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 09/02/2025
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)
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 hospital failed to assess the discharge planning process on a regular basis as evidenced by failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs. Findings: Review of Rehabilitation Hospital document titled "Performance Improvement Monitoring and Indicators 2025", undated, revealed in part: "Priority Focus Area: UR/Discharge Planning. Performance Standards Measures/Indicators/Outcomes. Threshold 100%. Data Collection All Patients. Frequency of Collection/reporting Monthly and Quarterly. Review of Rehabiliation Hospital document titled "QI/PI Report QTR 2-2025" revealed in part: "Utilization Review Committee Function" (Includes social services/discharge planning). Quality indicators: Discharge planning is initiated by case manager and continues with social worker. Quality outcomes and results of monitoring activities: 2nd Quarter-April, May, June. April-Admissions 15, Discharges 12. May-Admissions 15, discharges 16, and June-Admissions 15, Discharges 19. Further review of "QI/PI Report QTR 2-2025" failed to reveal the rehabilitation hospital assessed its discharge planning process on a regular basis by completing an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs. During an interview on 09/02/2025 at 2:41 PM, S2DON stated the rehabilitation hospital did not assess the discharge planning process on a regular basis by completing an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.