Chi St. Lukes Health - Baylor Rehabilitation


About the Facility

CMS Certification Number (CCN)
45T862
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
17200 St. Luke's Way
Phone Number
(502) 596-6346

Facility Medical Condition Statistics

All other conditions
32
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
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
30

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
2.273
Comparative performance category
No Different than the National Benchmark
Catheter days
645
Predicted number of infections (B)
1.318
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
99
Denominator
99
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
15.2
Denominator
86
Average observed change score
15.0
Change in patients ability to move around
Average risk-adjusted change score
36.2
Denominator
86
Average observed change score
35.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
76
Denominator
86
Facility rate
88.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
70
Denominator
86
Facility rate
81.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
99
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
1,863
Predicted number of infections (B)
0.638
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
26
Number of health care workers
45
Rate of flu vaccination
57.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
7
Number of eligible stays
79
Unadjusted potentially preventable readmission rate
8.86
Risk-standardized potentially preventable readmission rate (RSRR)
8.61
Lower limit of the 95% confidence interval on the RSRR
6.50
Upper limit of the 95% confidence interval on the RSRR
11.06
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
84
Unadjusted potentially preventable readmission rate
1.19
Risk-standardized potentially preventable readmission rate (RSRR)
4.25
Lower limit of the 95% confidence interval on the RSRR
2.77
Upper limit of the 95% confidence interval on the RSRR
6.60
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)
35
Number of eligible stays
54
Observed discharge to community rate
64.81
Risk-standardized discharge to community rate
66.15
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
56.99
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.53
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.05
Number of eligible episodes
80
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
95
Denominator
99
Facility rate
96.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
99
Facility observed rate
1.0
Facility risk-adjusted rate
1.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
34
Number of health care workers
43
Rate of COVID-19 vaccination
79.1