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)
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.