Hackley Hospital


About the Facility

CMS Certification Number (CCN)
23T066
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
1700 Clinton Street
Phone Number
(231) 728-4007

Facility Medical Condition Statistics

All other conditions
112
Brain disease or condition (non-traumatic)
14
Brain injury (traumatic)
28
Hip or femur fracture
28
Hip or knee replacement, amputation or other bone or joint condition
48
Nervous system disorder (excluding stroke)
14
Spinal cord disease or condition (non-traumatic)
32
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
116

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
228
Predicted number of infections (B)
0.620
Number of infections reported (A)
2
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
392
Denominator
392
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.6
Denominator
296
Average observed change score
14.7
Change in patients ability to move around
Average risk-adjusted change score
33.3
Denominator
296
Average observed change score
36.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
178
Denominator
296
Facility rate
60.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
192
Denominator
296
Facility rate
64.9
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
392
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.379
SIR 95% confidence interval - upper limit
2.880
Comparative performance category
No Different than the National Benchmark
Patient days
6,492
Predicted number of infections (B)
3.350
Number of infections reported (A)
4
SIR (A/B)
1.194
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
66
Number of health care workers
163
Rate of flu vaccination
40.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
16
Number of eligible stays
218
Unadjusted potentially preventable readmission rate
7.34
Risk-standardized potentially preventable readmission rate (RSRR)
8.00
Lower limit of the 95% confidence interval on the RSRR
6.27
Upper limit of the 95% confidence interval on the RSRR
9.89
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
11
Number of eligible stays
230
Unadjusted potentially preventable readmission rate
4.78
Risk-standardized potentially preventable readmission rate (RSRR)
4.63
Lower limit of the 95% confidence interval on the RSRR
3.19
Upper limit of the 95% confidence interval on the RSRR
6.01
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)
151
Number of eligible stays
198
Observed discharge to community rate
76.26
Risk-standardized discharge to community rate
76.12
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.61
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
81.00
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.05
Number of eligible episodes
197
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
390
Denominator
392
Facility rate
99.5
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
392
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
130
Number of health care workers
154
Rate of COVID-19 vaccination
84.4