Holy Cross Hospital


About the Facility

CMS Certification Number (CCN)
10T073
Ownership Type
Non-profit
CMS Region
Atlanta
Certification Date
Address
4725 North Federal Highway
Phone Number
(954) 776-3075

Facility Medical Condition Statistics

All other conditions
171
Brain disease or condition (non-traumatic)
102
Brain injury (traumatic)
19
Hip or femur fracture
92
Hip or knee replacement, amputation or other bone or joint condition
99
Nervous system disorder (excluding stroke)
179
Spinal cord disease or condition (non-traumatic)
18
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
115

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.258
SIR 95% confidence interval - upper limit
2.758
Comparative performance category
No Different than the National Benchmark
Catheter days
2,050
Predicted number of infections (B)
2.960
Number of infections reported (A)
3
SIR (A/B)
1.014
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
797
Denominator
797
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
9.6
Denominator
664
Average observed change score
10.8
Change in patients ability to move around
Average risk-adjusted change score
22.4
Denominator
664
Average observed change score
23.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
241
Denominator
664
Facility rate
36.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
195
Denominator
664
Facility rate
29.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
797
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.132
SIR 95% confidence interval - upper limit
1.407
Comparative performance category
No Different than the National Benchmark
Patient days
13,628
Predicted number of infections (B)
5.803
Number of infections reported (A)
3
SIR (A/B)
0.517
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
151
Number of health care workers
249
Rate of flu vaccination
60.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
58
Number of eligible stays
760
Unadjusted potentially preventable readmission rate
7.63
Risk-standardized potentially preventable readmission rate (RSRR)
8.11
Lower limit of the 95% confidence interval on the RSRR
6.78
Upper limit of the 95% confidence interval on the RSRR
9.83
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
67
Number of eligible stays
887
Unadjusted potentially preventable readmission rate
7.55
Risk-standardized potentially preventable readmission rate (RSRR)
6.83
Lower limit of the 95% confidence interval on the RSRR
5.62
Upper limit of the 95% confidence interval on the RSRR
8.33
Comparative performance category
Worse than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
393
Number of eligible stays
705
Observed discharge to community rate
55.74
Risk-standardized discharge to community rate
57.77
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
54.27
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.16
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.10
Number of eligible episodes
772
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
756
Denominator
797
Facility rate
94.9
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
37
Denominator
788
Facility observed rate
4.7
Facility risk-adjusted rate
4.5
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
77
Number of health care workers
77
Rate of COVID-19 vaccination
100.0