Southeast Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
043034
Ownership Type
Physician
CMS Region
Dallas
Certification Date
Address
905 Borgognoni Drive
Phone Number
(870) 265-4333

Facility Medical Condition Statistics

All other conditions
29
Brain disease or condition (non-traumatic)
-
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
27
Spinal cord disease or condition (non-traumatic)
21
Spinal cord injury (traumatic)
-
Stroke
42

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
155
Predicted number of infections (B)
0.421
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
141
Denominator
141
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.3
Denominator
120
Average observed change score
13.5
Change in patients ability to move around
Average risk-adjusted change score
31.1
Denominator
120
Average observed change score
30.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
83
Denominator
120
Facility rate
69.2
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
72
Denominator
120
Facility rate
60.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
141
Facility rate
0.7
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Patient days
1,789
Predicted number of infections (B)
0.742
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
40
Number of health care workers
71
Rate of flu vaccination
56.3
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
112
Unadjusted potentially preventable readmission rate
11.61
Risk-standardized potentially preventable readmission rate (RSRR)
9.07
Lower limit of the 95% confidence interval on the RSRR
6.97
Upper limit of the 95% confidence interval on the RSRR
11.58
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
8
Number of eligible stays
126
Unadjusted potentially preventable readmission rate
6.35
Risk-standardized potentially preventable readmission rate (RSRR)
5.42
Lower limit of the 95% confidence interval on the RSRR
3.35
Upper limit of the 95% confidence interval on the RSRR
8.12
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)
47
Number of eligible stays
99
Observed discharge to community rate
47.47
Risk-standardized discharge to community rate
55.09
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
47.11
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.90
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.15
Number of eligible episodes
221
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
137
Denominator
141
Facility rate
97.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
141
Facility observed rate
2.8
Facility risk-adjusted rate
2.8
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
63
Number of health care workers
77
Rate of COVID-19 vaccination
81.8