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)
A0450 MEDICAL RECORD SERVICES
CFR(s): 482.24(c)(1)

All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure all patient medical record entries are complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. This deficient practice is evidenced by: 1) Failure to ensure the LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) being used on all medical records was completed in its entirety in 5 (#8, #14, #16, #17, #23) of 30 medical records reviewed; and 2) Failure to ensure the Weekly Treatment Team notes were authenticated by all disciplines in attendance in 10 (#7, #11 - #15, #17, #18, #22, #23) of 30 medical records reviewed. Findings: 1) Failure to ensure the LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) being used on all medical records was completed in its entirety in 5 (#8, #14, #16, #17, #23) of 30 medical records reviewed A review of hospital policy titled, "Advanced and Other Healthcare Directives, DNR Orders, LAPOST," policy number unavailable, origination 03/2020 and last revised/approved 01/2024, revealed in part: "POLICY At the time of admission, patients shall be informed of their right under Louisiana and Federal Law to make decisions regarding medical care, including the right to accept or refuse medical treatment and the right to formulate an advanced directive. No patent shall be discriminated against with respect to provisions of care or otherwise, based on whether he or she executed an advanced directive. DEFININTIONS OF TERMS C. LaPOST (Louisiana Physician Order for Scope of Treatment) - An easily identifiable and standardized document that translates a patient's end of life wishes and goals of care into a physician order that transfers across health care settings. Guidelines for treating patient who present with a Louisiana Physician Order for Scope of Treatment ("LaPOST") form and for assisting patients in completing LaPOST forms. A. Policy 1. The Louisiana Physician Order for Scope of Treatment (LaPOST) is a physician order form that translates a patient's end of life wishes and goals of care into physician orders that transfer with the patient across health care settings. 3. The LaPOST document must be signed by physician and by the patient, or if the patient lacks decision-making capacity, the legally recognized personal health care representative. 4. The LaPOST document can be completed on a qualified patient regardless of age. It is useful for patients who have a life limiting illness with a prognosis of one year or less, or who are frail and elderly. It is used as a part of the health care planning process and is complementary with advanced directives. The LaPOST document however, may be used in the absence of those documents. C. Procedure 2. COMPLETING A LaPOST FORM WITH A PATIENT a. If the patient or the patient's legally recognized personal health care representative wishes to complete a LaPOST form, the patient's physician should be contacted. The physician should discuss treatment options including information about the patient's advanced directive (if any) or other statements the patient has made regarding his/her wishes for endo of life care and treatments. The benefits, burdens, efficacy and appropriateness of treatment and medical interventions should be discussed by the physician with the patient and/or the patient's legally recognized personal health care representative. b. another member of the health care team such as a nurse or social worker can explain the LaPOST form to the patient and/or the patient's legally recognized personal health care representative, however the physician is responsible for discussing the treatment options with the patient or the patient's legally recognized personal health care representative. c. the above-described discussions will be documented in the medical record, dated and timed. E. The LaPOST document must be signed by a physician and by the patient, or it the patient lacks decision making capacity, the patient's legally recognized personal health care representative." A review of medical records revealed: --A review of Patient #8's medical record revealed an admission date of 03/13/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 03/13/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box B which was related to medical interventions a patient would choose if he/she had a pulse or was breathing, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; --A review of Patient #14's medical record revealed an admission date of 02/11/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient (a date was not placed) and by S22MD on 02/11/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box B which was related to medical interventions a patient would choose if he/she had a pulse or was breathing, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; --A review of Patient #16's medical record revealed an admission date of 01/26/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 01/26/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive; and --A review of Patient #17's medical record revealed an admission date of 01/16/2026 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient and S22MD on 01/16/2026. The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive. --A review of Patient #23's medical record revealed an admission date of 11/07/2025 and the document titled, "LOUSISANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST) which was signed by patient on 11/07/2025 and S20MD (a date was not placed). The document failed to be completed in its entirety and failed to reveal the patient's diagnosis, the completion of Box C which was related to artificially administered fluids and nutrition and the completion of Box D which included whom the information was discussed with, the basis for the orders, and the indication of the patient having or not having an Advanced Directive. In an interview on 04/09/2026 at 11:00 a.m., S25Consult confirmed the above-mentioned findings. 2) Failure to ensure the Weekly Treatment Team notes were authenticated by all disciplines in attendance in 10 (#7, #11 - #15, #17, #18, #22, #23) of 30 medical records reviewed A review of the hospital document titled, "Bogalusa Rehabilitation Inpatient Rehabilitation Services: Treatment Team," Policy 06-04-01, adopted 03/2021, and date unavailable for last reviewed/revised, revealed in part: "POLICY Bogalusa Rehab Hospital's inpatients are staffed by an interdisciplinary treatment team at least every 7 days at a regularly scheduled time. The treatment team evaluates patient progress towards goals, discharge criteria and plans, and establishes post-discharge recommendations. POLICY STATEMENT The interdisciplinary treatment team consists of each discipline actively treating the patient during the IRF [inpatient rehabilitation facility] stay. It includes (but is not limited to) the following: 1. Medical Director of Rehabilitation Services 2. Director of Nurses or Utilization Review Nurse 3. Physical therapist 4. Occupational therapist 5. Social Services 6. Speech therapy 7. Dietary Manager [.]" A review of medical records revealed the interdisciplinary treatment team weekly team conference as follows: --A review of Patient #7's medical record revealed the document titled, "Weekly Team Conference" and dated 01/13/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #11's medical record revealed the document titled, "Weekly Team Conference" and dated 03/02/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S32RN; Physical Therapy, S15PT; and Case Management, S33RN; --A review of Patient #12's medical record revealed the document titled, "Weekly Team Conference" and dated 03/02/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S32RN; Physical Therapy, S15PT; and Case Management, S33RN; --A review of Patient #13's medical record revealed the document titled, "Weekly Team Conference" and dated 02/23/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN and Physical Therapy, S15PT; --A review of Patient #14's medical record revealed the document titled, "Weekly Team Conference" and dated 02/17/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S14RN; Occupational Therapy, S8OT; and Case Management, S33RN; --A review of Patient #15's medical record revealed the document titled, "Weekly Team Conference" and dated 02/10/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S29RN and Case Management, S33RN; --A review of Patient #17's medical record revealed the document titled, "Weekly Team Conference" and dated 01/20/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #18's medical record revealed the document titled, "Weekly Team Conference" and dated 01/20/2026. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP; --A review of Patient #22's medical record revealed the document titled, "Weekly Team Conference" and dated 11/11/2025. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; Occupational Therapy, S16COTA; and Speech Language Pathology, S31SLP; and --A review of Patient #23's medical record revealed the document titled, "Weekly Team Conference" and dated 11/11/2025. This document failed to reveal the authentication (which would include electronic signature with date/time) of the following team members that were listed as being present during this conference: Nursing, S34RN; Physical Therapy, S30PTA; and Speech Language Pathology, S31SLP In an interview on 04/09/2026 at 11:00 a.m., S25Consult confirmed the above-mentioned findings.