Encompass Health Rehabilitation Hospital of the Mi


About the Facility

CMS Certification Number (CCN)
673044
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
2304 Highway 121
Bedford, Texas 76021
Phone Number
(817) 684-2000

Facility Medical Condition Statistics

All other conditions
308
Brain disease or condition (non-traumatic)
152
Brain injury (traumatic)
35
Hip or femur fracture
109
Hip or knee replacement, amputation or other bone or joint condition
266
Nervous system disorder (excluding stroke)
232
Spinal cord disease or condition (non-traumatic)
30
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
182

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.026
SIR 95% confidence interval - upper limit
2.604
Comparative performance category
No Different than the National Benchmark
Catheter days
1,312
Predicted number of infections (B)
1.894
Number of infections reported (A)
1
SIR (A/B)
0.528
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
1,294
Denominator
1,294
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
14.1
Denominator
1,107
Average observed change score
14.5
Change in patients ability to move around
Average risk-adjusted change score
37.5
Denominator
1,108
Average observed change score
36.5
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
822
Denominator
1,108
Facility rate
74.2
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
865
Denominator
1,108
Facility rate
78.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
1,294
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.424
SIR 95% confidence interval - upper limit
1.920
Comparative performance category
No Different than the National Benchmark
Patient days
18,587
Predicted number of infections (B)
7.212
Number of infections reported (A)
7
SIR (A/B)
0.971
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
331
Number of health care workers
365
Rate of flu vaccination
90.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
137
Number of eligible stays
1,050
Unadjusted potentially preventable readmission rate
13.05
Risk-standardized potentially preventable readmission rate (RSRR)
10.94
Lower limit of the 95% confidence interval on the RSRR
9.50
Upper limit of the 95% confidence interval on the RSRR
12.54
Comparative performance category
Worse than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
61
Number of eligible stays
1,162
Unadjusted potentially preventable readmission rate
5.25
Risk-standardized potentially preventable readmission rate (RSRR)
5.06
Lower limit of the 95% confidence interval on the RSRR
4.16
Upper limit of the 95% confidence interval on the RSRR
6.27
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)
602
Number of eligible stays
904
Observed discharge to community rate
66.59
Risk-standardized discharge to community rate
67.90
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.03
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.64
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
1,350
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
1,286
Denominator
1,294
Facility rate
99.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
1,293
Facility observed rate
0.4
Facility risk-adjusted rate
0.4
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
332
Number of health care workers
367
Rate of COVID-19 vaccination
90.5