Wellspan Surgery and Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
39T327
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
55 Monument Rd
Phone Number
(717) 812-6100

Facility Medical Condition Statistics

All other conditions
176
Brain disease or condition (non-traumatic)
46
Brain injury (traumatic)
26
Hip or femur fracture
131
Hip or knee replacement, amputation or other bone or joint condition
150
Nervous system disorder (excluding stroke)
31
Spinal cord disease or condition (non-traumatic)
59
Spinal cord injury (traumatic)
19
Stroke
159

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.110
SIR 95% confidence interval - upper limit
2.171
Comparative performance category
No Different than the National Benchmark
Catheter days
1,613
Predicted number of infections (B)
3.043
Number of infections reported (A)
2
SIR (A/B)
0.657
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
776
Denominator
776
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.5
Denominator
656
Average observed change score
12.5
Change in patients ability to move around
Average risk-adjusted change score
32.7
Denominator
656
Average observed change score
35.3
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
273
Denominator
656
Facility rate
41.6
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
418
Denominator
656
Facility rate
63.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
776
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.122
SIR 95% confidence interval - upper limit
1.305
Comparative performance category
No Different than the National Benchmark
Patient days
16,168
Predicted number of infections (B)
6.255
Number of infections reported (A)
3
SIR (A/B)
0.480
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
192
Number of health care workers
193
Rate of flu vaccination
99.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
38
Number of eligible stays
622
Unadjusted potentially preventable readmission rate
6.11
Risk-standardized potentially preventable readmission rate (RSRR)
7.71
Lower limit of the 95% confidence interval on the RSRR
6.40
Upper limit of the 95% confidence interval on the RSRR
9.43
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
27
Number of eligible stays
677
Unadjusted potentially preventable readmission rate
3.99
Risk-standardized potentially preventable readmission rate (RSRR)
4.52
Lower limit of the 95% confidence interval on the RSRR
3.41
Upper limit of the 95% confidence interval on the RSRR
6.12
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)
414
Number of eligible stays
596
Observed discharge to community rate
69.46
Risk-standardized discharge to community rate
70.49
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.99
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.78
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.15
Number of eligible episodes
618
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
750
Denominator
776
Facility rate
96.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
10
Denominator
774
Facility observed rate
1.3
Facility risk-adjusted rate
1.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
135
Number of health care workers
155
Rate of COVID-19 vaccination
87.1