Comanche County Hospital Authority


About the Facility

CMS Certification Number (CCN)
37T056
Ownership Type
Government
CMS Region
Dallas
Certification Date
Address
3401 W. Gore Blvd.
Phone Number
(580) 355-8620

Facility Medical Condition Statistics

All other conditions
46
Brain disease or condition (non-traumatic)
Data not available for this reporting period.
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
71
Hip or knee replacement, amputation or other bone or joint condition
23
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)
Data not available for this reporting period.
Stroke
45

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
347
Predicted number of infections (B)
0.502
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
204
Denominator
204
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
9.8
Denominator
186
Average observed change score
10.7
Change in patients ability to move around
Average risk-adjusted change score
28.4
Denominator
186
Average observed change score
31.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
71
Denominator
186
Facility rate
38.2
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
90
Denominator
186
Facility rate
48.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
204
Facility rate
0.5
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.032
SIR 95% confidence interval - upper limit
3.170
Comparative performance category
No Different than the National Benchmark
Patient days
3,576
Predicted number of infections (B)
1.556
Number of infections reported (A)
1
SIR (A/B)
0.643
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
103
Number of health care workers
150
Rate of flu vaccination
68.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
24
Number of eligible stays
319
Unadjusted potentially preventable readmission rate
7.52
Risk-standardized potentially preventable readmission rate (RSRR)
9.19
Lower limit of the 95% confidence interval on the RSRR
7.42
Upper limit of the 95% confidence interval on the RSRR
11.59
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
20
Number of eligible stays
353
Unadjusted potentially preventable readmission rate
5.67
Risk-standardized potentially preventable readmission rate (RSRR)
6.10
Lower limit of the 95% confidence interval on the RSRR
4.38
Upper limit of the 95% confidence interval on the RSRR
9.28
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)
190
Number of eligible stays
291
Observed discharge to community rate
65.29
Risk-standardized discharge to community rate
63.61
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
58.90
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.12
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.95
Number of eligible episodes
301
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
198
Denominator
204
Facility rate
97.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
204
Facility observed rate
2.0
Facility risk-adjusted rate
1.9
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
50
Number of health care workers
61
Rate of COVID-19 vaccination
82.0