could work.

During an interview on 10/04/25 at 6:41 PM, the facility Director confirmed the facility did not have a day program for the clients.