Valley Baptist Health System Rehab Unit


About the Facility

CMS Certification Number (CCN)
45T033
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
2101 Pease Street
Phone Number
(956) 389-1550

Facility Medical Condition Statistics

All other conditions
95
Brain disease or condition (non-traumatic)
14
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
35
Hip or knee replacement, amputation or other bone or joint condition
51
Nervous system disorder (excluding stroke)
41
Spinal cord disease or condition (non-traumatic)
13
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
76

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.044
SIR 95% confidence interval - upper limit
4.326
Comparative performance category
No Different than the National Benchmark
Catheter days
465
Predicted number of infections (B)
1.140
Number of infections reported (A)
1
SIR (A/B)
0.877
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
328
Denominator
328
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.0
Denominator
273
Average observed change score
14.6
Change in patients ability to move around
Average risk-adjusted change score
32.9
Denominator
274
Average observed change score
35.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
185
Denominator
274
Facility rate
67.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
181
Denominator
274
Facility rate
66.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
328
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.117
SIR 95% confidence interval - upper limit
2.310
Comparative performance category
No Different than the National Benchmark
Patient days
5,509
Predicted number of infections (B)
2.860
Number of infections reported (A)
2
SIR (A/B)
0.699
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
30
Number of health care workers
30
Rate of flu vaccination
100.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
239
Unadjusted potentially preventable readmission rate
5.44
Risk-standardized potentially preventable readmission rate (RSRR)
7.70
Lower limit of the 95% confidence interval on the RSRR
6.05
Upper limit of the 95% confidence interval on the RSRR
9.70
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
13
Number of eligible stays
277
Unadjusted potentially preventable readmission rate
4.69
Risk-standardized potentially preventable readmission rate (RSRR)
4.90
Lower limit of the 95% confidence interval on the RSRR
3.52
Upper limit of the 95% confidence interval on the RSRR
6.77
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)
146
Number of eligible stays
231
Observed discharge to community rate
63.20
Risk-standardized discharge to community rate
65.01
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
59.42
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.54
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.02
Number of eligible episodes
257
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
323
Denominator
328
Facility rate
98.5
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
327
Facility observed rate
1.5
Facility risk-adjusted rate
1.5
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
23
Number of health care workers
24
Rate of COVID-19 vaccination
95.8