About the Facility
- CMS Certification Number (CCN)
- 19T027
- Ownership Type
- Non-profit
- CMS Region
- Dallas
- Certification Date
- Address
524 Dr. Michael Debakey Drive
- Phone Number
- (337) 491-7595
Facility Medical Condition Statistics
- All other conditions
- 100
- Brain disease or condition (non-traumatic)
- 19
- Brain injury (traumatic)
- 11
- Hip or femur fracture
- 41
- Hip or knee replacement, amputation or other bone or joint condition
- 47
- Nervous system disorder (excluding stroke)
- 17
- Spinal cord disease or condition (non-traumatic)
- 33
- Spinal cord injury (traumatic)
- Data not available for this reporting period.
- Stroke
- 60
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
- 444
- Predicted number of infections (B)
- 0.640
- Number of infections reported (A)
- 1
- SIR (A/B)
- Not Available
- Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
- Numerator
- 319
- Denominator
- 319
- Facility rate
- 100.0
- Change in patients ability to care for themselves
- Average risk-adjusted change score
- 12.2
- Denominator
- 287
- Average observed change score
- 12.5
- Change in patients ability to move around
- Average risk-adjusted change score
- 28.4
- Denominator
- 287
- Average observed change score
- 28.8
- Percentage of patients who are at or above an expected ability to care for themselves at discharge
- Numerator
- 168
- Denominator
- 287
- Facility rate
- 58.5
- Percentage of patients who are at or above an expected ability to move around at discharge
- Numerator
- 145
- Denominator
- 287
- Facility rate
- 50.5
- Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
- Numerator
- 0
- Denominator
- 319
- Facility rate
- 0.0
- Clostridium difficile Infection (CDI)
- Standardized infection ratio (SIR) 95% confidence interval - lower limit
- 0.020
- SIR 95% confidence interval - upper limit
- 1.984
- Comparative performance category
- No Different than the National Benchmark
- Patient days
- 4,672
- Predicted number of infections (B)
- 2.486
- Number of infections reported (A)
- 1
- SIR (A/B)
- 0.402
- Percentage of healthcare personnel who got a flu shot for the current season
- Number of health care workers vaccinated
- 33
- Number of health care workers
- 35
- Rate of flu vaccination
- 94.3
- Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
- Number of potentially preventable readmissions following discharge
- 51
- Number of eligible stays
- 401
- Unadjusted potentially preventable readmission rate
- 12.72
- Risk-standardized potentially preventable readmission rate (RSRR)
- 10.85
- Lower limit of the 95% confidence interval on the RSRR
- 8.99
- Upper limit of the 95% confidence interval on the RSRR
- 13.12
- Comparative performance category
- Worse than the National Rate
- Rate of potentially preventable hospital readmissions during the IRF stay
- Number of potentially preventable readmissions
- 11
- Number of eligible stays
- 430
- Unadjusted potentially preventable readmission rate
- 2.56
- Risk-standardized potentially preventable readmission rate (RSRR)
- 4.02
- Lower limit of the 95% confidence interval on the RSRR
- 2.84
- Upper limit of the 95% confidence interval on the RSRR
- 5.51
- 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)
- 211
- Number of eligible stays
- 340
- Observed discharge to community rate
- 62.06
- Risk-standardized discharge to community rate
- 59.89
- Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 55.39
- Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
- 64.23
- Comparative performance category
- Worse than the National Rate
- Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
- MSPB score
- 1.03
- Number of eligible episodes
- 424
- Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
- Numerator
- 319
- Denominator
- 319
- Facility rate
- 100.0
- Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
- Numerator
- 14
- Denominator
- 319
- Facility observed rate
- 4.4
- Facility risk-adjusted rate
- 6.1
- Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
- Number of health care workers vaccinated
- 40
- Number of health care workers
- 54
- Rate of COVID-19 vaccination
- 74.1