MIPS Center Impact Evaluation v3
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1.
Center Name & CCN#:
*
-- Please Select --
Advanced Health & Rehab of Twiggs County 115727
Archway Health & Rehab 115728
Avalon Health & Rehab 115528
Azalea Health & Rehab 115642
Bainbridge Nursing Home 115324
Baptist Village 115615
Bayview Nursing & Rehab 115593
Bolingreen Health & Rehab 115346
Brentwood Health & Rehab 115361
Brightmoor Health & Rehab 115556
Calhoun Nursing Home 115264
Camellia Health & Rehab 115598
Carlyle Place 115680
Carrollton Nursing & Rehab 115368
Cedar Springs Health & Rehab 115381
Center for Advanced Rehab Parkside 115040
Chaplinwood Health & Rehab 115477
Chatuge Regional Nursing Home 115701
Cherry Blossom Health & Rehab 115652
Christian City Rehab 115573
Chulio Hills Health & Rehab 115287
Coastal Manor 115665
Cook Senior Living Center 115655
Cumming Health & Rehab 115551
Dade Health & Rehab 115558
Dawson Health & Rehab 115483
Delmar Gardens of Gwinnett 115350
Delmar Gardens of Smyrna 115350
Eagle Health & Rehab 115618
Early Memorial Nursing Home/LifeBrite 115271
Eastman Health & Rehab 115622
Eatonton Health & Rehab 115595
Effingham Health Care Center 115106
Elberta Healthcare 115657
Emanuel Medical Center Nursing Home 115704
Evergreen Health & Rehab 115720
Fifth Avenue Healthcare 115319
Florence Hand Home 115277
Folkston Park Care & Rehab 115630
Fort Gaines Health & Rehab 115696
Fountainview Center for Alzheimer's 115697
Friendship Health & Rehab 115559
Georgia War Veterans Home - Milledgeville
Gateway Health & Rehab 115560
Gracemore Nursing 115554
Gray Health & Rehab 115466
Gwinnett Extended Care Center 115645
Habersham Home 115099
Hartwell Health & Rehab 115435
Hazelhurst Court Care & Rehab 115626
Heart of GA Nursing & Rehab 115471
Heritage Inn of Barnesville 115447
Heritage Inn of Sandersville 115369
Heritage Inn of Statesboro 115597
Hill Haven Nursing Home 115710
Laurel Park 115673
Lee County Health & Rehab 115614
Lifecare Center of Gwinnett 115347
Lillian Carter 115550
Lynn Haven Health & Rehab 115474
Madison Health & Rehab 115457
Magnolia Manor of Marion Co. 115599
Memorial Manor Nursing Home 115711
Miller Nursing Home 115039
Miona Geriatric & Dementia Center 115338
Montezuma Health & Rehab 115364
NHC Healthcare of Fort Oglethorpe 115492
Northridge Health & Rehab 115714
Oakview Health & Rehab 115428
Oakview Waverly Hall 115428
Oceanside Health & Rehab 115459
Orchard Health and Rehab 115522
Orchard View Rehab 115146
Oxley Park Health & Rehab 115387
Palemon Gaskins Memorial Nursing Home 115713
Parkside Ellijay
Pinewood Manor 115586
Presbyterian Home Quitman 115498
Presbyterian Village - Austell 115490
Providence Health & Rehab of Sparta 115397
PruittHealth - Ft. Oglethorpe 115409
PruittHealth - Forsyth 115418
PruittHealth - Ashburn 115491
PruittHealth - Bethany 115700
PruittHealth - Blue Ridge 115468
PruittHealth - Brookhaven 115313
PruittHealth - Crestwood 115385
PruittHealth - Decatur 115647
PruittHealth - Eastside 115391
PruittHealth - Fitzgerald 115617
PruittHealth - Greenville 115658
PruittHealth - Griffin 115529
PruittHealth - Holly Hill 115562
PruittHealth - Jasper 115677
PruittHealth - Lakehaven 115373
PruittHealth - Lilburn 115516
PruittHealth - Moultrie 115505
PruittHealth - Ocilla 115608
PruittHealth - Lafayette 115304
PruittHealth - Palmyra 115628
PruittHealth - Savannah 115339
PruittHealth - Shepherd Hills 115452
PruittHealth - Sunrise 115668
PruittHealth - Valdosta 115377
PruittHealth - Fairburn 115506
Rehabilitation Center of South GA 115676
Reliable Health & Rehab at Lakewood 115717
Ridgewood Manor 115341
River Towne Center 115566
Riverside Health & Rehab 115353
Riverview Health & Rehab 115641
Rockmart Health & Rehab 115530
Roswell Nursing & Rehab 115422
Sadie G. Mays 115542
Savannah Beach Health & Rehab 115633
Scott Health & Rehab 115671
Sears Manor Brunswick 115520
Senior Care Center of Brunswick 115721
Signature Healthcare at Tower Road 115115
Signature Healthcare of Buckhead 115110
Signature Healthcare of Savannah 115120
Signature Healthcare of Marietta 115206
Sparta Health & Rehab 115382
St. George Village
Summerhill Senior Living Community 115430
Syl-View Healthcare and Rehabilitation 115544
The Lodge 115552
The Oaks - Carrollton 115384
The Oaks - Marshes of Skidaway 115715
The Oaks Nursing Center 115705
The Place at Dean's Bridge 115290
The Place at Martinez 115308
The Retreat 115675
Thomson Nursing & Rehab 115365
Townsend Park 115461
Traditions Health &Rehab 115473
Twin Fountains Home 115709
Twin Oaks Convalescent Center 115513
Union County Nursing Home 115695
Warm Springs Medical Center Nursing Home 115603
Waycross Health & Rehab 115605
Westbury Medical Home Jackson 115563
Westbury - Conyers 115469
Westbury - McDonough 115463
Westview Nursing & Rehabilitation 115547
Westview Nursing Home 115547
Winder Healthcare 115536
Winthrop Health & Rehab 115395
Wood Dale Health & Rehab 115374
Woodstock Health & Rehab 115421
Wynfield Park 115625
2.
Is this your baseline report?
*
Yes
No
3.
If this is not your baseline report, what quarter/year are you reporting for?
-- None --
Q1 2017
Q2 2017
Q3 2017
Q4 2017
Q1 2018
Q2 2018
Q3 2018
Q4 2018
Q1 2019
Q2 2019
Q3 2019
Q4 2019
4.
Name of person submitting the form:
*
5.
Email address of person submitting the form:
*
6.
Date signed MIPS Participation Agreement:
*
mm/dd/yyyy
7.
Have the program champion(s) at your center changed?
*
Yes
No
8.
If your program champion(s) have changed, please enter the new champion(s) name(s) & email(s) below:
9.
M&M certification completion date:
*
mm/dd/yyyy
10.
Enter the following data:
Response
Comments
Anti-Psychotic Drug Rate (%, Quality Measure)
LS Depressive Symptoms (%, Quality Measure)
LS Antianxiety/Sedative Hypnotics (%, Quality Measure)
LS Rehospitalization Rate (%, Trend Tracker)
LS Pain (% Quality Measure)
Total Employee Turnover Rate (%, Facility Record)
Number of residents with active M&M care plan (# 1-15, facility Record)
Overall State Rating (1-5 scale, NH Compare)
Quality Measure Star Rating (1-5 scale, NH Compare)
11.
Upon completion of certification and implementation of program, outline plan for program sustainability and/or changes to enhance program: