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 03/19/2024
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)
A0045 MEDICAL STAFF
CFR(s): 482.12(a)(1)

[The governing body must] determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff.


This STANDARD is not met as evidenced by:
Based on record review and interview, the governing body failed to ensure radiologists were eligible for medical staff membership and were properly credentialed before providing services for the hospital. The deficient practice is evidenced by radiology reports for imaging studies performed at the facility and signed by physicians not listed on the medical staff roster in 2 (#1, #3) of 3 (#1-#3) reviewed medical records. Findings: Review of the Medical Staff By-Laws, adopted January 2020, revealed in part, "Categories of accepted physician applicants include internists, general practitioners, orthopedists, psychiatrists, ENT's, neurologists and surgeons. Other applicants will be reviewed on a case by case basis." Review of the medical record for Patient #1 revealed the patient had x-rays of the right and left knees performed on 01/03/2024 at the facility by a mobile x-ray company. The x-rays were read by a physician not listed on the list of active medical staff. Review of the medical record for Patient #3 revealed the patient had a chest x-ray performed on 03/15/2024 at the facility by a mobile x-ray company. The x-rays were read by a physician not listed on the list of active medical staff. In interview on 03/19/2024 at 11:50 a.m., S2DMCD verified the radiologists were not on the medical staff and had not been credentialed.