Brooks Rehabilitation Hospital University Campus


About the Facility

CMS Certification Number (CCN)
103039
Ownership Type
Non-profit
CMS Region
Atlanta
Certification Date
Address
3599 University Blvd S
Phone Number
(904) 858-7625

Facility Medical Condition Statistics

All other conditions
692
Brain disease or condition (non-traumatic)
332
Brain injury (traumatic)
138
Hip or femur fracture
228
Hip or knee replacement, amputation or other bone or joint condition
302
Nervous system disorder (excluding stroke)
132
Spinal cord disease or condition (non-traumatic)
151
Spinal cord injury (traumatic)
91
Stroke
514

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.012
SIR 95% confidence interval - upper limit
1.134
Comparative performance category
No Different than the National Benchmark
Catheter days
2,700
Predicted number of infections (B)
4.350
Number of infections reported (A)
1
SIR (A/B)
0.230
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
2,450
Denominator
2,466
Facility rate
99.4
Change in patients ability to care for themselves
Average risk-adjusted change score
11.5
Denominator
2,039
Average observed change score
12.3
Change in patients ability to move around
Average risk-adjusted change score
30.6
Denominator
2,039
Average observed change score
28.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
979
Denominator
2,039
Facility rate
48.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
1,135
Denominator
2,039
Facility rate
55.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
4
Denominator
2,466
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.323
SIR 95% confidence interval - upper limit
0.866
Comparative performance category
Better than the National Benchmark
Patient days
60,371
Predicted number of infections (B)
29.353
Number of infections reported (A)
16
SIR (A/B)
0.545
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
1,213
Number of health care workers
1,505
Rate of flu vaccination
80.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
130
Number of eligible stays
1,650
Unadjusted potentially preventable readmission rate
7.88
Risk-standardized potentially preventable readmission rate (RSRR)
7.38
Lower limit of the 95% confidence interval on the RSRR
6.37
Upper limit of the 95% confidence interval on the RSRR
8.48
Comparative performance category
Better than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
108
Number of eligible stays
1,885
Unadjusted potentially preventable readmission rate
5.73
Risk-standardized potentially preventable readmission rate (RSRR)
4.30
Lower limit of the 95% confidence interval on the RSRR
3.70
Upper limit of the 95% confidence interval on the RSRR
4.96
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)
808
Number of eligible stays
1,531
Observed discharge to community rate
52.78
Risk-standardized discharge to community rate
60.37
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
57.60
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.73
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.12
Number of eligible episodes
1,556
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
2,444
Denominator
2,466
Facility rate
99.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
7
Denominator
2,449
Facility observed rate
0.3
Facility risk-adjusted rate
0.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
969
Number of health care workers
1,126
Rate of COVID-19 vaccination
86.1