Chca Conroe Lp


About the Facility

CMS Certification Number (CCN)
45T222
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
504 Medical Center Blvd
Conroe, Texas 77304
Phone Number
(936) 525-3964

Facility Medical Condition Statistics

All other conditions
129
Brain disease or condition (non-traumatic)
39
Brain injury (traumatic)
24
Hip or femur fracture
77
Hip or knee replacement, amputation or other bone or joint condition
57
Nervous system disorder (excluding stroke)
18
Spinal cord disease or condition (non-traumatic)
21
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
69

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
446
Predicted number of infections (B)
0.853
Number of infections reported (A)
1
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
360
Denominator
364
Facility rate
98.9
Change in patients ability to care for themselves
Average risk-adjusted change score
15.1
Denominator
321
Average observed change score
15.9
Change in patients ability to move around
Average risk-adjusted change score
38.4
Denominator
321
Average observed change score
39.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
272
Denominator
321
Facility rate
84.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
266
Denominator
321
Facility rate
82.9
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
364
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
1.381
Comparative performance category
No Different than the National Benchmark
Patient days
5,866
Predicted number of infections (B)
2.169
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
22
Number of health care workers
45
Rate of flu vaccination
48.9
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
42
Number of eligible stays
444
Unadjusted potentially preventable readmission rate
9.46
Risk-standardized potentially preventable readmission rate (RSRR)
9.12
Lower limit of the 95% confidence interval on the RSRR
7.54
Upper limit of the 95% confidence interval on the RSRR
11.12
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
35
Number of eligible stays
510
Unadjusted potentially preventable readmission rate
6.86
Risk-standardized potentially preventable readmission rate (RSRR)
6.45
Lower limit of the 95% confidence interval on the RSRR
4.62
Upper limit of the 95% confidence interval on the RSRR
9.22
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)
261
Number of eligible stays
408
Observed discharge to community rate
63.97
Risk-standardized discharge to community rate
63.13
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
58.98
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.16
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.04
Number of eligible episodes
437
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
361
Denominator
364
Facility rate
99.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
362
Facility observed rate
0.6
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
32
Number of health care workers
43
Rate of COVID-19 vaccination
74.4