Encompass Health Rehabilitation Hospital of Modest


About the Facility

CMS Certification Number (CCN)
053040
Ownership Type
Non-profit
CMS Region
San Francisco
Certification Date
Address
1303 Mable Avenue
Phone Number
(209) 857-3400

Facility Medical Condition Statistics

All other conditions
140
Brain disease or condition (non-traumatic)
21
Brain injury (traumatic)
24
Hip or femur fracture
62
Hip or knee replacement, amputation or other bone or joint condition
129
Nervous system disorder (excluding stroke)
84
Spinal cord disease or condition (non-traumatic)
23
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
179

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.031
SIR 95% confidence interval - upper limit
3.050
Comparative performance category
No Different than the National Benchmark
Catheter days
792
Predicted number of infections (B)
1.617
Number of infections reported (A)
1
SIR (A/B)
0.618
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
648
Denominator
649
Facility rate
99.8
Change in patients ability to care for themselves
Average risk-adjusted change score
12.4
Denominator
571
Average observed change score
12.5
Change in patients ability to move around
Average risk-adjusted change score
30.7
Denominator
571
Average observed change score
30.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
342
Denominator
571
Facility rate
59.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
348
Denominator
571
Facility rate
60.9
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
649
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.011
SIR 95% confidence interval - upper limit
1.099
Comparative performance category
No Different than the National Benchmark
Patient days
12,787
Predicted number of infections (B)
4.489
Number of infections reported (A)
1
SIR (A/B)
0.223
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
198
Number of health care workers
262
Rate of flu vaccination
75.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
43
Number of eligible stays
718
Unadjusted potentially preventable readmission rate
5.99
Risk-standardized potentially preventable readmission rate (RSRR)
7.86
Lower limit of the 95% confidence interval on the RSRR
6.47
Upper limit of the 95% confidence interval on the RSRR
9.67
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
41
Number of eligible stays
801
Unadjusted potentially preventable readmission rate
5.12
Risk-standardized potentially preventable readmission rate (RSRR)
5.54
Lower limit of the 95% confidence interval on the RSRR
4.32
Upper limit of the 95% confidence interval on the RSRR
7.44
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)
480
Number of eligible stays
661
Observed discharge to community rate
72.62
Risk-standardized discharge to community rate
71.43
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.18
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.43
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
739
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
647
Denominator
649
Facility rate
99.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
9
Denominator
647
Facility observed rate
1.4
Facility risk-adjusted rate
1.4
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
212
Number of health care workers
244
Rate of COVID-19 vaccination
86.9