Millcreek Community Hospital


About the Facility

CMS Certification Number (CCN)
39T198
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
5515 Peach St
Phone Number
(814) 868-2462

Facility Medical Condition Statistics

All other conditions
34
Brain disease or condition (non-traumatic)
34
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
31
Nervous system disorder (excluding stroke)
44
Spinal cord disease or condition (non-traumatic)
15
Spinal cord injury (traumatic)
-
Stroke
17

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
184
Predicted number of infections (B)
0.379
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
182
Denominator
183
Facility rate
99.5
Change in patients ability to care for themselves
Average risk-adjusted change score
9.2
Denominator
161
Average observed change score
10.4
Change in patients ability to move around
Average risk-adjusted change score
20.8
Denominator
161
Average observed change score
23.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
63
Denominator
161
Facility rate
39.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
45
Denominator
161
Facility rate
28.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
4
Denominator
183
Facility rate
2.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.946
Comparative performance category
No Different than the National Benchmark
Patient days
2,858
Predicted number of infections (B)
1.539
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
13
Number of health care workers
38
Rate of flu vaccination
34.2
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
15
Number of eligible stays
161
Unadjusted potentially preventable readmission rate
9.32
Risk-standardized potentially preventable readmission rate (RSRR)
8.71
Lower limit of the 95% confidence interval on the RSRR
6.93
Upper limit of the 95% confidence interval on the RSRR
10.88
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
6
Number of eligible stays
179
Unadjusted potentially preventable readmission rate
3.35
Risk-standardized potentially preventable readmission rate (RSRR)
4.44
Lower limit of the 95% confidence interval on the RSRR
2.75
Upper limit of the 95% confidence interval on the RSRR
6.30
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)
86
Number of eligible stays
152
Observed discharge to community rate
56.58
Risk-standardized discharge to community rate
59.12
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
53.29
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
64.96
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.00
Number of eligible episodes
209
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
179
Denominator
183
Facility rate
97.8
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
7
Denominator
178
Facility observed rate
3.9
Facility risk-adjusted rate
4.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
37
Number of health care workers
40
Rate of COVID-19 vaccination
92.5