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)
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.