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)
A0340 MEDICAL STAFF PERIODIC APPRAISALS
CFR(s): 482.22(a)(1)

The medical staff must periodically conduct appraisals of its members.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed conduct periodic appraisals of its members. The deficient practice is evidenced by failure to conduct medical staff reappointments at least every 24 months. Findings: Review of the Medical Staff By-Laws, adopted January 2020, revealed in part, "Each applicant will be reappointed not more than every two years." Review of the medical staff file for S3MD revealed an initial appointment to the medical staff on 09/08/2023. Further review revealed S3MD was not reappointed within 2 years as stated in the medical staff by-laws. Review of the medical staff file for S4MD revealed an initial appointment to the medical staff on 01/30/2020. Further review revealed S4MD was not reappointed within 2 years as stated in the medical staff by-laws. In interview on 03/19/2024 between 1:00 p.m. and 1:15 p.m., S2DMCD verified the medical staff files did not include documentation that either had been through the reappointment process after the initial appointment to the medical staff.