Pam Health Rehabilitation Hospital of Surprise


About the Facility

CMS Certification Number (CCN)
033039
Ownership Type
For Profit
CMS Region
San Francisco
Certification Date
Address
13060 West Bell Road
Phone Number
(623) 499-9100

Facility Medical Condition Statistics

All other conditions
52
Brain disease or condition (non-traumatic)
26
Brain injury (traumatic)
35
Hip or femur fracture
49
Hip or knee replacement, amputation or other bone or joint condition
103
Nervous system disorder (excluding stroke)
232
Spinal cord disease or condition (non-traumatic)
15
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
127

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.256
SIR 95% confidence interval - upper limit
5.040
Comparative performance category
No Different than the National Benchmark
Catheter days
1,102
Predicted number of infections (B)
1.311
Number of infections reported (A)
2
SIR (A/B)
1.526
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
623
Denominator
623
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.8
Denominator
519
Average observed change score
14.5
Change in patients ability to move around
Average risk-adjusted change score
26.7
Denominator
519
Average observed change score
26.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
306
Denominator
519
Facility rate
59.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
228
Denominator
519
Facility rate
43.9
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
4
Denominator
623
Facility rate
0.6
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.232
SIR 95% confidence interval - upper limit
2.486
Comparative performance category
No Different than the National Benchmark
Patient days
8,892
Predicted number of infections (B)
3.285
Number of infections reported (A)
3
SIR (A/B)
0.913
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
112
Number of health care workers
190
Rate of flu vaccination
58.9
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
38
Number of eligible stays
457
Unadjusted potentially preventable readmission rate
8.32
Risk-standardized potentially preventable readmission rate (RSRR)
8.92
Lower limit of the 95% confidence interval on the RSRR
7.32
Upper limit of the 95% confidence interval on the RSRR
10.94
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
33
Number of eligible stays
524
Unadjusted potentially preventable readmission rate
6.30
Risk-standardized potentially preventable readmission rate (RSRR)
5.95
Lower limit of the 95% confidence interval on the RSRR
4.55
Upper limit of the 95% confidence interval on the RSRR
7.92
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)
237
Number of eligible stays
403
Observed discharge to community rate
58.81
Risk-standardized discharge to community rate
59.73
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
55.42
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
63.60
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
514
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
598
Denominator
623
Facility rate
96.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
622
Facility observed rate
0.6
Facility risk-adjusted rate
0.5
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
149
Number of health care workers
201
Rate of COVID-19 vaccination
74.1