COMPASS MEMORIAL HEALTHCARE
NPI 1053368191
General Acute Care Hospital - Critical Access in Marengo, IA

Hospital Compare Quality Information

Star ratings information gives patients a useful way to compare local hospitals by highlighting important quality factors like readmissions, mortality, safety of care, patient experience and timely and effective care. The ratings are presented as stars, ranging from 1 to 5. A higher number of stars indicates better performance in each quality aspect.

• Overall Quality Rating Not Available - There are too few measures or measure groups reported to calculate a star rating or measure group score.

  The overall rating is calculated by taking the weighted average of these group of scores. If a hospital is missing a measure category or group, the weights are redistributed amongst the qualifying measure categories or groups.

• Nurse Communication - 5 out of 5 stars - Excellent

  Nurse communication - star rating

• Doctor Communication - 5 out of 5 stars - Excellent

  Doctor communication - star rating

• Staff Responsiveness - 5 out of 5 stars - Excellent

  Staff responsiveness - star rating

• Communication About Medicines - 5 out of 5 stars - Excellent

  Communication about medicines - star rating

• Discharge Information - 4 out of 5 stars - Good

  Discharge information - star rating

• Care Transition - 4 out of 5 stars - Good

  Care transition - star rating

• Cleanliness - 5 out of 5 stars - Excellent

  Cleanliness - star rating

• Quietness - 4 out of 5 stars - Good

  Quietness - star rating

• Recommend Hospital - 5 out of 5 stars - Excellent

  Recommend hospital - star rating

• Hospital Type Critical Access Hospitals - Government - Local

• Emergency Services: Yes

  Shows if the hospital provides emergency services like acute medical care or trauma care.

• Meaningful Use of Electronic Health Records:

  Shows if the hospital meets the criteria for promoting interoperability of Electronic Health Record Systems (EHRS).

Hospital Complications and Mortality Quality Ratings

• Rate of complications for hip/knee replacement patients is number of cases too small

  Evaluation Period: July 2020 - March 2023

• Death rate for heart attack patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Death rate for COPD patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Death rate for heart failure patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Death rate for pneumonia patients is no different than the national rate

  Evaluation Period: July 2020 - June 2023

• Death rate for stroke patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

Unplanned Hospital Visits Quality Ratings

• Hospital return days for heart attack patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Hospital return days for heart failure patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Hospital return days for pneumonia patients is average days per 100 discharges

  Evaluation Period: July 2020 - June 2023

• Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) is number of cases too small

  Evaluation Period: January 2020 - December 2022

• Rate of inpatient admissions for patients receiving outpatient chemotherapy is no different than the national rate

  Evaluation Period: January 2022 - December 2022

• Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy is no different than the national rate

  Evaluation Period: January 2022 - December 2022

• Acute Myocardial Infarction (AMI) 30-Day Readmission Rate is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Rate of readmission for chronic obstructive pulmonary disease (COPD) patients is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Heart failure (HF) 30-Day Readmission Rate is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Rate of readmission after hip/knee replacement is number of cases too small

  Evaluation Period: July 2020 - June 2023

• Rate of readmission after discharge from hospital (hospital-wide) is no different than the national rate

  Evaluation Period: July 2022 - June 2023

• Pneumonia (PN) 30-Day Readmission Rate is no different than the national rate

  Evaluation Period: July 2020 - June 2023

Hospital Timely and Effective Care Quality Ratings

• Emergency department volume is low

  Evaluation Period: January 2022 - December 2022

• Admit Decision Time to ED Departure Time for Admitted Patients - non psychiatric/mental health disorders is 30

  Evaluation Period: January 2023 - December 2023

• Admit Decision Time to ED Departure Time for Admitted Patients - psychiatric/mental health disorders is not available

  Evaluation Period: January 2023 - December 2023

• Percentage of healthcare personnel who are up to date with COVID-19 vaccinations is not available%

  Percentage of healthcare personnel who completed COVID-19 primary vaccination series.
  Evaluation Period: October 2023 - December 2023

• Hospital Harm - Severe Hypoglycemia is not available

  Evaluation Period: January 2023 - December 2023

• Hospital Harm - Severe Hyperglycemia is not available

  Evaluation Period: January 2023 - December 2023

• Healthcare workers given influenza vaccination is 100%

  Percentage of healthcare workers given influenza vaccination.
  Evaluation Period: October 2023 - March 2024

• Average (median) time patients spent in the emergency department before leaving from the visit A lower number of minutes is better is 118 minutes

  Average time patients spent in the emergency department before leaving from the visit.
  Evaluation Period: January 2023 - December 2023

• Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. A lower number of minutes is better is not available minutes

  Average time patients spent in the emergency department before being sent home.
  Evaluation Period: January 2023 - December 2023

• Left before being seen is 1 %

  Percentage of patients who left the emergency department before being seen.
  Evaluation Period: January 2022 - December 2022

• Head CT results is not available %

  Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival.
  Evaluation Period: January 2023 - December 2023

• Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients is not available %

  Percentage of patients receiving appropriate recommendation for follow-up screening colonoscopy.
  Evaluation Period: January 2022 - December 2022

• Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery is not available %

  Percentage of patients who had cataract surgery and had improvement in visual function within 90 days following the surgery.
  Evaluation Period: January 2022 - December 2022

• ST-Segment Elevation Myocardial Infarction (STEMI) is not available

  Evaluation Period: January 2023 - December 2023

• Safe Use of Opioids - Concurrent Prescribing is 14

  Evaluation Period: January 2023 - December 2023

• Appropriate care for severe sepsis and septic shock is not available %

  Severe Sepsis and Septic Shock. Sepsis is a complication that happens when a patient has an extreme response to an infection. Higher percentages are better.
  Evaluation Period: January 2023 - December 2023

• Septic Shock 3-Hour Bundle is not available %

  Septic Shock 3 Hour.
  Evaluation Period: January 2023 - December 2023

• Septic Shock 6-Hour Bundle is not available %

  Severe Sepsis 6 Hour.
  Evaluation Period: January 2023 - December 2023

• Severe Sepsis 3-Hour Bundle is not available

  Evaluation Period: January 2023 - December 2023

• Severe Sepsis 6-Hour Bundle is not available %

  Septic Shock 6 Hour.
  Evaluation Period: January 2023 - December 2023

• Discharged on Antithrombotic Therapy is not available

  Evaluation Period: January 2023 - December 2023

• Anticoagulation Therapy for Atrial Fibrillation/Flutter is not available

  Evaluation Period: January 2023 - December 2023

• Antithrombotic Therapy by End of Hospital Day 2 is not available

  Evaluation Period: January 2023 - December 2023

• Discharged on Statin Medication is not available

  Evaluation Period: January 2023 - December 2023

• Venous Thromboembolism Prophylaxis is not available

  Evaluation Period: January 2023 - December 2023

• Intensive Care Unit Venous Thromboembolism Prophylaxis is not available

  Evaluation Period: January 2023 - December 2023

CLIA Information

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 applies to facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CLIA Program sets standards for clinical laboratory testing and issues certificates. The NPI / CLIA crosswalk information for this NPI number is:

CLIA Number

16D0386618

Facility Type

Hospital

Certificate Effective Date

March 01, 2025

Certificate Expiration Date

February 28, 2027

Laboratory Director

DR. JONATHAN W. NEWBERRY

Certificate Type

Certificate of Compliance

Certificate Type Description

This CLIA certificate is issued to Compass Memorial Healthcare after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements. This type of certificate is issued to laboratories that perform nonwaived (moderate and/or high complexity) testing.

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