Phelps Memorial Hospital


About the Facility

CMS Certification Number (CCN)
33T261
Ownership Type
Non-profit
CMS Region
New York
Certification Date
Address
701 North Broadway
Phone Number
(914) 366-3708

Facility Medical Condition Statistics

All other conditions
21
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
12
Hip or knee replacement, amputation or other bone or joint condition
11
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
33

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
234
Predicted number of infections (B)
0.484
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
105
Denominator
107
Facility rate
98.1
Change in patients ability to care for themselves
Average risk-adjusted change score
10.3
Denominator
96
Average observed change score
11.4
Change in patients ability to move around
Average risk-adjusted change score
26.9
Denominator
96
Average observed change score
29.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
42
Denominator
96
Facility rate
43.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
40
Denominator
96
Facility rate
41.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
107
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.074
Comparative performance category
No Different than the National Benchmark
Patient days
4,443
Predicted number of infections (B)
2.790
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
Not Available
Number of health care workers
Not Available
Rate of flu vaccination
Not Available
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
11
Number of eligible stays
166
Unadjusted potentially preventable readmission rate
6.63
Risk-standardized potentially preventable readmission rate (RSRR)
8.40
Lower limit of the 95% confidence interval on the RSRR
6.39
Upper limit of the 95% confidence interval on the RSRR
10.78
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
5
Number of eligible stays
184
Unadjusted potentially preventable readmission rate
2.72
Risk-standardized potentially preventable readmission rate (RSRR)
4.27
Lower limit of the 95% confidence interval on the RSRR
2.58
Upper limit of the 95% confidence interval on the RSRR
6.69
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)
91
Number of eligible stays
147
Observed discharge to community rate
61.90
Risk-standardized discharge to community rate
63.44
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
56.64
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
69.30
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.04
Number of eligible episodes
157
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
105
Denominator
107
Facility rate
98.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
106
Facility observed rate
0.9
Facility risk-adjusted rate
1.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
172
Number of health care workers
172
Rate of COVID-19 vaccination
100.0