Dialysis Facility

Davita Fallbrook Dialysis

Quality Rating

Chain Owned Facility

Chain Organization: DaVita

Address

11321 Fallbrook Dr

Houston, TX 77065

Contact

(281) 890-5468

Certification Date

09/10/2019

Details

CMS Certification Number

742552

Ownership Type

Profit

Number of Dialysis Stations

16

Services Offered

In-center hemodialysis Yes
Peritoneal dialysis No
Home hemodialysis training No
Shifts starting after 5 p.m. No

Quality Measures

Survival Category

As Expected

Hospitalization Category

As Expected

Readmission Category

As Expected

Transfusion Category

As Expected

Waitlist Ratio Category

As Expected

ED Encounters within 30 Days Category

As Expected

Additional Measures

Percentage of Adult HD Patients with Kt/V ≥ 1.2

91%

Percentage of Adult PD Patients with Kt/V ≥ 1.7

%

Percentage of Patients with Hemoglobin < 10 g/dL

7%

Percentage of Patients with Hemoglobin > 12 g/dL

7%

Mortality Measures

Mortality Rate

15.4

Mortality Rate Upper Confidence Limit

27.9

Mortality Rate Lower Confidence Limit

7.3

Hospitalization Measures

Hospitalization Rate

201.2

Hospitalization Rate Upper Confidence Limit

337.5

Hospitalization Rate Lower Confidence Limit

129.1

Readmission Measures

Readmission Rate

20

Readmission Rate Upper Confidence Limit

34.4

Readmission Rate Lower Confidence Limit

10

Transfusion Measures

Transfusion Rate

27

Transfusion Rate Upper Confidence Limit

162

Transfusion Rate Lower Confidence Limit

6.6

Waitlist Measures

Waitlist Ratio

0.99

Waitlist Ratio Upper Confidence Limit

2.89

Waitlist Ratio Lower Confidence Limit

0.2

Percentage of Prevalent Patients Waitlisted (PPPW)

PPPW Percentage

8.1

PPPW Upper Confidence Limit

37.9

PPPW Lower Confidence Limit

1.3

Standardized Emergency Department Encounter Ratio (SEDR)

SEDR Ratio

1.08

SEDR Upper Confidence Limit

2.33

SEDR Lower Confidence Limit

0.52

ED Encounters within 30 Days of Hospital Discharge (ED30)

ED30 Ratio

0.79

ED30 Upper Confidence Limit

1.77

ED30 Lower Confidence Limit

0.26

Standardized Infection Ratio (SIR)

SIR

0

SIR Upper Confidence Limit

0.63

SIR Lower Confidence Limit

Fistula Measures

Fistula Rate

54.6

Fistula Rate Upper Confidence Limit

77.6

Fistula Rate Lower Confidence Limit

30.1

Long-Term Catheter Measures

Long-Term Catheter Percentage

28

Serum Phosphorus Measures

Percentage of Patients with Serum Phosphorus < 3.5 mg/dL

4

Percentage of Patients with Serum Phosphorus 3.5-4.5 mg/dL

17

Percentage of Patients with Serum Phosphorus 4.6-5.5 mg/dL

32

Percentage of Patients with Serum Phosphorus 5.6-7.0 mg/dL

20

Percentage of Patients with Serum Phosphorus > 7.0 mg/dL

26