Encompass Health Rehabilitation Hospital of San Ju


About the Facility

CMS Certification Number (CCN)
403025
Ownership Type
For Profit
CMS Region
New York
Certification Date
Address
3rd Floor University Hospital Medical Center
Phone Number
(787) 274-5100

Facility Medical Condition Statistics

All other conditions
50
Brain disease or condition (non-traumatic)
40
Brain injury (traumatic)
52
Hip or femur fracture
158
Hip or knee replacement, amputation or other bone or joint condition
128
Nervous system disorder (excluding stroke)
140
Spinal cord disease or condition (non-traumatic)
52
Spinal cord injury (traumatic)
15
Stroke
210

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
304
Predicted number of infections (B)
0.827
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
822
Denominator
825
Facility rate
99.6
Change in patients ability to care for themselves
Average risk-adjusted change score
11.6
Denominator
764
Average observed change score
11.1
Change in patients ability to move around
Average risk-adjusted change score
31.3
Denominator
764
Average observed change score
29.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
399
Denominator
764
Facility rate
52.2
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
441
Denominator
764
Facility rate
57.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
825
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
0.941
Comparative performance category
Better than the National Benchmark
Patient days
11,871
Predicted number of infections (B)
3.183
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
160
Number of health care workers
201
Rate of flu vaccination
79.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
12
Number of eligible stays
135
Unadjusted potentially preventable readmission rate
8.89
Risk-standardized potentially preventable readmission rate (RSRR)
9.76
Lower limit of the 95% confidence interval on the RSRR
7.40
Upper limit of the 95% confidence interval on the RSRR
12.95
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
3
Number of eligible stays
139
Unadjusted potentially preventable readmission rate
2.16
Risk-standardized potentially preventable readmission rate (RSRR)
4.53
Lower limit of the 95% confidence interval on the RSRR
3.09
Upper limit of the 95% confidence interval on the RSRR
6.51
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)
95
Number of eligible stays
119
Observed discharge to community rate
79.83
Risk-standardized discharge to community rate
73.94
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.62
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
79.01
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
110
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
805
Denominator
825
Facility rate
97.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
824
Facility observed rate
0.1
Facility risk-adjusted rate
0.1
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
142
Number of health care workers
170
Rate of COVID-19 vaccination
83.5