Sentara Williamsburg Regional


About the Facility

CMS Certification Number (CCN)
49T066
Ownership Type
Non-profit
CMS Region
Philadelphia
Certification Date
Address
100 Sentara Circle
Phone Number
(757) 984-7409

Facility Medical Condition Statistics

All other conditions
Data not available for this reporting period.
Brain disease or condition (non-traumatic)
-
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)
-
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
18

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
6
Predicted number of infections (B)
0.010
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
32
Denominator
32
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.0
Denominator
29
Average observed change score
13.9
Change in patients ability to move around
Average risk-adjusted change score
32.6
Denominator
29
Average observed change score
36.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
14
Denominator
29
Facility rate
48.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
18
Denominator
29
Facility rate
62.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
32
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
337
Predicted number of infections (B)
0.114
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
54
Number of health care workers
58
Rate of flu vaccination
93.1
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
4
Number of eligible stays
104
Unadjusted potentially preventable readmission rate
3.85
Risk-standardized potentially preventable readmission rate (RSRR)
8.19
Lower limit of the 95% confidence interval on the RSRR
6.41
Upper limit of the 95% confidence interval on the RSRR
10.57
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
3
Number of eligible stays
109
Unadjusted potentially preventable readmission rate
2.75
Risk-standardized potentially preventable readmission rate (RSRR)
4.64
Lower limit of the 95% confidence interval on the RSRR
2.89
Upper limit of the 95% confidence interval on the RSRR
7.36
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)
48
Number of eligible stays
79
Observed discharge to community rate
60.76
Risk-standardized discharge to community rate
61.78
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
54.14
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.95
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.91
Number of eligible episodes
93
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
32
Denominator
32
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
32
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
51
Number of health care workers
54
Rate of COVID-19 vaccination
94.4