Upmc Mercy


About the Facility

CMS Certification Number (CCN)
39T028
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
1400 Locust Street
Phone Number
(877) 287-3422

Facility Medical Condition Statistics

All other conditions
44
Brain disease or condition (non-traumatic)
66
Brain injury (traumatic)
77
Hip or femur fracture
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
25
Nervous system disorder (excluding stroke)
24
Spinal cord disease or condition (non-traumatic)
69
Spinal cord injury (traumatic)
35
Stroke
199

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.635
SIR 95% confidence interval - upper limit
4.819
Comparative performance category
No Different than the National Benchmark
Catheter days
735
Predicted number of infections (B)
2.002
Number of infections reported (A)
4
SIR (A/B)
1.998
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
545
Denominator
545
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.7
Denominator
445
Average observed change score
13.8
Change in patients ability to move around
Average risk-adjusted change score
36.5
Denominator
445
Average observed change score
35.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
294
Denominator
445
Facility rate
66.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
322
Denominator
445
Facility rate
72.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
545
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.129
SIR 95% confidence interval - upper limit
0.978
Comparative performance category
Better than the National Benchmark
Patient days
19,125
Predicted number of infections (B)
9.869
Number of infections reported (A)
4
SIR (A/B)
0.405
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
324
Number of health care workers
334
Rate of flu vaccination
97.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
17
Number of eligible stays
294
Unadjusted potentially preventable readmission rate
5.78
Risk-standardized potentially preventable readmission rate (RSRR)
7.99
Lower limit of the 95% confidence interval on the RSRR
6.27
Upper limit of the 95% confidence interval on the RSRR
10.26
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
26
Number of eligible stays
354
Unadjusted potentially preventable readmission rate
7.34
Risk-standardized potentially preventable readmission rate (RSRR)
5.65
Lower limit of the 95% confidence interval on the RSRR
4.08
Upper limit of the 95% confidence interval on the RSRR
7.20
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)
146
Number of eligible stays
260
Observed discharge to community rate
56.15
Risk-standardized discharge to community rate
63.42
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
57.60
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.91
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.09
Number of eligible episodes
283
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
545
Denominator
545
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
22
Denominator
544
Facility observed rate
4.0
Facility risk-adjusted rate
3.8
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
256
Number of health care workers
275
Rate of COVID-19 vaccination
93.1