Christus Mother Frances Hospital- Sulphur Springs


About the Facility

CMS Certification Number (CCN)
45T236
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
115 Airport Road
Phone Number
(903) 438-4569

Facility Medical Condition Statistics

All other conditions
36
Brain disease or condition (non-traumatic)
Data not available for this reporting period.
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
32
Hip or knee replacement, amputation or other bone or joint condition
45
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
12
Spinal cord injury (traumatic)
-
Stroke
24

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
125
Predicted number of infections (B)
0.182
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
172
Denominator
172
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.9
Denominator
158
Average observed change score
12.6
Change in patients ability to move around
Average risk-adjusted change score
26.2
Denominator
158
Average observed change score
31.5
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
106
Denominator
158
Facility rate
67.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
65
Denominator
158
Facility rate
41.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
172
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
Not Available
Comparative performance category
Not Available
Patient days
1,794
Predicted number of infections (B)
0.780
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
17
Number of health care workers
18
Rate of flu vaccination
94.4
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
11
Number of eligible stays
174
Unadjusted potentially preventable readmission rate
6.32
Risk-standardized potentially preventable readmission rate (RSRR)
8.47
Lower limit of the 95% confidence interval on the RSRR
6.45
Upper limit of the 95% confidence interval on the RSRR
10.72
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
7
Number of eligible stays
187
Unadjusted potentially preventable readmission rate
3.74
Risk-standardized potentially preventable readmission rate (RSRR)
4.96
Lower limit of the 95% confidence interval on the RSRR
3.06
Upper limit of the 95% confidence interval on the RSRR
7.02
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)
119
Number of eligible stays
157
Observed discharge to community rate
75.80
Risk-standardized discharge to community rate
68.50
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
63.52
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.65
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.01
Number of eligible episodes
191
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
169
Denominator
172
Facility rate
98.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
172
Facility observed rate
1.2
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
32
Number of health care workers
52
Rate of COVID-19 vaccination
61.5