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Overview

Address
529 CAPP HARLAN ROAD, TOMPKINSVILLE, KY 42167
Phone
(270) 487-9231
Hospital Type
Acute Care
Ownership
Non-Profit (Other)
Emergency Services
Yes
1 /5
CMS Overall Rating
p0
Acute Care — General medical and surgical hospital participating in Medicare IPPS. Subject to CMS quality reporting and payment adjustment programs (VBP, HRRP, HAC).

CMS Star Rating — Quality Domain Breakdown

CMS computes the overall star rating from five quality domains. Each domain compares this hospital's measures against national benchmarks.

Mortality 3 of 7 measures reported
3
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 1 of 8 measures reported
1
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 4 of 11 measures reported
2
2
Better No different Worse
30-day unplanned readmission rates for heart attack, heart failure, pneumonia, COPD, hip/knee replacement, and CABG.
Patient Experience 8 of 8 measures reported
8 measures reported (comparative data not available for this domain)
HCAHPS survey scores — patient-reported experience with communication, responsiveness, cleanliness, and discharge planning.
Timely & Effective Care 8 of 12 measures reported
8 measures reported (comparative data not available for this domain)
Process-of-care measures including flu immunization, blood clot prevention, and appropriate use of imaging.

Readmissions — Hospital Readmissions Reduction Program

The Excess Readmission Ratio (ERR) compares this hospital's 30-day readmission rate to expected, adjusting for patient mix. An ERR of 1.0 means readmissions are as expected; > 1.0 triggers a Medicare payment penalty (up to 3%).

This hospital has excess readmissions in at least one condition and is subject to HRRP payment reduction.
Acute Myocardial Infarction (Heart Attack)
— Not reported
Heart Failure 74 discharges
1.1101 p95
Pneumonia 133 discharges
1.1648 p98
COPD 59 discharges
1.0331 p77
Hip/Knee Replacement
— Not reported
CABG Surgery
— Not reported
Expected (1.0) National median

Value-Based Purchasing

The Hospital VBP Program adjusts Medicare payments based on clinical quality. The Total Performance Score (TPS) is a weighted composite of four domains, each worth 25%. This hospital's TPS is above the national median, suggesting a positive payment adjustment.

40.4 p80
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
7.8 p71
Nat'l median: 5.0
Measures mortality rates for conditions like heart attack, heart failure, pneumonia, and COPD. Based on 30-day risk-standardized mortality.
Person & Community Engagement 25% weight
16.0 p87
Nat'l median: 8.8
Based on HCAHPS patient experience survey results — communication with nurses and doctors, hospital cleanliness, pain management, discharge information.
Efficiency & Cost Reduction 25% weight
16.7 p90
Nat'l median: 2.5
Based on Medicare Spending Per Beneficiary (MSPB). Measures episode-of-care costs from 3 days before admission through 30 days after discharge.

CMS Payment Programs

Three Medicare programs adjust hospital payments based on quality performance. Hospitals can be penalized under multiple programs simultaneously.

Readmissions (HRRP)
Penalized
Worst ERR: 1.1648
Value-Based Purchasing
40.4 TPS
Above national median
HAC Reduction
Payment Reduced
HAC Score: 1.6665

Complications & Deaths

30-day mortality rates, patient safety indicators, and complication rates. "Better" means statistically significantly better than the national rate.

Measure Score vs. National Denominator
COMP_HIP_KNEE
Hybrid_HWM 4.80 No Different Than the National Rate 169
MORT_30_AMI Number of Cases Too Small
MORT_30_CABG
MORT_30_COPD 8.80 No Different Than the National Rate 49
MORT_30_HF 10.10 No Different Than the National Rate 57
MORT_30_PN 17.50 No Different Than the National Rate 133
MORT_30_STK Number of Cases Too Small
PSI_03 0.53 No Different Than the National Rate 691
PSI_04
PSI_06 0.21 No Different Than the National Rate 766
PSI_08 0.27 No Different Than the National Rate 800
PSI_09
PSI_10
PSI_11
PSI_12
PSI_13
PSI_14
PSI_15
PSI_90

Patient Experience (HCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems — standardized patient survey measuring satisfaction with care.

Measure Score Star Rating
H_COMP_1_A_P: Nurses "always" communicated well 79%
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 4%
H_COMP_1_U_P: Nurses "usually" communicated well 17%
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score
H_COMP_1_STAR_RATING: Nurse communication - star rating 4
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 91%
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 1%
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 8%
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 80%
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 3%
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 17%
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 67%
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 7%
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 26%
H_COMP_2_A_P: Doctors "always" communicated well 94%
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 1%
H_COMP_2_U_P: Doctors "usually" communicated well 5%
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score
H_COMP_2_STAR_RATING: Doctor communication - star rating 5
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 97%
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 0%
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 3%
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 92%
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 0%
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 8%
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 92%
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 2%
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 6%
H_COMP_5_A_P: Staff "always" explained 62%
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 13%
H_COMP_5_U_P: Staff "usually" explained 25%
H_COMP_5_LINEAR_SCORE: Communication about medicines - linear mean score
H_COMP_5_STAR_RATING: Communication about medicines - star rating 4
H_MED_FOR_A_P: Staff "always" explained new medications 74%
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7%
H_MED_FOR_U_P: Staff "usually" explained new medications 19%
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 51%
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 19%
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 30%
H_COMP_6_N_P: No, staff "did not" give patients this information 22%
H_COMP_6_Y_P: Yes, staff "did" give patients this information 78%
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score
H_COMP_6_STAR_RATING: Discharge information - star rating 1
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 24%
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 76%
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 19%
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 81%
H_CLEAN_HSP_A_P: Room was "always" clean 78%
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 5%
H_CLEAN_HSP_U_P: Room was "usually" clean 17%
H_CLEAN_LINEAR_SCORE: Cleanliness - linear mean score
H_CLEAN_STAR_RATING: Cleanliness - star rating 4
H_QUIET_HSP_A_P: "Always" quiet at night 70%
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 4%
H_QUIET_HSP_U_P: "Usually" quiet at night 26%
H_QUIET_LINEAR_SCORE: Quietness - linear mean score
H_QUIET_STAR_RATING: Quietness - star rating 4
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 5%
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 18%
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 77%
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating 4
H_RECMND_DN: "NO", patients would not recommend the hospital (they probably would not or definitely would not recommend it) 2%
H_RECMND_DY: "YES", patients would definitely recommend the hospital 69%
H_RECMND_PY: "YES", patients would probably recommend the hospital 29%
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score
H_RECMND_STAR_RATING: Recommend hospital - star rating 4
H_STAR_RATING: Summary star rating 4

Healthcare Associated Infections

Standardized Infection Ratios (SIR). A SIR < 1.0 means fewer infections than predicted based on national baseline data.

Measure Score (SIR) vs. National
HAI_1_CILOWER
HAI_1_CIUPPER
HAI_1_DOPC 468.000
HAI_1_ELIGCASES 0.271
HAI_1_NUMERATOR 0.000
HAI_1_SIR
HAI_2_CILOWER
HAI_2_CIUPPER
HAI_2_DOPC 246.000
HAI_2_ELIGCASES 0.134
HAI_2_NUMERATOR 0.000
HAI_2_SIR
HAI_3_CILOWER
HAI_3_CIUPPER
HAI_3_DOPC
HAI_3_ELIGCASES
HAI_3_NUMERATOR
HAI_3_SIR
HAI_4_CILOWER
HAI_4_CIUPPER
HAI_4_DOPC
HAI_4_ELIGCASES
HAI_4_NUMERATOR
HAI_4_SIR
HAI_5_CILOWER
HAI_5_CIUPPER
HAI_5_DOPC 6833.000
HAI_5_ELIGCASES 0.122
HAI_5_NUMERATOR 0.000
HAI_5_SIR
HAI_6_CILOWER 0.025 No Different than National Benchmark
HAI_6_CIUPPER 2.430 No Different than National Benchmark
HAI_6_DOPC 6833.000 No Different than National Benchmark
HAI_6_ELIGCASES 2.030 No Different than National Benchmark
HAI_6_NUMERATOR 1.000 No Different than National Benchmark
HAI_6_SIR 0.493 No Different than National Benchmark

Timely & Effective Care

Process-of-care measures including ED wait times, treatment timeliness, and preventive care.

Measure Score Condition
EDV low Emergency Department
GMCS Electronic Clinical Quality Measure
GMCS_Malnutrition_Diagnosis_Documented Electronic Clinical Quality Measure
GMCS_Malnutrition_Screening Electronic Clinical Quality Measure
GMCS_Nutrition_Assessment Electronic Clinical Quality Measure
GMCS_Nutritional_Care_Plan Electronic Clinical Quality Measure
HH_HYPER Electronic Clinical Quality Measure
HH_HYPO 1.0 Electronic Clinical Quality Measure
HH_ORAE Electronic Clinical Quality Measure
IMM_3 80.0 Healthcare Personnel Vaccination
OP_18a 121.0 Emergency Department
OP_18b 118.0 Emergency Department
OP_18c 151.0 Emergency Department
OP_18d 243.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 36.0 Emergency Department
OP_29 Colonoscopy care
OP_31 Cataract surgery outcome
OP_40 Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 18.0 Electronic Clinical Quality Measure
SEP_1 47.0 Sepsis Care
SEP_SH_3HR Sepsis Care
SEP_SH_6HR Sepsis Care
SEV_SEP_3HR 60.0 Sepsis Care
SEV_SEP_6HR Sepsis Care
STK_02 Electronic Clinical Quality Measure
STK_03 Electronic Clinical Quality Measure
STK_05 Electronic Clinical Quality Measure
VTE_1 38.0 Electronic Clinical Quality Measure
VTE_2 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI Number of Cases Too Small
EDAC_30_HF 86.00 More Days Than Average per 100 Discharges
EDAC_30_PN 96.20 More Days Than Average per 100 Discharges
Hybrid_HWR 16.80 No Different Than the National Rate
OP_32
OP_35_ADM
OP_35_ED
OP_36
READM_30_AMI Number of Cases Too Small
READM_30_CABG
READM_30_COPD 18.80 No Different Than the National Rate
READM_30_HF 21.80 No Different Than the National Rate
READM_30_HIP_KNEE
READM_30_PN 18.80 No Different Than the National Rate

Medicare Spending Per Beneficiary

MSPB ratio: values > 1.0 mean this hospital's episode spending is higher than the national median hospital.

Value
0.92

Financial Health (Cost Report — FY 2024)

All Data

Every labeled metric surfaced for this hospital, with national medians and percentiles where a benchmark is available.

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Source Metric Value National Median Pctl. Raw key
Cost Report Cost-to-Charge Ratio 0.43 metrics.cost_to_charge_ratio
Cost Report Current Ratio 15.83 metrics.current_ratio
Cost Report Employees per Bed 3.52 metrics.employees_per_bed
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Fund Balance ($) $29,540,347 metrics.fund_balance
Cost Report Net Income ($) $284,259 metrics.net_income
Cost Report Net Patient Revenue ($) $19,586,919 metrics.net_patient_revenue
Cost Report Operating Margin (%) -15.7% metrics.operating_margin
Cost Report Total Assets ($) $31,081,775 metrics.total_assets
Cost Report Total Costs ($) $18,245,028 metrics.total_costs
Cost Report Total Liabilities ($) $1,541,428 metrics.total_liabilities
Cost Report Total Margin (%) 1.2% metrics.total_margin
Cost Report Uncompensated Care (%) 2.2% metrics.uncompensated_care_pct
General Information Address 529 CAPP HARLAN ROAD Address
General Information City/Town TOMPKINSVILLE City/Town
General Information Count of Facility MORT Measures 3 Count of Facility MORT Measures
General Information Count of Facility Pt Exp Measures 8 Count of Facility Pt Exp Measures
General Information Count of Facility READM Measures 4 Count of Facility READM Measures
General Information Count of Facility Safety Measures 1 Count of Facility Safety Measures
General Information Count of Facility TE Measures 8 Count of Facility TE Measures
General Information Count of MORT Measures Better 0 Count of MORT Measures Better
General Information Count of MORT Measures No Different 3 Count of MORT Measures No Different
General Information Count of MORT Measures Worse 0 Count of MORT Measures Worse
General Information Count of READM Measures Better 0 Count of READM Measures Better
General Information Count of READM Measures No Different 2 Count of READM Measures No Different
General Information Count of READM Measures Worse 2 Count of READM Measures Worse
General Information Count of Safety Measures Better 0 Count of Safety Measures Better
General Information Count of Safety Measures No Different 1 Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 Count of Safety Measures Worse
General Information County/Parish MONROE County/Parish
General Information Emergency Services Yes Emergency Services
General Information Facility ID 180105 Facility ID
General Information Facility Name MONROE COUNTY MEDICAL CENTER Facility Name
General Information Hospital overall rating 1 Hospital overall rating
General Information Hospital overall rating footnote Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Other Hospital Ownership
General Information Hospital Type Acute Care Hospitals Hospital Type
General Information Meets criteria for birthing friendly designation Meets criteria for birthing friendly designation
General Information MORT Group Footnote MORT Group Footnote
General Information MORT Group Measure Count 7 MORT Group Measure Count
General Information Pt Exp Group Footnote Pt Exp Group Footnote
General Information Pt Exp Group Measure Count 8 Pt Exp Group Measure Count
General Information READM Group Footnote READM Group Footnote
General Information READM Group Measure Count 11 READM Group Measure Count
General Information Safety Group Footnote Safety Group Footnote
General Information Safety Group Measure Count 8 Safety Group Measure Count
General Information State KY State
General Information TE Group Footnote TE Group Footnote
General Information TE Group Measure Count 12 TE Group Measure Count
General Information Telephone Number (270) 487-9231 Telephone Number
General Information ZIP Code 42167 ZIP Code
HAC Reduction Program fiscal_year 2,026 fiscal_year
HAC Reduction Program measures — cdi — sir 0.81 measures.cdi.sir
HAC Reduction Program payment_reduction Yes payment_reduction
HAC Reduction Program total_hac_score 1.67 total_hac_score
Medicare Spending per Beneficiary End Date 12/31/2024 End Date
Medicare Spending per Beneficiary Measure ID MSPB-1 Measure ID
Medicare Spending per Beneficiary Start Date 01/01/2024 Start Date
Medicare Spending per Beneficiary Value 0.92 Value
Readmissions (HRRP) COPD — Excess readmission ratio 1.03 0.9969 p77 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 15.8% READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Number of discharges 59 READM-30-COPD-HRRP.num_discharges
Readmissions (HRRP) COPD — Number of readmissions 12 READM-30-COPD-HRRP.num_readmissions
Readmissions (HRRP) COPD — Predicted readmission rate 16.4% READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.11 0.9983 p95 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 16.6% READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 74 READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 21 READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 18.5% READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 1.16 0.9955 p98 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 14.2% READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 133 READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 32 READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 16.5% READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 7.78 5.00 p71 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 16.67 2.50 p90 efficiency_score
Value-Based Purchasing Person & Community Engagement 16.00 8.75 p87 person_community_score
Value-Based Purchasing Total Performance Score 40.44 29.50 p80 total_performance_score
Methodology

Full methodology →