Ascension Sacred Heart Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
523025
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
13111 N Port Washington Rd Second Floor
Phone Number
(414) 585-1374

Facility Medical Condition Statistics

All other conditions
16
Brain disease or condition (non-traumatic)
17
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
11
Hip or knee replacement, amputation or other bone or joint condition
13
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)
-
Stroke
76

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
196
Predicted number of infections (B)
0.353
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
134
Denominator
135
Facility rate
99.3
Change in patients ability to care for themselves
Average risk-adjusted change score
8.9
Denominator
111
Average observed change score
8.2
Change in patients ability to move around
Average risk-adjusted change score
24.0
Denominator
112
Average observed change score
23.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
33
Denominator
112
Facility rate
29.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
41
Denominator
112
Facility rate
36.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
135
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.042
SIR 95% confidence interval - upper limit
4.176
Comparative performance category
No Different than the National Benchmark
Patient days
3,362
Predicted number of infections (B)
1.181
Number of infections reported (A)
1
SIR (A/B)
0.847
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
142
Number of health care workers
153
Rate of flu vaccination
92.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
1
Number of eligible stays
42
Unadjusted potentially preventable readmission rate
2.38
Risk-standardized potentially preventable readmission rate (RSRR)
8.45
Lower limit of the 95% confidence interval on the RSRR
6.37
Upper limit of the 95% confidence interval on the RSRR
11.27
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
2
Number of eligible stays
46
Unadjusted potentially preventable readmission rate
4.35
Risk-standardized potentially preventable readmission rate (RSRR)
5.05
Lower limit of the 95% confidence interval on the RSRR
3.28
Upper limit of the 95% confidence interval on the RSRR
7.26
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)
25
Number of eligible stays
41
Observed discharge to community rate
60.98
Risk-standardized discharge to community rate
64.24
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
54.90
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.52
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.16
Number of eligible episodes
42
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
135
Denominator
135
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
135
Facility observed rate
1.5
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
76
Number of health care workers
78
Rate of COVID-19 vaccination
97.4