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)
A0454 CONTENT OF RECORD: ORDERS DATED & SIGNED
CFR(s): 482.24(c)(2)

All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure verbal orders were dated, timed and/or authenticated promptly by the ordering provider in 4 (#3, #4, #7, #9) of 30 medical records reviewed for verbal orders. Findings A review of the hospital document titled, "Bogalusa Rehabilitation Hospital Medical Staff Rules & Regulations," Policy 00-06-01, adopted 01/2020, and date unavailable for last reviewed/revised, revealed in part: "Article X - Adoption and Amendment of Bylaws VERBAL & ELECTRONIC ORDERS: Any order received verbally or electronically (by phone, fax, etc.) from a medical staff physician will be taken by a party authorized by scope of practice to accept such orders (i.e. licensed nurse). -The physician giving the order will have up to 10 days following the date the order was given to sign or countersign authenticated such orders. -All authentications will include the signature, date and time of the authentication. Article IX - RULES & REGULATIONS OF MEDICAL STAFF 19. Verbal and telephone orders will only be given to health care professionals operating within their scope of practice. Physician is required to co-sign verbal or telephone orders. Verbal orders must be clearly documented with the names of who received the order, who gave the order, when it was recorded and when it was implemented. Verbal orders must be authenticated in timeframe specified in hospital policy in accordance with regulations (within 10 days)." A review of the hospital document titled, "Bogalusa Rehabilitation Hospital Orders & Evaluation," Policy 06-01-05, adopted 12/2022, and date unavailable for last reviewed/revised, revealed in part: "POLICY STATEMENT All MD orders must be dated/timed. All verbal and/or telephone orders have to be co-signed by the physician within 10 calendar days following the date on an order per Louisiana Statute. Although, "prompt" cosigning is preferred within 48 hours." A review of medical records revealed: --Patient #3's medical record revealed an admission date of 02/06/2026 and the document titled, "PRN MEDICATIONS." The document was authenticated as telephone order read back (TORB), however the document failed to include a date and time associated with this order and the provider had not authenticated/cosigned this TORB order; -Patient #4's medical record revealed an admission date of 03/10/2026 and the document titled, "XPRESS RAY, INC MOBILE X-RAY SERVICE EXAM REQUISTION/ORDER FORM" and dated 03/25/2026. This order form failed to reveal the name of the ordering provider, the time associated with the order, provider authentication of this order and the medical record failed to reveal an entry in the provider's orders related to this x-ray; --Patient #7's medical record revealed an admission date of 12/31/2025 and the document titled, "XPRESS RAY, INC MOBILE X-RAY SERVICE EXAM REQUISTION/ORDER FORM" and dated 01/14/2026. This order form failed to reveal the time associated with the order, provider authentication of this order and the medical record failed to reveal an entry in the provider's orders related to this x-ray; and --Patient #9's medical record revealed an admission date of 08/04/2025 and the document titled, "PRN MEDICATIONS." The document was authenticated as telephone order read back (TORB), however the document failed to include a date and time associated with this order and the provider had not authenticated/cosigned this TORB order. In an interview on 04/09/2026 at 11:00 a.m. confirmed the above-mentioned findings.