Providence Holy Cross Medical Center


About the Facility

CMS Certification Number (CCN)
05T278
Ownership Type
Non-profit
CMS Region
San Francisco
Certification Date
Address
15031 Rinaldi St
Phone Number
(818) 496-4415

Facility Medical Condition Statistics

All other conditions
Data not available for this reporting period.
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
18
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
66

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
178
Predicted number of infections (B)
0.485
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
131
Denominator
131
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
9.4
Denominator
118
Average observed change score
9.2
Change in patients ability to move around
Average risk-adjusted change score
24.3
Denominator
118
Average observed change score
22.5
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
37
Denominator
118
Facility rate
31.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
43
Denominator
118
Facility rate
36.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
131
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.029
SIR 95% confidence interval - upper limit
2.840
Comparative performance category
No Different than the National Benchmark
Patient days
4,507
Predicted number of infections (B)
1.737
Number of infections reported (A)
1
SIR (A/B)
0.576
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
22
Number of health care workers
31
Rate of flu vaccination
71.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
4
Number of eligible stays
64
Unadjusted potentially preventable readmission rate
6.25
Risk-standardized potentially preventable readmission rate (RSRR)
8.71
Lower limit of the 95% confidence interval on the RSRR
6.54
Upper limit of the 95% confidence interval on the RSRR
11.75
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
2
Number of eligible stays
71
Unadjusted potentially preventable readmission rate
2.82
Risk-standardized potentially preventable readmission rate (RSRR)
4.58
Lower limit of the 95% confidence interval on the RSRR
3.08
Upper limit of the 95% confidence interval on the RSRR
7.14
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)
40
Number of eligible stays
61
Observed discharge to community rate
65.57
Risk-standardized discharge to community rate
69.04
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
60.07
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
77.29
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.07
Number of eligible episodes
58
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
129
Denominator
131
Facility rate
98.5
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
131
Facility observed rate
1.5
Facility risk-adjusted rate
1.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
25
Number of health care workers
25
Rate of COVID-19 vaccination
100.0