CHRISTUS TRINITY MOTHER FRANCES REHABILITATION HOS

CMS Certification Number

453056

Ownership Type

For profit

Catheter-associated urinary tract infections (CAUTI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

Not Available

6

Other Measure

2.126

-

Catheter-associated urinary tract infections (CAUTI) - Comparative performance category

No Different than the National Benchmark

-

Catheter-associated urinary tract infections (CAUTI) - Catheter days

1,303

-

Catheter-associated urinary tract infections (CAUTI) - Predicted number of infections (B)

1.409

-

Catheter-associated urinary tract infections (CAUTI) - Number of infections reported (A)

0

-

Catheter-associated urinary tract infections (CAUTI)

0.000

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Denominator

1,805

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Numerator

1,805

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan

100.0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Denominator

1,805

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Numerator

4

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay

0.2

-

Change in patients' ability to care for themselves

13.2

-

Change in patients' ability to care for themselves - Denominator

1,609

-

Change in patients' ability to care for themselves - Average observed change score

13.2

-

Change in patients' ability to move around

34.7

-

Change in patients' ability to move around - Denominator

1,609

-

Change in patients' ability to move around - Average observed change score

34.8

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

1,609

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

1,192

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge

74.1

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

1,609

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

1,222

-

Percentage of patients who are at or above an expected ability to move around at discharge

75.9

-

Clostridium difficile Infection (CDI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

0.071

-

Clostridium difficile Infection (CDI) - SIR 95% confidence interval - upper limit

0.763

-

Clostridium difficile Infection (CDI) - Comparative performance category

Better than the National Benchmark

-

Clostridium difficile Infection (CDI) - Patient days

25,041

-

Clostridium difficile Infection (CDI) - Predicted number of infections (B)

10.707

-

Clostridium difficile Infection (CDI) - Number of infections reported (A)

3

-

Clostridium difficile Infection (CDI)

0.280

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers

386

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers vaccinated

350

-

Percentage of healthcare personnel who got a flu shot for the current season

90.7

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Unadjusted potentially preventable readmission rate

8.24

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of potentially preventable readmissions following discharge

148

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF

8.51

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Lower limit of the 95% confidence interval on the RSRR

7.46

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Upper limit of the 95% confidence interval on the RSRR

9.71

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of eligible stays

1,796

-

Rate of potentially preventable hospital readmissions during the IRF stay - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions during the IRF stay - Unadjusted potentially preventable readmission rate

4.63

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of potentially preventable readmissions

91

-

Rate of potentially preventable hospital readmissions during the IRF stay

5.41

-

Rate of potentially preventable hospital readmissions during the IRF stay - Lower limit of the 95% confidence interval on the RSRR

4.45

-

Rate of potentially preventable hospital readmissions during the IRF stay - Upper limit of the 95% confidence interval on the RSRR

6.50

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of eligible stays

1,967

-

Rate of successful return to home or community from an IRF - Comparative performance category

Better than the National Rate

-

Rate of successful return to home or community from an IRF - Observed number of discharges to community (DTC)

1,220

-

Rate of successful return to home or community from an IRF - Observed discharge to community rate

74.89

-

Rate of successful return to home or community from an IRF

71.74

-

Rate of successful return to home or community from an IRF - Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate

69.94

-

Rate of successful return to home or community from an IRF - Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate

73.61

-

Rate of successful return to home or community from an IRF - Number of eligible stays

1,629

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs - Number of eligible episodes

2,249

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs

0.89

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Denominator

1,805

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Numerator

1,804

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified

99.9

-

Other Measure

0.8

-

Other Measure

1,805

-

Other Measure

14

-

Percentage of patients with pressure ulcers/pressure injuries that are new or worsened

0.8

-

Other Measure

388

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series - Number of health care workers vaccinated

335

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series

86.3

-