Upmc Passavant


About the Facility

CMS Certification Number (CCN)
39T107
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
9100 Babcock Blvd.
Phone Number
(877) 287-3422

Facility Medical Condition Statistics

All other conditions
78
Brain disease or condition (non-traumatic)
21
Brain injury (traumatic)
19
Hip or femur fracture
16
Hip or knee replacement, amputation or other bone or joint condition
60
Nervous system disorder (excluding stroke)
33
Spinal cord disease or condition (non-traumatic)
34
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
113

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.555
SIR 95% confidence interval - upper limit
5.942
Comparative performance category
No Different than the National Benchmark
Catheter days
504
Predicted number of infections (B)
1.374
Number of infections reported (A)
3
SIR (A/B)
2.183
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
372
Denominator
372
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
14.3
Denominator
314
Average observed change score
15.5
Change in patients ability to move around
Average risk-adjusted change score
43.5
Denominator
313
Average observed change score
44.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
244
Denominator
314
Facility rate
77.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
270
Denominator
314
Facility rate
86.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
372
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
0.921
Comparative performance category
Better than the National Benchmark
Patient days
6,306
Predicted number of infections (B)
3.254
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
35
Number of health care workers
40
Rate of flu vaccination
87.5
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
206
Unadjusted potentially preventable readmission rate
8.74
Risk-standardized potentially preventable readmission rate (RSRR)
8.86
Lower limit of the 95% confidence interval on the RSRR
6.86
Upper limit of the 95% confidence interval on the RSRR
11.07
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
7
Number of eligible stays
227
Unadjusted potentially preventable readmission rate
3.08
Risk-standardized potentially preventable readmission rate (RSRR)
4.24
Lower limit of the 95% confidence interval on the RSRR
2.94
Upper limit of the 95% confidence interval on the RSRR
6.39
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)
128
Number of eligible stays
175
Observed discharge to community rate
73.14
Risk-standardized discharge to community rate
70.00
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
64.77
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.98
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.98
Number of eligible episodes
195
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
372
Denominator
372
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
371
Facility observed rate
1.1
Facility risk-adjusted rate
1.4
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
34
Number of health care workers
40
Rate of COVID-19 vaccination
85.0