Upmc St Margaret


About the Facility

CMS Certification Number (CCN)
39T102
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
815 Freeport Road
Phone Number
(877) 287-3422

Facility Medical Condition Statistics

All other conditions
83
Brain disease or condition (non-traumatic)
20
Brain injury (traumatic)
11
Hip or femur fracture
41
Hip or knee replacement, amputation or other bone or joint condition
81
Nervous system disorder (excluding stroke)
30
Spinal cord disease or condition (non-traumatic)
22
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
89

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
320
Predicted number of infections (B)
0.872
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
378
Denominator
378
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.7
Denominator
324
Average observed change score
13.5
Change in patients ability to move around
Average risk-adjusted change score
37.5
Denominator
324
Average observed change score
38.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
210
Denominator
324
Facility rate
64.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
242
Denominator
324
Facility rate
74.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
378
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
0.942
Comparative performance category
Better than the National Benchmark
Patient days
6,684
Predicted number of infections (B)
3.182
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
23
Number of health care workers
34
Rate of flu vaccination
67.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
18
Number of eligible stays
188
Unadjusted potentially preventable readmission rate
9.57
Risk-standardized potentially preventable readmission rate (RSRR)
8.97
Lower limit of the 95% confidence interval on the RSRR
7.01
Upper limit of the 95% confidence interval on the RSRR
11.39
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
18
Number of eligible stays
217
Unadjusted potentially preventable readmission rate
8.29
Risk-standardized potentially preventable readmission rate (RSRR)
6.52
Lower limit of the 95% confidence interval on the RSRR
4.42
Upper limit of the 95% confidence interval on the RSRR
9.47
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)
105
Number of eligible stays
168
Observed discharge to community rate
62.50
Risk-standardized discharge to community rate
64.24
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
57.83
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
69.96
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.03
Number of eligible episodes
177
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
378
Denominator
378
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
377
Facility observed rate
1.3
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
24
Number of health care workers
27
Rate of COVID-19 vaccination
88.9