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 713026 (X3) Date Survey Completed 04/09/2026
Name of Provider or Supplier Bogalusa Rehabilitation Hospital Street Address, City, State 621 Columbia Street, Bogalusa, LA
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)
A0000 Recertification Survey Abbreviations: MD = Doctor of Medicine BLS = Basic Life Support AED = Automatic External Defibrillator EMS = Emergency Medical Services VIN = Vehicle Identification Number H & P = History and Physical CVA = Cerebrovascular Accident PI/QI = Performance Improvement/Quality Improvement
A0052 MEDICAL STAFF
CFR(s): 482.12((a)(8), (a)(9)

[The governing body must:] (8) Ensure that, when telemedicine services are furnished to the hospital's patients through an agreement with a distant-site hospital, the agreement is written and that it specifies that it is the responsibility of the governing body of the distant-site hospital to meet the requirements in paragraphs (a)(1) through (a)(7) of this section with regard to the distant -site hospital's physicians and practitioners providing telemedicine services. The governing body of the hospital whose patients are receiving the telemedicine services may, in accordance with §482.22(a)(3) of this part, grant privileges based on its medical staff recommendations that rely on information provided by the distant-site hospital. (9) Ensure that when telemedicine services are furnished to the hospital's patients through an agreement with a distant-site telemedicine entity, the written agreement specifies that the distant-site telemedicine entity is a contractor of services to the hospital and as such, in accordance with §482.12(e), furnishes the contracted services in a manner that permits the hospital to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in paragraphs (a)(1) through (a)(7) of this section with regard to the distant-site telemedicine entity ' s physicians and practitioners providing telemedicine services. The governing body of the hospital whose patients are receiving the telemedicine services may, in accordance with §482.22(a)(4) of this part, grant privileges to physicians and practitioners employed by the distant-site telemedicine entity based on such hospital's medical staff recommendations; such staff recommendations may rely on information provided by the distant-site telemedicine entity.


This STANDARD is not met as evidenced by:
Based on record review and interview the hospital failed to grant privileges to the individual physicians employed by the distant-site telemedicine entity. Findings: Review of the provided medical staff files failed to include any radiologists. In interview on 04/08/2026 at 2:20 PM, S3CPO verified the contracted radiology provider was responsible for ensuring the radiologists maintained the credentialing to meet state and federal regulations and the governing body of the hospital had granted privileges to the group not the individual physicians. S3CPO verified she did not have a list of the names of the radiologists who worked for the contracted entity and the hospital was not updated as radiologists were added or removed from the group.
A0073 INSTITUTIONAL PLAN AND BUDGET
CFR(s): 482.12(d)

The institution must have an overall institutional plan that meets the following conditions: (1) The plan must include an annual operating budget that is prepared according to generally accepted accounting principles. (2) The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense. (3) The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable. (4) The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following: (i) Acquisition of land; (ii) Improvement of land, buildings, and equipment; or (iii) The replacement, modernization, and expansion of buildings and equipment.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure the institutional plan included the current year annual operating budget which included all anticipated income and expenses prepared according to generally accepted accounting principles. Findings: Review of the hospital's policy #00-06-03 titled "General Provisions - Budget", adopted January 2020 revealed in part: "Policy - Institutional Budget & Plan: The hospital shall have an institutional budget & plan that meets the following conditions: - An annual operating budget that is prepared according to the generally accepted principles; - It shall include all income and expenses, including all programming with revenue stream & expense." Review of the Governing Board minutes dated January 21st, 2026 revealed in part: New Business: This meeting is an annual/quarterly meeting of the Governing Board. Review and approval of the 3-year capital expenditure and budget. Review of the documents attached to the Governing Board minutes dated January 21st, 2026 revealed in part the 3-year capital expenditure budget summary document, but no annual operating budget was found. On 04/06/2026 at 9:25 a.m., during the entrance conference with S24EA, a document request list was provided which outlined the request for a copy of the hospital's current annual operating budget and Governing Board meeting minutes from 01/01/2025 to present. On 04/06/2026 at 2:33 p.m., a second request was made to S24EA and S1NSM for all outstanding requested documents from the document request list provided during the entrance conference which included the hospital's current annual operating budget and Governing Board meeting minutes from 01/01/2025 to present. On 04/07/2026 at 8:17 a.m., a third request was made to S3CPO for the hospital's current annual operating budget and Governing Board meeting minutes from 01/01/2025 to present. S3CPO stated she would provide it. On 04/08/2026 at 8:28 a.m., a fourth request was made to S3CPO for the hospital's current annual operating budget and Governing Board meeting minutes from 01/01/2025 to present. S3CPO stated she would provide it. On 04/09/2026 at 9:25 a.m., a fifth request was made to S3CPO for the hospital's current annual operating budget and Governing Board meeting minutes from 01/01/2025 to present. S3CPO stated she would provide it. On 04/09/2026 at 5:20 p.m., S3CPO provided the hospital's Governing Board meeting minutes for the following dates: September 25th, 2025 (Special Meeting); October 22nd, 2025 (Agenda only, no minutes); July 23rd, 2025; January 21st, 2026; and March 10th, 2026 (Special Meeting). On 04/09/2026 at 6:00 p.m., during the exit conference, S3CPO stated the hospital's current annual operating budget was within the Governing Board meeting minutes dated January 21st, 2026.
A0115 PATIENT RIGHTS
CFR(s): 482.13

A hospital must protect and promote each patient's rights.


This CONDITION is not met as evidenced by:
Based on observations and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights. The deficient practice was evidenced by: 1) Failure to ensure the medical record was prominently documented as to whether or not the patient had an advanced directive in 2 (#22, #23) of 30 medical records reviewed (See Findings Tag A0132); 2) Failure to ensure the basic life support guidelines were followed during an emergent condition of 1 (#6) of 1 rapid response event reviewed (See Findings Tag A0144); 3) Failure to ensure the nurse call system was functioning via call buttons located on the side rails of the patient's beds in Rooms "a"- "k" (See Findings Tag A0144); 4) Failure to ensure documentation of quality controls performed on glucometers used in the hospital (See Findings Tag A0144); 5) Failure to ensure the driver of the hospital's van that transports patients had a chauffer's license and followed hospital policy (See Findings Tag A0144); 6) Failure to ensure the hospital's van was in safe operating condition for patient transportation (See Findings Tag A0144); and 7) Failure to appropriately label the patient's electronic medical record with the appropriate code status in 3 (#8, #16, #17) of 30 medical records reviewed (See Findings Tag A0144).
A0132 PATIENT RIGHTS: INFORMED DECISION
CFR(s): 482.13(b)(3)

The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates).


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure the medical record was prominently documented as to whether or not the patient had an advanced directive in 2 (#22, #23) of 30 medical records reviewed. Findings: A review of hospital policy titled, "Advanced and Other Healthcare Directives, DNR Orders, LAPOST," policy number unavailable, origination 03/2020 and last revised/approved 01/2024, revealed in part: "POLICY At the time of admission, patients shall be informed of their right under Louisiana and Federal Law to make decisions regarding medical care, including the right to accept or refuse medical treatment and the right to formulate an advanced directive. No patent shall be discriminated against with respect to provisions of care or otherwise, based on whether he or she executed an advanced directive. PROCEDURE FOR DETERMING, DOCUMENTING PRESENCE OF AND COMPLETING AN ADVANCED DIRECTIVE B. The Hospital will inquire of each patient at the time of admission whether or not he/she has executed an Advanced Directive and will document the answer in the patient's medical record. PROCEDURE 1. At the time of admission, all adult patients, 18 years or older, or their representative, will be asked by the admitting nurse or case manager if he/she has existing living will or durable power of attorney for health care. The admitting nurse or case manager will indicate on the Advanced Directive Acknowledgement sheet either "yes" or "no", or "revoked" based on the response from the patient or representative. The admitting nurse or case manager will ask the patient or representative to provide the original, to be copied and returned, or a copy of the advanced directive. The admitting nurse or case manager will acknowledge receipt of the Advance Directive." A review of medical records revealed the following: --Patient #22's medical record revealed a document titled, "Pre-Admission Assessment," completed on 11/10/2025 at 1:00 p.m. This assessment included a category as "Advanced directives" with the corresponding answer as, "Full code." A review of the medical record failed to reveal the documentation of patient inquiry at the time of admission related to whether or not the patient had executed an Advanced Directive; and --Patient #23's medical record revealed a document titled, "Pre-Admission Assessment," completed on 11/07/2025 at 1:45 p.m. This assessment included a category labeled as "Advanced directives" with the corresponding answer as, "Full code." A review of the medical record failed to reveal the documentation of patient inquiry at the time of admission related to whether or not the patient had executed an Advanced Directive. In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned findings. S25Consult confirmed the documentation in the pre-admission screening related to the Advance Directive category did not acknowledge whether or not the patient had an Advance Directive and only indicated the patient's code status.
A0144 PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.


This STANDARD is not met as evidenced by:
Based on record review, observation, and interview, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by: 1) Failure to ensure the basic life support guidelines were followed during an emergent condition of 1 (#6) of 1 rapid response event reviewed; 2) Failure to ensure the nurse call system was functioning via call buttons located on the side rails of the patient's beds in Rooms "a"- "k"; 3) Failure to ensure documentation of quality controls performed on glucometers used in the hospital; 4) Failure to ensure the driver of the hospital's van that transports patients had a chauffer's license and followed hospital policy; 5) Failure to ensure the hospital's van was in safe operating condition for patient transportation; and 6) Failure to appropriately label the patient's electronic medical record with the appropriate code status in 3 (#8, #16, #17) of 30 medical records reviewed. Findings: 1) Failure to ensure the basic life support guidelines were followed during an emergent condition of 1 (Patient #6) of 1 rapid response event reviewed Review of the hospital's policy # EM-29 titled, "Code Blue," effective date 06/2025 revealed in part: Policy: 1. Code Blue Team: the code blue team is available on a 24-hour basis and should be activated for any emergency (cardiac or respiratory) requiring resuscitation. All staff members are required to maintain BLS certification. 3. Code Blue Carts: Code Blue carts are to be kept in designated on each nursing unit. Post Code Blue Event, the code blue cart is to be promptly checked, exchanged, and supplies restocked by staff from the unit where the cart was used. References: BLS Provider Manual- American Heart Association. BLS guideline recommended administering 100% oxygen (10-12 LPM) during cardiopulmonary resuscitation (CPR) as soon as it becomes available. Use a bag-mask device with a reservoir to maximize oxygen delivery. Patient #6 Review of Patient #6's medical record revealed Patient #6 was admitted on 10/07/2025 for Circulatory Disorder and was a full code. Further review of medical record revealed Patient #6 became unresponsive while in the bathroom on 10/09/2025 and CPR was initiated. Review of the Patient #6's rapid response event form dated 10/09/2025 from 8:00 PM to 8:31 PM revealed Patient #6 became unresponsive in the bathroom and was transferred to bed where it was noted that Patient #6's pupils were fixated and agonal respiratory. CPR was started by staff, AED applied, oxygen increased to 10 liters via nasal cannula, and 911 called. Further review revealed MD and EMS arrived and Patient #6 was pronounced at 8:31 PM. In an interview on 04/08/2026 at 8:55 AM with S1NSM verified the above information. In an interview on 04/08/2026 at 10:35 AM S14RN verified a non-rebreather mask used to deliver 100% oxygen during an emergent situation is stored in the emergency cart at the nurses' station. 2) Failure to ensure the nurse call system was functioning via call buttons located on the side rails of the patient's beds in Rooms "a"- "k" Observations made during a walk-though on 04/06/2026 from 10:20 AM to 12:12 PM revealed nurse call buttons were located on the each side rails of the patient beds in Rooms "a" - "k." Each bed's side rails contained a nurse call button located on its interior sides (mattress sides). The nurse call button was a red button with a picture of a bell. When each of the call button was depressed, it did not activate the nurse call system at the nurses' station, illuminate the call light above the entry door or activate an audible sound that would be indicative of a patient calling for assistance. This had the potential to place undue distress and/or harm on a patient and/or a family member attempting to call staff for assistance. In an interview on 04/06/2026 at 11:00 AM S1NSM verified the above-mentioned information. 3) Failure to ensure documentation of quality controls performed on glucometers used in the hospital Observations during a walk-through of the facility and its corresponding medication room on 04/06/2026 from 10:15 a.m. to 12:10 p.m. revealed the current glucometers being used by the hospital as the EvenCare PROVIEW Meter #1 serial number (SN) #M12Y00187369, Ref: MPH4540 RLI8EMQ and EvenCare PROVIEW Meter #2 SN# unavailable (a number was not on back of meter), Ref: MPH4540 V1RE22EMQ. A request was initiated during the observations of the medication room with S14RN for the most recent documentation of quality controls being performed on each glucometer. A request was also initiated for the owner's manual related to the EvenCare PROVIEW Glucose Meter. A review of the Medline's, online user's guide titled, "EVENCARE ProView BLOOD GLUCOSE MONITORING SYSTEM USER'S GUIDE" revealed, in part: "You should perform a control solution test when: o Using the meter for the first time. o Using a new package of EVENCARE ProView Blood Glucose Test Strips. o At least once per week to verify that the meter and test strips are working properly together. o If the test strip bottle is left open. o The meter is dropped. o You suspect the meter and test strips are not working properly together. o A patient's test results do not agree with how they feel. o A patient's readings appear to be abnormally high or low. o Test strips have been exposed to a condition outside the specified storage conditions. o Practicing your testing technique." In an interview on 04/06/2026, during the observations of the medication room, S14RN confirmed the hospital did not have any documentation of quality controls being performed on these 2 glucose meters. S14RN confirmed she has performed quality control testing on the 2 glucose meters; however she has never documented this information. 4) Failure to ensure the driver of the hospital's van that transports patients has a chauffer's license and followed hospital transport policy. Requests were initiated for a policy related to transportation/transportation of patients on 04/07/2026 at 1:35 p.m. with S3CPO; a second request on 04/08/2026 at 8:30 a.m. with S3CPO and S25Consult; and a third request on 04/09/2026 at 2:30 p.m. with S3CPO and S25Consult. A policy or policies related to transportation/transportation of patients were not presented to the survey team. Review of the requirements for a Class "D" Chauffer's license and Class "E" Personal license in Louisiana revealed: (d) Class "D" Chauffeur's License. Permits the operation of all vehicles included in Class "E" plus any single motor vehicle used in commerce to transport passengers or property if the motor vehicle has a gross vehicle weight rating of ten thousand one or more pounds but less than twenty-six thousand one pounds, or any combination of vehicles used in commerce to transport passengers or property if the motor vehicle has a combined gross vehicle weight rating of ten thousand one or more pounds but less than twenty-six thousand one pounds inclusive of a towed unit with a gross vehicle weight rating of more than ten thousand pounds; or any vehicle designed or utilized for the transportation of passengers for hire or fee; and not utilized in the transportation of materials found to be hazardous under the provisions of the Hazardous Materials Transportation Act which requires the vehicle to bear a placard under the provision of Hazardous Materials Regulations, 49 CFR Part 172, Subpart F. The provisions of this Subparagraph shall not apply to taxi cab drivers. Taxi cab drivers shall only comply with the requirements for a Class "E" driver's license. (e) Class "E" Driver's License - "Personal Vehicle". Permits the operation of any single motor vehicle under ten thousand one pounds gross vehicle weight rating or any such vehicle towing a vehicle not in excess of ten thousand pounds gross vehicle weight rating; any personal use of recreational vehicle or combination of vehicles; or any vehicle which is not within the definition of Group "A", "B", "C", or "D" and not utilized in the transportation of materials found to be hazardous under the provision of the Hazardous Materials Transportation Act which requires the vehicle to bear a placard under provisions of the Hazardous Materials Regulations (49 CFR Part 172, Subpart F). This class of vehicles does not include the operation of motorcycles and motor scooters except as an endorsement to the basic license. In an interview on 04/07/2026 at 1:30 PM S3CPO verified S26RSW is the driver for the hospital who transports patients. On 04/09/2026 at 2:15 PM an observation was made of S26RSW driving the hospital van to transport a discharged patient home. Observations included S26RSW working the lift alone to place the patient in the van. In interview on 04/09/2026 at 3:39 PM, S3CPO verified S26RSW had a Class "E"- personal vehicle driver's license and the hospital had no documentation a driving record was requested from the state before allowing her to drive the van. 5) Failure to ensure the hospital's van was in safe operating condition for patient transportation On 04/07/2026 from 1:30 PM to 1:45 a tour of the hospital van revealed the van's VIN # was IFDEE3FS8CDB24530. Further observation revealed the following: no inspection sticker, no license plate, and no first aid kit. In an interview on 04/07/2026 1:45 PM S3CPO verified the hospital van has insurance. S3CPO presented the following insurance card with the following information: Progressive Paloverde Insurance Company Policy # 02248404 Effective Date: 12/16/2025 Expiration Date: 06/16/2026 Make/Model: Ford Transit T-350 H Year: 2016 Vehicle Identification #: 1FDES8PM3GKB26144 Name of Insured: Bogalusa Rehabilitation Hospital, LLC A request was made for the correct insurance card for the hospital van with the VIN# IFDEE3FS8CDB24530 from S3CPO on 04/07/2026 at 1:50 PM, 04/08/2026 at 8:40 AM, and 04/09/2026 2:30 PM. As of exit conference on 04/09/2026 at 6:30 PM, S3CPO had not provided an insurance card for the hospital van (VIN# IFDEE3FS8CDB24530) being used to transport patients. 6) Failure to appropriately label the patient's electronic medical record with the appropriate code status in 3 (#8, #16, #17) of 30 medical records reviewed. A review of medical records revealed: --Patient #8's medical record revealed an admission on 03/13/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response as "FULL CODE." This status also appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," revealed an order for "Code Status" and the corresponding response as "DNR." A review of document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) revealed Box A. "CARDIOPULMONARY RESUSCITATION (CPR): PERSON IS UNRESONSIVE, PULSELESS, AND IS NOT BREATHING," and the option checked as, "DNR/Do Not Attempt Resuscitation (Allow Natural Death)." The LaPOST form was not completed in its entirety, however the form was signed by the patient and S22MD on 03/13/2026; --Patient #16's medical record revealed an admission on 01/26/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response was not assigned (blank). This blank status appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," dated 01/26/2026, revealed an order for "Code Status" and the corresponding response as "Full code"; --Patient #17's medical record revealed an admission on 01/16/2026. The electronic medical record (EMR) face sheet had a category labeled as "Code Status" and the corresponding response was not assigned (blank). This blank status appeared in the demographic ribbon across the top of the EMR when this patient was selected. A review of the document titled, "Physician Admission Orders," dated 01/16/2026, revealed an order for "Code Status" and the corresponding response as "Full"; The clarification of the patient's code status in an emergency situation could place each of these patients safety at risk due to the withholding of emergency care related to the wrong code status being identified or emergency care being performed on a patient that had made the choice to waive emergency resuscitation care. In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned findings.
A0273 DATA COLLECTION & ANALYSIS
CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3)

(a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital's governing body.


This STANDARD is not met as evidenced by:
Based on record review and an interview, the hospital failed to provide documentation of a comprehensive ongoing program which measured, analyzed, tracked and recognized trends of quality indicators related to all services provided by the hospital. Findings: Review of the hospital's policy #02-02-01 titled "Quality Assessment & Performance Improvement" adopted January 2020 with no reviewed/revised date revealed in part" "Policy: The Hospital has an effective, written and ongoing hospital-wide program designed to assess and improve the quality of patient care. The Performance Improvement plan is approved by the Governing Board and is overseen ultimately by the Governing Board via reports from the Performance Improvement Committee. Procedure: The Performance Improvement Committee will collect indicator data from the designated department heads on a monthly basis, the committee chair, will compile data into a report for the Administrator to present to Medical Staff. The Committee will make recommendations for improving patient care, addressing problem indicators, and overall improvement of services. Information will be discussed during department head meetings and recorded as part of the minutes. Formal reports will be done quarterly by the Committee chair and submitted for the Administrator to present to Medical Staff. The procedure is as follows: 1. Each department head is given indicators to track based on the previous quarter's performance or on identified problem areas; 2. Tracking is done monthly, discussed during department head meetings with minutes reflecting any changes or corrective action needed; and 3. Information/outcomes are reported on a quarterly basis. Formal reports are also presented quarterly to the Medical Staff and the Governing Board by the Administrator." Review of the January 21st, 2026, Annual Board Meeting of the Whole which included review of the 2025 4th quarter PI/QI reports and committee function the committees provided minimal information, if any at all, regarding the quality indicators for the quarter and the quality outcomes and results of the monitoring activities gathered from the tracking and trending process. Review of the minutes from the quarterly respective board meetings held in 2025 were similar, with no detailed description of what was discussed. On 04/09/2026 at 3:56 p.m., the survey team requested the data collected and any other documentation related to how it was analyzed. S3CPO verified she did not have the information. S3CPO said the data was compiled by the corporate office and then the information was sent back to the hospital for inclusion in the committee minutes. S3CPO stated she would try to get the information, but it was not provided by the time of exit on 04/09/2026 at 6:15 p.m.
A0297 QAPI PERFORMANCE IMPROVEMENT PROJECTS
CFR(s): 482.21(d)

As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital's services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to provide evidence of ongoing Quality Improvement projects which included quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Findings: Review of the minutes provided for the Quality Improvement committee failed to reveal data related to special projects initiated to improve the quality of patient care. The minutes in most situations simply stated which topics were discussed but did not contain any relevant data. Most of the Quality Improvement topics listed in the minutes referred to reports and attachments at the end of the minutes, which were not present. On 04/09/2026 at 3:56 PM, S3CPO verified she did not have the information. S3CPO said the data was compiled by the corporate office and then the information was sent back to the hospital for inclusion in the committee minutes.
A0343 COMPOSITION OF THE MEDICAL STAFF
CFR(s): 482.22(a)(4)

When telemedicine services are furnished to the hospital's patients through an agreement with a distant-site telemedicine entity, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant- site telemedicine entity when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital's governing body ensures, through its written agreement with the distant-site telemedicine entity, that the distant-site telemedicine entity furnishes services that, in accordance with §482.12(e), permit the hospital to comply with all applicable conditions of participation for the contracted services. The hospital's governing body must also ensure, through its written agreement with the distant-site telemedicine entity, that all of the following provisions are met: (i) The distant-site telemedicine entity's medical staff credentialing and privileging process and standards at least meet the standards at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides the hospital with a current list of the distant-site physician's or practitioner's privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving such telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site telemedicine entity such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital's patients, and all complaints the hospital has received about the distant-site physician or practitioner.


This STANDARD is not met as evidenced by:
Based on record review and interview the hospital 1) failed to ensure the contracted entity providing radiology services provided a current list of credentialed physicians; and 2) the hospital failed to inform the contracted entity of all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital's patients, and all complaints the hospital has received about the distant-site physician or practitioner. Findings: Review of the provided medical staff files failed to include any radiologists. In interview on 04/08/2026 at 2:20 PM, S3CPO verified the contracted radiology provider was responsible for ensuring the radiologists maintained the credentialing to meet state and federal regulations and the governing body of the hospital had granted privileges to the group. S3CPO verified she did not have a list of the names of the radiologists who worked for the contracted entity and the hospital was not updated as radiologists were added or removed from the group. S3CO verified they did not have any information about the individual physicians and had not evaluated their invividual performance.
A0358 MEDICAL STAFF RESPONSIBILITIES - H&P
CFR(s): 482.22(c)(5)(i)

[ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure that a medical history and physical examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 3 (#18, #2, #24) of 14 (#6, #15-#19., #21, #24-#30) records reviewed. Findings: Review of the hospital's policy # 00-06-01 titled "Medical Staff By-Laws", revealed in part: ARTICLEII- Purpose: The purpose of the Medical Staff is develop and adopt bylaws and rules for self-governance of professional activity with accountability directly to the Governing Board. Section 3: Responsibilities of the Membership: 2. Each member of the Medical Staff shall: Completion of the Addendum to H&P justifying IRF admission following the pre-admission screening and after the order to admit but within the 24-hour post-admission window. This may be completed as part of the H&P or on the approved separate form. Complete and transcribed H&P on all patients no less than seven (7) days prior to admission or withing twenty-four (24) hours of admission. A. The H&P must be transcribed and, on the patient's, medical record within 24 hours of admission. The physician should document in the progress notes indicating H&P has been dictated. Review of Patient #18's medical record revealed Patient #18 was admitted on 01/15/2026 at 3:45 PM for CVA with right body involvement and discharged on 01/23/2026. Further review of Patient #18's medical record revealed the History & Physical was completed on 01/27/2026 at 11:31 AM. In an interview on 04/08/2026 at 3:49 PM S1NSM verified the above mentioned information. Review of Patient #21's medical record revealed Patient #21 was admitted on 03/17/2026 for Neuromuscular Disorder and discharged on 03/28/2026. Further review of Patient #21's medical record revealed the History & Physical was completed on 03/19/2026 at 4:26 PM. In an interview on 04/09/2026 at 5:00 PM S25Consultant verified the above mentioned information. Review of Patient #24's medical record revealed Patient #24 was admitted on 11/03/2025 at 2:15 PM for Non-Traumatic Spinal Cord Dysfunction and discharged on 11/17/2025. Further review of Patient #24's medical record revealed the History & Physical was completed on 11/18/2025 at 6:40 PM. In an interview on 04/09/2026 at 4:36 PM S25Consultant verified the above mentioned information.
A0395 RN SUPERVISION OF NURSING CARE
CFR(s): 482.23(b)(3)

A registered nurse must supervise and evaluate the nursing care for each patient.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure a registered nurse evaluated the nursing care for each patient. This deficient practice was evidenced by: 1) Failure to perform dressing change on a peripherally inserted central catheter (PICC) per policy in 1 (#10) of 30 medical records reviewed; 2) Failure to perform daily weight per provider order in 3 (#12, #15, #23) of 30 medical records reviewed; and 3) Failure to administer medication as prescribed in 1 (#22) of 30 medical records reviewed; Findings: 1) Failure to perform dressing change on a peripherally inserted central catheter (PICC) per policy in 1 of 30 medical records reviewed A review of the hospital document titled, "Bogalusa Rehabilitation Hospital PICC Line," Policy 05-17-02, adopted 03/2021, and date unavailable for last reviewed/revised, revealed in part: "PROCEDURE Dressings will be changed within 24 hours of insertion and every 7 days hours or as needed." A review of Patient #10's medical record revealed an admission date of 03/03/2026 and a discharge date of 03/15/2026. A review of document titled, "Nursing Shift Assessment," dated 03/15/2026 with a start time of 7:00 a.m. and end time of 7:00 p.m. revealed a nursing note at 10:25 a.m. by S28LPN as follows, "1025-Changed Tegaderm dressing d/t dressing last changed on 3/3 & was coming off." In an interview on 04/08/2026 at 10:35 a.m., S28LPN confirmed above-mentioned information and confirmed the dressing had not been changed since 03/03 as was indicated on the Tegaderm dressing. 2) Failure to perform daily weight per provider order in 3 (#12, #15, #23) of 30 medical records reviewed A review of medical records revealed: --Patient #12's medical record revealed an admission date of 02/26/2026 and a discharge date of 03/13/2026. A review of the document titled, "Physician Admission Orders" dated 02/26/2026 revealed an order for "Daily" weights. A review of the patient's Medication Administration Record (MAR) revealed a row labeled "DAILY WEIGHTS EVERY NIGHT" and a performance time indicated as 5:00 a.m. on each day. The MAR failed to reveal the documentation of a weight on 02/27/2026 to 03/06/2026, 03/10/2026, 03/11/2026 and 03/13/2026; --Patient #15's medical record revealed an admission date of 02/04/2026 and a discharge date of 02/13/2026. A review of the document titled, "Physician Admission Orders" dated 02/04/2026 revealed an order for "Daily" weights. A review of the patient's Medication Administration Record (MAR) revealed a row labeled "DAILY WEIGHTS EVERY NIGHT" and a performance time indicated as 5:00 a.m. on each day. The MAR failed to reveal the documentation of a weight on 02/05/2026 to 02/13/2026; and --Patient #23's medical record revealed an admission date of 11/07/2025 and a discharge date of 11/17/2025. A review of the document titled, "Physician Admission Orders" dated 11/07/2025 revealed an order for "Daily" weights. A review of the patient's Medication Administration Record (MAR) revealed a row labeled "DAILY WEIGHTS EVERY NIGHT" and a performance time indicated as 5:00 a.m. on each day. The MAR failed to reveal the documentation of a weight on 11/08/2025 to 11/11/2025 and 11/13/2025 to 11/17/2025. In an interview on 04/09/2026 at 11:00 a.m., S25Consult confirmed above-mentioned findings and the daily weight would be documented on the MAR section of the medical record. 3) Failure to administer medication as prescribed in 1 (#22) of 30 medical records reviewed A review of Patient #22's medical record revealed a provider order dated 11/22/2025 at 9:30 a.m. for, "Vitamin D 50,000 units po weekly on Sundays." A review of the patient's Medication Administration Record (MAR) revealed a row labeled with handwritten print as follows: "Vitamin D 50,000 units PO Q weekly (Sundays) 11-22-25." This row also had a handwritten box surrounding the day indicated as 11/23/2025. However, the MAR failed to reveal the administration of this prescribed medication on 11/22/2025 or 11/23/2025. In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned findings.
A0450 MEDICAL RECORD SERVICES
CFR(s): 482.24(c)(1)

All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure all patient medical record entries are complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. This deficient practice is evidenced by: 1) Failure to ensure the LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) being used on all medical records was completed in its entirety in 5 (#8, #14, #16, #17, #23) of 30 medical records reviewed; and 2) Failure to ensure the Weekly Treatment Team notes were authenticated by all disciplines in attendance in 10 (#7, #11 - #15, #17, #18, #22, #23) of 30 medical records reviewed. Findings: 1) Failure to ensure the LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) being used on all medical records was completed in its entirety in 5 (#8, #14, #16, #17, #23) of 30 medical records reviewed A review of hospital policy titled, "Advanced and Other Healthcare Directives, DNR Orders, LAPOST," policy number unavailable, origination 03/2020 and last revised/approved 01/2024, revealed in part: "POLICY At the time of admission, patients shall be informed of their right under Louisiana and Federal Law to make decisions regarding medical care, including the right to accept or refuse medical treatment and the right to formulate an advanced directive. No patent shall be discriminated against with respect to provisions of care or otherwise, based on whether he or she executed an advanced directive. DEFININTIONS OF TERMS C. LaPOST (Louisiana Physician Order for Scope of Treatment) - An easily identifiable and standardized document that translates a patient's end of life wishes and goals of care into a physician order that transfers across health care settings. Guidelines for treating patient who present with a Louisiana Physician Order for Scope of Treatment ("LaPOST") form and for assisting patients in completing LaPOST forms. A. Policy 1. The Louisiana Physician Order for Scope of Treatment (LaPOST) is a physician order form that translates a patient's end of life wishes and goals of care into physician orders that transfer with the patient across health care settings. 3. The LaPOST document must be signed by physician and by the patient, or if the patient lacks decision-making capacity, the legally recognized personal health care representative. 4. The LaPOST document can be completed on a qualified patient regardless of age. It is useful for patients who have a life limiting illness with a prognosis of one year or less, or who are frail and elderly. It is used as a part of the health care planning process and is complementary with advanced directives. The LaPOST document however, may be used in the absence of those documents. C. Procedure 2. COMPLETING A LaPOST FORM WITH A PATIENT a. If the patient or the patient's legally recognized personal health care representative wishes to complete a LaPOST form, the patient's physician should be contacted. The physician should discuss treatment options including information about the patient's advanced directive (if any) or other statements the patient has made regarding his/her wishes for endo of life care and treatments. The benefits, burdens, efficacy and appropriateness of treatment and medical interventions should be discussed by the physician with the patient and/or the patient's legally recognized personal health care representative. b. another member of the health care team such as a nurse or social worker can explain the LaPOST form to the patient and/or the patient's legally recognized personal health care representative, however the physician is responsible for discussing the treatment options with the patient or the patient's legally recognized personal health care representative. c. the above-described discussions will be documented in the medical record, dated and timed. E. The LaPOST document must be signed by a physician and by the patient, or it the patient lacks decision making capacity, the patient's legally recognized personal health care representative." A review of medical records revealed: --A review of Patient #8's medical record revealed an admission date of 03/13/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 03/13/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box B which was related to medical interventions a patient would choose if he/she had a pulse or was breathing, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; --A review of Patient #14's medical record revealed an admission date of 02/11/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient (a date was not placed) and by S22MD on 02/11/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box B which was related to medical interventions a patient would choose if he/she had a pulse or was breathing, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; --A review of Patient #16's medical record revealed an admission date of 01/26/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 01/26/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; and --A review of Patient #17's medical record revealed an admission date of 01/16/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 01/16/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive. --A review of Patient #23's medical record revealed an admission date of 11/07/2025 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient on 11/07/2025 and S20MD (a date was not placed). The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive. In an interview on 04/09/2026 at 11:00 a.m., S25Consult confirmed the above-mentioned findings. 2) Failure to ensure the Weekly Treatment Team notes were authenticated by all disciplines in attendance in 10 (#7, #11 - #15, #17, #18, #22, #23) of 30 medical records reviewed A review of the hospital document titled, "Bogalusa Rehabilitation Inpatient Rehabilitation Services: Treatment Team," Policy 06-04-01, adopted 03/2021, and date unavailable for last reviewed/revised, revealed in part: "POLICY Bogalusa Rehab Hospital's inpatients are staffed by an interdisciplinary treatment team at least every 7 days at a regularly scheduled time. The treatment team evaluates patient progress towards goals, discharge criteria and plans, and establishes post-discharge recommendations. POLICY STATEMENT The interdisciplinary treatment team consists of each discipline actively treating the patient during the IRF [inpatient rehabilitation facility] stay. It includes (but is not limited to) the following: 1. Medical Director of Rehabilitation Services 2. Director of Nurses or Utilization Review Nurse 3. Physical therapist 4. Occupational therapist 5. Social Services 6. Speech therapy 7. Dietary Manager [.]" A review of medical records revealed the interdisciplinary treatment team weekly team conference as follows: --A review of Patient #7's medical record revealed the document titled, "Weekly Team Conference" and dated 01/13/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #11's medical record revealed the document titled, "Weekly Team Conference" and dated 03/02/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S32RN; Physical Therapy, S15PT; and Case Management, S33RN; --A review of Patient #12's medical record revealed the document titled, "Weekly Team Conference" and dated 03/02/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S32RN; Physical Therapy, S15PT; and Case Management, S33RN; --A review of Patient #13's medical record revealed the document titled, "Weekly Team Conference" and dated 02/23/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN and Physical Therapy, S15PT; --A review of Patient #14's medical record revealed the document titled, "Weekly Team Conference" and dated 02/17/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S14RN; Occupational Therapy, S8OT; and Case Management, S33RN; --A review of Patient #15's medical record revealed the document titled, "Weekly Team Conference" and dated 02/10/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN and Case Management, S33RN; --A review of Patient #17's medical record revealed the document titled, "Weekly Team Conference" and dated 01/20/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #18's medical record revealed the document titled, "Weekly Team Conference" and dated 01/20/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #22's medical record revealed the document titled, "Weekly Team Conference" and dated 11/11/2025. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; Occupational Therapy, S16COTA; and Speech Language Pathology, S31SLP; and --A review of Patient #23's medical record revealed the document titled, "Weekly Team Conference" and dated 11/11/2025. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP In an interview on 04/09/2026 at 11:00 a.m., S25Consult confirmed the above-mentioned findings.
A0454 CONTENT OF RECORD: ORDERS DATED & SIGNED
CFR(s): 482.24(c)(2)

All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure verbal orders were dated, timed and/or authenticated promptly by the ordering provider in 4 (#3, #4, #7, #9) of 30 medical records reviewed for verbal orders. Findings A review of the hospital document titled, "Bogalusa Rehabilitation Hospital Medical Staff Rules & Regulations," Policy 00-06-01, adopted 01/2020, and date unavailable for last reviewed/revised, revealed in part: "Article X - Adoption and Amendment of Bylaws VERBAL & ELECTRONIC ORDERS: Any order received verbally or electronically (by phone, fax, etc.) from a medical staff physician will be taken by a party authorized by scope of practice to accept such orders (i.e. licensed nurse). -The physician giving the order will have up to 10 days following the date the order was given to sign or countersign authenticated such orders. -All authentications will include the signature, date and time of the authentication. Article IX - RULES & REGULATIONS OF MEDICAL STAFF 19. Verbal and telephone orders will only be given to health care professionals operating within their scope of practice. Physician is required to co-sign verbal or telephone orders. Verbal orders must be clearly documented with the names of who received the order, who gave the order, when it was recorded and when it was implemented. Verbal orders must be authenticated in timeframe specified in hospital policy in accordance with regulations (within 10 days)." A review of the hospital document titled, "Bogalusa Rehabilitation Hospital Orders & Evaluation," Policy 06-01-05, adopted 12/2022, and date unavailable for last reviewed/revised, revealed in part: "POLICY STATEMENT All MD orders must be dated/timed. All verbal and/or telephone orders have to be co-signed by the physician within 10 calendar days following the date on an order per Louisiana Statute. Although, "prompt" cosigning is preferred within 48 hours." A review of medical records revealed: --Patient #3's medical record revealed an admission date of 02/06/2026 and the document titled, "PRN MEDICATIONS." The document was authenticated as telephone order read back (TORB), however the document failed to include a date and time associated with this order and the provider had not authenticated/cosigned this TORB order; -Patient #4's medical record revealed an admission date of 03/10/2026 and the document titled, "XPRESS RAY, INC MOBILE X-RAY SERVICE EXAM REQUISTION/ORDER FORM" and dated 03/25/2026. This order form failed to reveal the name of the ordering provider, the time associated with the order, provider authentication of this order and the medical record failed to reveal an entry in the provider's orders related to this x-ray; --Patient #7's medical record revealed an admission date of 12/31/2025 and the document titled, "XPRESS RAY, INC MOBILE X-RAY SERVICE EXAM REQUISTION/ORDER FORM" and dated 01/14/2026. This order form failed to reveal the time associated with the order, provider authentication of this order and the medical record failed to reveal an entry in the provider's orders related to this x-ray; and --Patient #9's medical record revealed an admission date of 08/04/2025 and the document titled, "PRN MEDICATIONS." The document was authenticated as telephone order read back (TORB), however the document failed to include a date and time associated with this order and the provider had not authenticated/cosigned this TORB order. In an interview on 04/09/2026 at 11:00 a.m. confirmed the above-mentioned findings.
A0457 CONTENT OF RECORD: STANDING ORDERS
CFR(s): 482.24(c)(3)

(3) Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital: (i) Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital's nursing and pharmacy leadership; (ii) Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines; (iii) Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure standing order protocols related to venous thromboembolism prophylaxis (VTE) were reviewed and approved by the medical staff, and the hospital's nursing and pharmacy leadership. Findings: A request was initiated on 04/08/2026 at 4:25 p.m. with S25Consult for a policy/procedure, protocol and its corresponding approval related to the hospital's VTE Prophylaxis Protocol. A review of medical records revealed the following: --Patient #2's medical record revealed the document, "Physician Admission Orders" dated 03/24/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #3's medical record revealed the document, "Physician Admission Orders" dated 02/06/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #4's medical record revealed the document, "Physician Admission Orders" dated 03/10/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #5's medical record revealed the document, "Physician Admission Orders" dated 02/24/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #6's medical record revealed the document, "Physician Admission Orders" dated 10/07/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #7's medical record revealed the document, "Physician Admission Orders" dated 12/31/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #8's medical record revealed the document, "Physician Admission Orders" dated 03/13/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #9's medical record revealed the document, "Physician Admission Orders" dated 08/04/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #10's medical record revealed the document, "Physician Admission Orders" dated 03/03/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #11's medical record revealed the document, "Physician Admission Orders" dated 02/27/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #12's medical record revealed the document, "Physician Admission Orders" dated 02/26/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #13's medical record revealed the document, "Physician Admission Orders" dated 02/19/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #14's medical record revealed the document, "Physician Admission Orders" dated 02/11/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #15's medical record revealed the document, "Physician Admission Orders" dated 02/04/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #16's medical record revealed the document, "Physician Admission Orders" dated 01/26/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #17's medical record revealed the document, "Physician Admission Orders" dated 01/16/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #18's medical record revealed the document, "Physician Admission Orders" dated 01/15/2026. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; --Patient #22's medical record revealed the document, "Physician Admission Orders" dated 11/11/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use; and --Patient #23's medical record revealed the document, "Physician Admission Orders" dated 11/07/2025. The orders included the category labeled, "Protocols" and the following order, "VTE Prophylaxis Protocol." The medical record failed to reveal documentation related to this protocol being initiated or interventions related to venous thromboembolism prophylactic treatment such as pharmacological agents or mechanical devices use. In an interview on 04/09/2026 at 9:00 a.m., S25Consult confirmed the above-mentioned findings and the hospital did not have a policy/procedure or protocol related to this physician order for VTE Prophylaxis Protocol.
A0468 CONTENT OF RECORD: DISCHARGE SUMMARY
CFR(s): 482.24(c)(4)(vii)

[All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure the discharge summary discussed the outcome of the hospitalization, disposition of care and provisions for follow-up care. This deficient practice was evidenced by: 1) Failure to identify the reason of patient discharge within 4 days of admissions with anticipated length of stay of 10-14 days in 1 (#5) of 30 medical records reviewed; and 2) Failure to update the nursing outcome of the hospitalization in 1 (#22) of 30 medical records reviewed. Findings: 1) Failure to identify the reason of patient discharge within 4 days of admissions with anticipated length of stay of 10-14 days in 1 (#5) of 30 medical records reviewed A review of Patient # 5's medical record revealed an admission date of 02/24/2026 and a discharge date of 02/28/2026. A review of the document titled, "Post-Admission Physical Examination: History and Physical," dated 02/24/2026 at 7:00 p.m. revealed in part, estimated length of stay of 10 - 14 days. A review of the document titled, "Physician Progress Note," dated 02/28/2026 at 12:30 p.m. and signed by S22MD on 02/28/2026 at 2:17 p.m. failed to reveal the patient was being discharge on this day and related reasoning of the unanticipated, early discharge of this patient. A review of the document titled, "Physician Discharge Summary," dated 03/01/2026 at 8:00 p.m. and signed by S22MD on 03/02/2026 at 8:54 p.m. failed to reveal to reveal the patient's the unanticipated, early discharge of this patient. A review of the document titled, "Nursing Shift Assessment," dated 02/28/2026 with a start time of 7:00 a.m. and an end time of 3:20 p.m. revealed a nurse entry by S4CDM at 3:19 p.m., "1519-Pt discharge to home in stable condition. Pt left the facility in private vehicle with caregiver. Med list and discharge instructions reviewed with Pt and caregiver. Pt and caregiver verbalized understanding." The nursing notes for this day fail to reveal any information as to the patient's unanticipated, early discharge. In an interview on 04/08/2026 at 9:40 a.m., S15PT confirmed Patient #5 was discharged early as she was missing her family. In an interview on 04/08/2026 at 9:40 a.m., S25Consult confirmed the above-mentioned findings and confirmed the discharge summary did not include the outcome of Patient #5's hospitalization as it related to her discharge within 4 days of admissions and recommended 10 - 14 days of inpatient treatment. 2) Failure to update the nursing outcome of the hospitalization in 1 (#22) of 30 medical records reviewed A review of Patient #22's medical record revealed an admission date of 11/11/2025 and a discharge date of 11/25/2025. A review of the document titled, "Weekly Team Conference," dated 11/11/2025 revealed the performance of this team conference on day 1 of the patient's admission. A review of the documentation from this conference revealed the category titled, "Functional Status Additional Status Updates" and the subcategory listed as "Nursing" had the comments, "New admit for debility r/t rhabdomyolysis, Noncompliant on medications at home." A review of the document titled, "Physician Discharge Summary" which was dated 12/02/2025 at 6:30 a.m. and signed by S21MD on 12/02/2025 at 7:31 a.m. revealed the category titled, "Functional Status Additional Status Updates" and the subcategory listed as "Nursing" had the comments, "New admit for debility r/t rhabdomyolysis, Noncompliant on medications at home." The discharge summary was not updated to reflect the outcome of the nursing care the patient received during the course of her admissions. In an interview on 04/08/2026 at 9:40 a.m., S25Consult confirmed the above-mentioned findings.
A0546 RADIOLOGIST RESPONSIBILITIES
CFR(s): 482.26(c), (c)(1)

§482.26(c) - Standard: Personnel (1) A qualified full-time, part-time or consulting radiologist must supervise the ionizing radiology services and must interpret only those radiologic tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section, a radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist was appointed to supervise the radiology services of the hospital. Findings: Review of the hospital's staff list failed to reveal a physician identified to supervise the hospital's radiology services. Review of the hospital 's list of privileged physicians failed to reveal a radiologist on staff. Review of the hospital 's governing body meeting minutes revealed the hospital priviledges were granted to the off site entity providing radiological services as a group, and not to the individual providers in that group. An interview was conducted on 04/08/2026 at 2:20 PM with S3CPO. S3CPO confirmed there had been no physician appointed to supervise the radiology services of the hospital.
A0631 THERAPEUTIC DIET MANUAL
CFR(s): 482.28(b)(3)

A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel.


This STANDARD is not met as evidenced by:
Based on observation and interview, the hospital failed to have an approved therapeutic diet manual with a publication or revision date of not more than 5 years old. Findings: Review of hospital policy "Delivery of Services: Food & Dietetic Services," adopted March 2021, revealed in part, " A current therapeutic diet manual is reviewed and approved at least annually by the dietician, dietary manager, and medical staff. The publication date of the manual must not be more than 5 years old. Copies of the dietary manual will be available to nursing, medical and dietary staff." Review of hospital therapeutic diet manual titled "Manual of Medical Nutrition Therapy," 6th Edition, revealed the manual was published in 2010. An interview was conducted on 04/08/2026 at 10:14 a.m. with S4CDM. S4CDM confirmed the hospital therapeutic diet manual, titled "Manual of Medical Nutrition Therapy," 6th Edition, was published in 2010 and was more than 5 years old.
A0701 MAINTENANCE OF PHYSICAL PLANT
CFR(s): 482.41(a)

The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.


This STANDARD is not met as evidenced by:
Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well being of the patients are assured. This was evident by failing to ensure the preventative maintenance was maintained for emergent equipment. Findings: Review of the hospital's policy number 00-04-02 titled "Physical Environment of Facility", adopted March 2021 revealed in part: PURPOSE: Our purpose is to provide in the rehabilitation hospital with a safe and accommodating environment. PROCEDURE: Electrical Appliances: Use of electrical appliances must be strictly controlled to protect and promote the health, safety, and comfort of patients, employees and visitors. Any and all electrical appliances brought into the hospital must be inspected and tagged by Plant Operations personnel prior to any use. Department heads are responsible for making the Plant Operations Directo aware of untagged equipment. Calibration of electrical equipment will be done and documented at least annually, unless manufacturer recommendations are different. All equipment will be serviced at least annually. Records of repairs are to be maintained on the maintenance log including the date. Observation during the hospital tour on 04/06/2026 from 10:20 AM to 12:12 PM revealed the following emergent equipment with past due preventive maintenance: Portable suction manufacturer Compass Health Model ASP-HD Serial Number ET181100069 tested 08/2025 and due preventive maintenance 02/2026; AED manufacturer ZOLL Model Plus serial number X121569450 tested 08/2025 and due preventive maintenance 02/2026; Oxygen concentrator manufacturer Invacare Model Perfecto 2 serial number 07042020B tested 07/2025 and due 01/2026; Oxygen concentrator manufacturer Invacare Model Perfecto 2 serial number 07032020B tested 08/2025 and due 02/2026. In an interview on 04/08/2026 at 8:30 AM S3CPO verified the above mentioned equipment was past due on the preventative maintenance. S3CPO further verified C29PE is supposed to test the above mentioned equipment every 6 months.
A0724 FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
CFR(s): 482.41(c)(2)

Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.


This STANDARD is not met as evidenced by:
Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients. This deficient practice was evidenced by: 1)failure to ensure a red electrical outlet was maintained; and 2)failure to ensure expired supplies were removed from the patient care area. Findings: 1)Failure to ensure a red electrical outlet was maintained Review of the hospital's policy number 00-04-02 titled "Physical Environment of Facility", adopted March 2021 revealed in part: PURPOSE: Our purpose is to provide in the rehabilitation hospital with a safe and accommodating environment. PROCEDURE: All wall receptacles are of the three-wire type. If they are lost, damaged or do not supply power, it will be immediately reported to Plant Operations. Observation on 04/06/2026 at 1:20 PM revealed a red outlet next to the emergency cart in the nurses' station not working when portable suction plugged into the red outlet. In an interview on 04/06/2026 at 1:25 PM S14RN confirmed she was unaware the red outlet next to the emergency cart in the nurses' station didn't work. 2)Failure to ensure expired supplies were removed from the patient care area. Observation during the hospital tour on 04/06/2026 from 10:20 AM to 12:12 PM revealed AED pads that expired 05/2025. Further observation revealed the expired AED pads were the only AED pad available in the hospital. In an interview on 04/06/2026 at 12:00 PM S1NSM verified the AED pads expired 05/2025 and the expired AED pads were the only AED pads in the hospital.
A0803 DISCHARGE PLANNING PROGRAM REVIEW

The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to provide detailed documentation of the ongoing periodic review of discharge plans to ensure plans were individualized for each patient and were effective in preventing readmission within the first 30 days after discharge. Findings: Review of the Quality Improvement minutes from 01/21/2026, for the last quarter of 2025 revealed documentation for utilization review was to include discharge planning review. The minutes indicated that the data presented was attached at the end of the minutes. Review of the attachments, failed to reveal any data related to the review of the discharge planning for appropriateness and the associated 30 day readmission rate. In interview on 04/09/2026 at 3:46 PM S3CPO verified the information was not attached to the minutes and stated the information was compiled by the corporate office and she would request the information. The information was not provided before survey exit on 04/09/2026 at 6:15 PM.
A0804 DISCHARGE PLANNING - PAC PROVIDER DATA

The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use on measures. The hospital must ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient’s goals and treatment preferences.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure post-acute care data on quality measures and data on resource measures were provided to patients to assist in the selection of post-acute care providers. Findings: Review of the provided documentation and patient records revealed the patients were given a list of post-acute care providers prior to discharge to assist in the selection of a care provider. The list did not contain any quality data and this information was not provided after several requests. In interview on 04/09/2026 at 6:00 PM during the exit conference, S3CPO verified the hospital did not have quality data for the providers on the list of post-acute care providers.
A0808 DISCHARGE PLANNING EVALUATION

The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure the documentation of a discharge planning evaluation taking place in 14 (#3 - #5, #7, #8, #10 - #15, #17, #22, #23) of 30 medical records reviewed for discharge planning. Findings: A review of hospital policy titled, "Bogalusa Rehabilitation Hospital Discharge Planning," Policy 01-01-05, an adoption date of 09/2022, revealed in part: "Discharge Planning POLICY Bogalusa Rehab Hospital's social services department shall provide discharge planning for each patient from the point of admission. Each & every patient will be evaluated for post-hospitalization needs and the social services department or designated staff will work with the patient, patient's family and treatment team to ensure that the patient is released to a safe environment. PROCEDURE Discharge planning begins upon admission and is documented on an ongoing basis throughout the course of the patient's hospitalization. Effective discharge planning requires a working knowledge of patient resources and community resources. Discharge planning is coordinated by social services, but is the responsibility of all treating staff. Discharge planning includes, but is not limited to screening each patient for the potential benefit from the following: 1. Home health services 2. Outpatient physical therapy, occupational therapy or speech therapy 3. Medical supplies/equipment 4. Transportation 5. Vocational rehabilitation 6. Nursing home placement 7. Patient/family training and education 8. Home evaluation (set up and coordination) 9. Potential for hospital re-admission[.] The discharge planning assessment is completed within 3 working days of admission on each patient. The social services department personnel will attend the treatment team meeting to obtain input as to the patient's functional level. It is important to remember that improvement is expected and anticipated, so discharge plans can and do change through the course of the patient's stay. The discharge plan must address the individual needs of the patient and will include, but not limited to: Residence[,] Work[,] Outpatient treatments[,] Medications[,] Equipment[,] Community resources[,] Family and patient education & training [and] Safety[.] Involvement of both patient and family must be documented. Discharge plan review: Each week, during the regularly scheduled team staffing/treatment plan review, the social services staff or designee shall present the discharge plan, destination, and planned discharge date for discussion with the Medical Director and team. Any recommendations or adjustments will be made or documented as part of the treatment plan review/updates. Social Services is responsible for following up with the patient and their families to ensure that team communication and discharge planning is thoroughly understood. Discharge Interview: Prior to discharge, social services staff will attempt to have the patient and family members participate in a discharge interview. This will be documented as part of the discharge plan and should include a review of the following: Each agency providing aftercare services for the patient[,] Contact name and phone number at the agency[,] When and where services are to be rendered [and] When recommended DME should be delivered[.] Follow Up: Post-discharge, social services staff will contact the patients at least once within 2 weeks of discharge to ascertain status of aftercare services." A review of hospital policy titled, "Interdisciplinary Assessment, Initial," policy number unavailable, origination 05/2021 and last revised/approved 01/2024, revealed in part: "POLICY: Each patient's physical, psychological, emotional, cultural, and social status are assessed upon admission by nursing and each discipline. The documentation is per the Initial Nursing Admit Assessment and the Therapy Evaluation Form. Social Services: The Case Manager/Social Worker shall complete an initial evaluation including psychosocial assessment within 72 hours of admission." A review of the hospital document provided by S25Consult on 04/09/2026 at 11:00 a.m. titled, "Social Service Assessment," revealed in part, information related to the discharge process including: special needs related to discharge, plan when current level of care is not longer needed, living situation, medical equipment and services currently using and discharge plan. During this same timeframe, S25Consult confirmed this would be the assessment form used and completed on each patient by social service. S25Consult further confirmed the hospital did not have a policy specific to this form but would be part of the discharge planning process. A review of medical records revealed the following: --Patient #3's medical record revealed a discharge date of 02/12/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #4's medical record revealed a discharge date of 03/10/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #5's medical record revealed a discharge date of 02/28/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #7's medical record revealed a discharge date of 01/16/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #8's medical record revealed a discharge date of 03/23/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #10's medical record revealed a discharge date of 03/15/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #11's medical record revealed a discharge date of 03/09]/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #12's medical record revealed a discharge date of 03/13/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #13's medical record revealed a discharge date of 02/26/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #14's medical record revealed a discharge date of 02/18/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #15's medical record revealed a discharge date of 02/13/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #17's medical record revealed a discharge date of 01/16/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #22's medical record revealed a discharge date of 11/11/2025. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; and --Patient #23's medical record revealed a discharge date of 11/17/2025. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned information.
A0815 DISCHARGE PLANNING-D/C PLANNING LIST

[The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.….


This STANDARD is not met as evidenced by:
Based on record review and interview the hospital failed to ensure the Home Health Agencies requested to be listed as available before placing them on a list to present to patients making post-acute care arrangements. Findings: Review of the documentation provided and medical records revealed a list of Home Health Agencies was provided to each patient prior to discharge to assist the patient in finding post-acute care. A request was made for the hospital to provide evidence that each agency listed had asked to be listed or had approved prior to being placed on the list. In interview on 04/09/2026 at 1:25 PM, S1NSM verified the providers did not ask to be listed.
A1134 DELIVERY OF SERVICES
CFR(s): 482.56(b)(2)

The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure a speech therapy evaluation was performed per provider order in 14 (#2 - #5, #7 - #16) of 30 medical records reviewed for rehabilitation orders for physical therapy, occupational therapy and/or speech therapy-language pathology. Findings: A review of hospital policy titled, "Interdisciplinary Assessment, Initial," policy number unavailable, origination 05/2021 and last revised/approved 01/2024, revealed in part: "POLICY: Each patient's physical, psychological, emotional, cultural, and social status are assessed upon admission by nursing and each discipline. The documentation is per the Initial Nursing Admit Assessment and the Therapy Evaluation Form. Therapy Documentation: 1. Physical Therapy, Occupational Therapy and Speech Pathology will complete their portion of the interdisciplinary patient assessment within 36 hours of the midnight of the day of admit." A review of medical records revealed the following: --Patient #2's medical record revealed a physician order dated 03/24/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #3's medical record revealed a physician order dated 02/06/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #4's medical record revealed a physician order dated 03/10/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #5's medical record revealed a physician order dated 02/24/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #7's medical record revealed a physician order dated 12/31/2025 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #8's medical record revealed a physician order dated 03/13/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #9's medical record revealed a physician order dated 08/04/2025 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #10's medical record revealed a physician order dated 03/03/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #11's medical record revealed a physician order dated 03/09/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #12's medical record revealed a physician order dated 02/26/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #13's medical record revealed a physician order dated 02/19/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #14's medical record revealed a physician order dated 02/11/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #15's medical record revealed a physician order dated 02/04/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; --Patient #16's medical record revealed a physician order dated 01/26/2026 for "Speech Therapy Evaluate, develop a plan of care and implement plan." The medical record failed to reveal the performance of a speech therapy evaluation to ascertain the patient's need of these services; In an interview on 03/09/2026 at 11:00 a.m., S25Consult confirmed the above-mentioned findings.
E0000 The entity is in compliance with federal emergency preparedness requirements.