Encompass Health Rehabilitation Hospital of Northw


About the Facility

CMS Certification Number (CCN)
033029
Ownership Type
For Profit
CMS Region
San Francisco
Certification Date
Address
1921 West Hospital Drive
Phone Number
(520) 742-2800

Facility Medical Condition Statistics

All other conditions
142
Brain disease or condition (non-traumatic)
45
Brain injury (traumatic)
70
Hip or femur fracture
101
Hip or knee replacement, amputation or other bone or joint condition
158
Nervous system disorder (excluding stroke)
149
Spinal cord disease or condition (non-traumatic)
27
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
133

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.047
SIR 95% confidence interval - upper limit
4.614
Comparative performance category
No Different than the National Benchmark
Catheter days
912
Predicted number of infections (B)
1.069
Number of infections reported (A)
1
SIR (A/B)
0.935
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
810
Denominator
813
Facility rate
99.6
Change in patients ability to care for themselves
Average risk-adjusted change score
14.1
Denominator
707
Average observed change score
13.7
Change in patients ability to move around
Average risk-adjusted change score
35.0
Denominator
707
Average observed change score
34.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
549
Denominator
707
Facility rate
77.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
507
Denominator
707
Facility rate
71.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
813
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.131
SIR 95% confidence interval - upper limit
1.406
Comparative performance category
No Different than the National Benchmark
Patient days
13,015
Predicted number of infections (B)
5.808
Number of infections reported (A)
3
SIR (A/B)
0.517
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
336
Number of health care workers
372
Rate of flu vaccination
90.3
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
58
Number of eligible stays
742
Unadjusted potentially preventable readmission rate
7.82
Risk-standardized potentially preventable readmission rate (RSRR)
9.02
Lower limit of the 95% confidence interval on the RSRR
7.38
Upper limit of the 95% confidence interval on the RSRR
10.98
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
31
Number of eligible stays
816
Unadjusted potentially preventable readmission rate
3.80
Risk-standardized potentially preventable readmission rate (RSRR)
4.60
Lower limit of the 95% confidence interval on the RSRR
3.50
Upper limit of the 95% confidence interval on the RSRR
6.02
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
488
Number of eligible stays
654
Observed discharge to community rate
74.62
Risk-standardized discharge to community rate
71.31
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.47
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.16
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
805
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
809
Denominator
813
Facility rate
99.5
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
8
Denominator
812
Facility observed rate
1.0
Facility risk-adjusted rate
1.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
220
Number of health care workers
243
Rate of COVID-19 vaccination
90.5