Bsa Health System


About the Facility

CMS Certification Number (CCN)
45T231
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
1600 Wallace Blvd
Phone Number
(806) 212-2000

Facility Medical Condition Statistics

All other conditions
19
Brain disease or condition (non-traumatic)
16
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
70
Hip or knee replacement, amputation or other bone or joint condition
45
Nervous system disorder (excluding stroke)
31
Spinal cord disease or condition (non-traumatic)
23
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
58

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.130
SIR 95% confidence interval - upper limit
2.556
Comparative performance category
No Different than the National Benchmark
Catheter days
949
Predicted number of infections (B)
2.585
Number of infections reported (A)
2
SIR (A/B)
0.774
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
271
Denominator
271
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.5
Denominator
250
Average observed change score
12.5
Change in patients ability to move around
Average risk-adjusted change score
29.2
Denominator
250
Average observed change score
33.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
120
Denominator
250
Facility rate
48.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
132
Denominator
250
Facility rate
52.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
271
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
1.590
Comparative performance category
No Different than the National Benchmark
Patient days
5,980
Predicted number of infections (B)
1.884
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
38
Number of health care workers
38
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
14
Number of eligible stays
284
Unadjusted potentially preventable readmission rate
4.93
Risk-standardized potentially preventable readmission rate (RSRR)
8.56
Lower limit of the 95% confidence interval on the RSRR
6.65
Upper limit of the 95% confidence interval on the RSRR
11.36
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
1
Number of eligible stays
297
Unadjusted potentially preventable readmission rate
0.34
Risk-standardized potentially preventable readmission rate (RSRR)
3.35
Lower limit of the 95% confidence interval on the RSRR
2.12
Upper limit of the 95% confidence interval on the RSRR
4.82
Comparative performance category
Better than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
182
Number of eligible stays
239
Observed discharge to community rate
76.15
Risk-standardized discharge to community rate
70.04
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.27
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.98
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.03
Number of eligible episodes
252
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
269
Denominator
271
Facility rate
99.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
269
Facility observed rate
1.5
Facility risk-adjusted rate
1.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
36
Number of health care workers
38
Rate of COVID-19 vaccination
94.7