Southern Hills Medical Center


About the Facility

CMS Certification Number (CCN)
44T197
Ownership Type
For Profit
CMS Region
Atlanta
Certification Date
Address
391 Wallace Rd
Phone Number
(615) 781-3470

Facility Medical Condition Statistics

All other conditions
76
Brain disease or condition (non-traumatic)
25
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
20
Hip or knee replacement, amputation or other bone or joint condition
21
Nervous system disorder (excluding stroke)
39
Spinal cord disease or condition (non-traumatic)
17
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
36

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
99
Predicted number of infections (B)
0.204
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
204
Denominator
204
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
15.6
Denominator
180
Average observed change score
17.3
Change in patients ability to move around
Average risk-adjusted change score
37.6
Denominator
180
Average observed change score
39.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
159
Denominator
180
Facility rate
88.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
148
Denominator
180
Facility rate
82.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
204
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
1.546
Comparative performance category
No Different than the National Benchmark
Patient days
4,132
Predicted number of infections (B)
1.938
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
12
Number of health care workers
21
Rate of flu vaccination
57.1
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
189
Unadjusted potentially preventable readmission rate
7.94
Risk-standardized potentially preventable readmission rate (RSRR)
8.47
Lower limit of the 95% confidence interval on the RSRR
6.72
Upper limit of the 95% confidence interval on the RSRR
10.78
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
9
Number of eligible stays
208
Unadjusted potentially preventable readmission rate
4.33
Risk-standardized potentially preventable readmission rate (RSRR)
4.72
Lower limit of the 95% confidence interval on the RSRR
3.19
Upper limit of the 95% confidence interval on the RSRR
6.40
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)
125
Number of eligible stays
162
Observed discharge to community rate
77.16
Risk-standardized discharge to community rate
73.36
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.62
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
78.34
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.02
Number of eligible episodes
171
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
202
Denominator
204
Facility rate
99.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
7
Denominator
203
Facility observed rate
3.4
Facility risk-adjusted rate
3.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
43
Number of health care workers
52
Rate of COVID-19 vaccination
82.7