Mission Hospital


About the Facility

CMS Certification Number (CCN)
05T567
Ownership Type
Non-profit
CMS Region
San Francisco
Certification Date
Address
27700 Medical Center Rd
Phone Number
(949) 365-2447

Facility Medical Condition Statistics

All other conditions
32
Brain disease or condition (non-traumatic)
61
Brain injury (traumatic)
38
Hip or femur fracture
18
Hip or knee replacement, amputation or other bone or joint condition
16
Nervous system disorder (excluding stroke)
11
Spinal cord disease or condition (non-traumatic)
28
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
86

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.046
SIR 95% confidence interval - upper limit
4.521
Comparative performance category
No Different than the National Benchmark
Catheter days
401
Predicted number of infections (B)
1.091
Number of infections reported (A)
1
SIR (A/B)
0.917
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
286
Denominator
286
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.8
Denominator
252
Average observed change score
14.6
Change in patients ability to move around
Average risk-adjusted change score
29.4
Denominator
252
Average observed change score
33.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
165
Denominator
252
Facility rate
65.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
136
Denominator
252
Facility rate
54.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
286
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.449
Comparative performance category
No Different than the National Benchmark
Patient days
5,365
Predicted number of infections (B)
2.067
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
39
Number of health care workers
56
Rate of flu vaccination
69.6
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
262
Unadjusted potentially preventable readmission rate
4.96
Risk-standardized potentially preventable readmission rate (RSRR)
8.07
Lower limit of the 95% confidence interval on the RSRR
6.30
Upper limit of the 95% confidence interval on the RSRR
10.42
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
6
Number of eligible stays
277
Unadjusted potentially preventable readmission rate
2.17
Risk-standardized potentially preventable readmission rate (RSRR)
3.78
Lower limit of the 95% confidence interval on the RSRR
2.55
Upper limit of the 95% confidence interval on the RSRR
5.82
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)
175
Number of eligible stays
216
Observed discharge to community rate
81.02
Risk-standardized discharge to community rate
77.47
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.57
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
81.59
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.97
Number of eligible episodes
259
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
284
Denominator
286
Facility rate
99.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
286
Facility observed rate
0.7
Facility risk-adjusted rate
0.9
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
292
Number of health care workers
298
Rate of COVID-19 vaccination
98.0