Mercy Rehabilitation Hospital, Llc


About the Facility

CMS Certification Number (CCN)
163025
Ownership Type
Non-profit
CMS Region
Kansas City
Certification Date
Address
1401 Campus Drive
Clive, Iowa 50325
Phone Number
(515) 381-6519

Facility Medical Condition Statistics

All other conditions
301
Brain disease or condition (non-traumatic)
42
Brain injury (traumatic)
48
Hip or femur fracture
100
Hip or knee replacement, amputation or other bone or joint condition
157
Nervous system disorder (excluding stroke)
90
Spinal cord disease or condition (non-traumatic)
16
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
170

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
704
Predicted number of infections (B)
0.883
Number of infections reported (A)
3
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
890
Denominator
891
Facility rate
99.9
Change in patients ability to care for themselves
Average risk-adjusted change score
14.2
Denominator
786
Average observed change score
15.6
Change in patients ability to move around
Average risk-adjusted change score
36.7
Denominator
786
Average observed change score
38.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
643
Denominator
786
Facility rate
81.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
676
Denominator
786
Facility rate
86.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
4
Denominator
891
Facility rate
0.4
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.107
SIR 95% confidence interval - upper limit
2.110
Comparative performance category
No Different than the National Benchmark
Patient days
13,155
Predicted number of infections (B)
3.132
Number of infections reported (A)
2
SIR (A/B)
0.639
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
270
Number of health care workers
288
Rate of flu vaccination
93.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
76
Number of eligible stays
1,074
Unadjusted potentially preventable readmission rate
7.08
Risk-standardized potentially preventable readmission rate (RSRR)
8.40
Lower limit of the 95% confidence interval on the RSRR
7.06
Upper limit of the 95% confidence interval on the RSRR
9.74
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
54
Number of eligible stays
1,183
Unadjusted potentially preventable readmission rate
4.56
Risk-standardized potentially preventable readmission rate (RSRR)
5.31
Lower limit of the 95% confidence interval on the RSRR
4.16
Upper limit of the 95% confidence interval on the RSRR
6.42
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)
709
Number of eligible stays
981
Observed discharge to community rate
72.27
Risk-standardized discharge to community rate
69.49
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.81
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.01
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
1,083
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
884
Denominator
891
Facility rate
99.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
8
Denominator
889
Facility observed rate
0.9
Facility risk-adjusted rate
0.9
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
227
Number of health care workers
247
Rate of COVID-19 vaccination
91.9