Pam Rehabilitation Hospital of Clear Lake


About the Facility

CMS Certification Number (CCN)
673061
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
110 East Medical Center Blvd
Webster, Texas 77598
Phone Number
(832) 224-9500

Facility Medical Condition Statistics

All other conditions
367
Brain disease or condition (non-traumatic)
226
Brain injury (traumatic)
106
Hip or femur fracture
237
Hip or knee replacement, amputation or other bone or joint condition
395
Nervous system disorder (excluding stroke)
933
Spinal cord disease or condition (non-traumatic)
64
Spinal cord injury (traumatic)
32
Stroke
423

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.065
SIR 95% confidence interval - upper limit
1.284
Comparative performance category
No Different than the National Benchmark
Catheter days
4,033
Predicted number of infections (B)
5.147
Number of infections reported (A)
2
SIR (A/B)
0.389
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
2,668
Denominator
2,672
Facility rate
99.9
Change in patients ability to care for themselves
Average risk-adjusted change score
12.3
Denominator
2,307
Average observed change score
13.2
Change in patients ability to move around
Average risk-adjusted change score
29.5
Denominator
2,307
Average observed change score
27.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
1,317
Denominator
2,307
Facility rate
57.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
1,248
Denominator
2,307
Facility rate
54.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
2,672
Facility rate
0.1
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.003
SIR 95% confidence interval - upper limit
0.322
Comparative performance category
Better than the National Benchmark
Patient days
40,347
Predicted number of infections (B)
15.313
Number of infections reported (A)
1
SIR (A/B)
0.065
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
448
Number of health care workers
937
Rate of flu vaccination
47.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
277
Number of eligible stays
2,091
Unadjusted potentially preventable readmission rate
13.25
Risk-standardized potentially preventable readmission rate (RSRR)
10.32
Lower limit of the 95% confidence interval on the RSRR
9.40
Upper limit of the 95% confidence interval on the RSRR
11.44
Comparative performance category
Worse than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
168
Number of eligible stays
2,395
Unadjusted potentially preventable readmission rate
7.01
Risk-standardized potentially preventable readmission rate (RSRR)
5.74
Lower limit of the 95% confidence interval on the RSRR
5.13
Upper limit of the 95% confidence interval on the RSRR
6.48
Comparative performance category
Worse than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
1,150
Number of eligible stays
1,827
Observed discharge to community rate
62.94
Risk-standardized discharge to community rate
69.23
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.85
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
71.33
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.06
Number of eligible episodes
2,734
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
2,647
Denominator
2,672
Facility rate
99.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
23
Denominator
2,665
Facility observed rate
0.9
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
692
Number of health care workers
816
Rate of COVID-19 vaccination
84.8