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)
A0808 DISCHARGE PLANNING EVALUATION

The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).


This STANDARD is not met as evidenced by:
Based on record review and interview, the hospital failed to ensure the documentation of a discharge planning evaluation taking place in 14 (#3 - #5, #7, #8, #10 - #15, #17, #22, #23) of 30 medical records reviewed for discharge planning. Findings: A review of hospital policy titled, "Bogalusa Rehabilitation Hospital Discharge Planning," Policy 01-01-05, an adoption date of 09/2022, revealed in part: "Discharge Planning POLICY Bogalusa Rehab Hospital's social services department shall provide discharge planning for each patient from the point of admission. Each & every patient will be evaluated for post-hospitalization needs and the social services department or designated staff will work with the patient, patient's family and treatment team to ensure that the patient is released to a safe environment. PROCEDURE Discharge planning begins upon admission and is documented on an ongoing basis throughout the course of the patient's hospitalization. Effective discharge planning requires a working knowledge of patient resources and community resources. Discharge planning is coordinated by social services, but is the responsibility of all treating staff. Discharge planning includes, but is not limited to screening each patient for the potential benefit from the following: 1. Home health services 2. Outpatient physical therapy, occupational therapy or speech therapy 3. Medical supplies/equipment 4. Transportation 5. Vocational rehabilitation 6. Nursing home placement 7. Patient/family training and education 8. Home evaluation (set up and coordination) 9. Potential for hospital re-admission[.] The discharge planning assessment is completed within 3 working days of admission on each patient. The social services department personnel will attend the treatment team meeting to obtain input as to the patient's functional level. It is important to remember that improvement is expected and anticipated, so discharge plans can and do change through the course of the patient's stay. The discharge plan must address the individual needs of the patient and will include, but not limited to: Residence[,] Work[,] Outpatient treatments[,] Medications[,] Equipment[,] Community resources[,] Family and patient education & training [and] Safety[.] Involvement of both patient and family must be documented. Discharge plan review: Each week, during the regularly scheduled team staffing/treatment plan review, the social services staff or designee shall present the discharge plan, destination, and planned discharge date for discussion with the Medical Director and team. Any recommendations or adjustments will be made or documented as part of the treatment plan review/updates. Social Services is responsible for following up with the patient and their families to ensure that team communication and discharge planning is thoroughly understood. Discharge Interview: Prior to discharge, social services staff will attempt to have the patient and family members participate in a discharge interview. This will be documented as part of the discharge plan and should include a review of the following: Each agency providing aftercare services for the patient[,] Contact name and phone number at the agency[,] When and where services are to be rendered [and] When recommended DME should be delivered[.] Follow Up: Post-discharge, social services staff will contact the patients at least once within 2 weeks of discharge to ascertain status of aftercare services." A review of hospital policy titled, "Interdisciplinary Assessment, Initial," policy number unavailable, origination 05/2021 and last revised/approved 01/2024, revealed in part: "POLICY: Each patient's physical, psychological, emotional, cultural, and social status are assessed upon admission by nursing and each discipline. The documentation is per the Initial Nursing Admit Assessment and the Therapy Evaluation Form. Social Services: The Case Manager/Social Worker shall complete an initial evaluation including psychosocial assessment within 72 hours of admission." A review of the hospital document provided by S25Consult on 04/09/2026 at 11:00 a.m. titled, "Social Service Assessment," revealed in part, information related to the discharge process including: special needs related to discharge, plan when current level of care is not longer needed, living situation, medical equipment and services currently using and discharge plan. During this same timeframe, S25Consult confirmed this would be the assessment form used and completed on each patient by social service. S25Consult further confirmed the hospital did not have a policy specific to this form but would be part of the discharge planning process. A review of medical records revealed the following: --Patient #3's medical record revealed a discharge date of 02/12/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #4's medical record revealed a discharge date of 03/10/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #5's medical record revealed a discharge date of 02/28/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #7's medical record revealed a discharge date of 01/16/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #8's medical record revealed a discharge date of 03/23/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #10's medical record revealed a discharge date of 03/15/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #11's medical record revealed a discharge date of 03/09]/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #12's medical record revealed a discharge date of 03/13/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #13's medical record revealed a discharge date of 02/26/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #14's medical record revealed a discharge date of 02/18/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #15's medical record revealed a discharge date of 02/13/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #17's medical record revealed a discharge date of 01/16/2026. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; --Patient #22's medical record revealed a discharge date of 11/11/2025. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; and --Patient #23's medical record revealed a discharge date of 11/17/2025. The medical record failed to reveal documentation of a Social Services Assessment, a discharge planning assessment, or post-discharge follow up to ascertain the status of aftercare services; In an interview on 04/09/2026 at 11:00 a.m. S25Consult confirmed the above-mentioned information.