| 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) |
| W0225 | INDIVIDUAL PROGRAM PLAN CFR(s): 483.440(c)(3)(v) The comprehensive functional assessment must include, as applicable, vocational skills. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long-term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. 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]) . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . ." 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). Continued review of C1's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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 the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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, including a vocational assessment. 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 which included a vocational assessment. 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 the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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 "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. During an interview on 09/30/25 at 1:45 PM, when asked about the vocational section of the CFAs, the QIDP stated the facility did not focus on vocational training. 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 training or vocational training program; however, the facility has already started working on implementing one. The Director confirmed the missing CFAs and stated his/her expectation was they would be completed timely. The Director stated it was his/her expectation the QIDP would have ensured the vocational section of the CFAs would be completed per regulatory requirement. Based on record review and interview, the facility failed to ensure the Comprehensive Functional Assessment (CFA) included an individualized vocational assessment for all domains for what skills clients can and cannot do and addressed job sampling, job development, on-site job training, and long-term follow-up for eight of eight sampled clients (Client (C) 1, C2, C3, C4, C5, C6, C7, and C8). The facility did not have a day training program for clients to be able to be properly assessed, learn new skills, and maintain the skills they have. This failure had the potential to negatively impact all 15 clients who resided at the facility. 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]) . . . Directs the assigned ICF/IID resident ' s comprehensive functional assessment (CFA) and individual program plan (IPP) . . ." 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). Continued review of C1's CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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 the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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, including a vocational assessment. 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 which included a vocational assessment. 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 the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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 "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. 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. Continued review of the CFA revealed the "Vocational" section failed to include what skills the client could and could not do and did not include the client was offered job sampling, job development, nor on-site job training opportunities. During an interview on 09/30/25 at 1:45 PM, when asked about the vocational section of the CFAs, the QIDP stated the facility did not focus on vocational training. 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 training or vocational training program; however, the facility has already started working on implementing one. The Director confirmed the missing CFAs and stated his/her expectation was they would be completed timely. The Director stated it was his/her expectation the QIDP would have ensured the vocational section of the CFAs would be completed per regulatory requirement. |