Hospital

MOUNT PLEASANT HOSPITAL

CCN: 420104 · MOUNT PLEASANT, SC 29466 · CHARLESTON County

Bottom quartile Middle Top quartile Percentile badges compare this hospital to all 5,426 hospitals nationally.

Overview

Address
3510 HIGHWAY 17 NORTH SUITE 140, MOUNT PLEASANT, SC 29466
Phone
(843) 724-2954
Hospital Type
Acute Care
Ownership
Non-Profit
Emergency Services
Yes
5 /5
★★★★★
CMS Overall Rating
p89
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 4 of 7 measures reported
4
Better No different Worse
30-day death rates for heart attack, heart failure, pneumonia, COPD, stroke, CABG, and kidney disease.
Safety of Care 4 of 8 measures reported
1
3
Better No different Worse
Healthcare-associated infections and patient safety indicators (PSI-90 composite).
Readmission 7 of 11 measures reported
6
1
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 10 of 12 measures reported
10 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) 0 discharges
— Not reported
Heart Failure 178 discharges
1.0766 p87
Pneumonia 200 discharges
0.9877 p44
COPD
0.9796 p33
Hip/Knee Replacement
0.8931 p23
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.

48.1 p91
Total Performance Score
National median: 29.5
Clinical Outcomes 25% weight
7.5 p67
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.
Safety 25% weight
13.3 p70
Nat'l median: 10.0
Patient safety measures including healthcare-associated infections (CLABSI, CAUTI, SSI, MRSA, C. diff) and perioperative complications.
Person & Community Engagement 25% weight
22.3 p97
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
5.0 p56
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: 1.0766
Value-Based Purchasing
48.1 TPS
Above national median
HAC Reduction
No Reduction
HAC Score: 0.1894

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 3.50 No Different Than the National Rate 143
Hybrid_HWM 3.50 No Different Than the National Rate 701
MORT_30_AMI — Number of Cases Too Small —
MORT_30_CABG — — —
MORT_30_COPD 7.90 No Different Than the National Rate 35
MORT_30_HF 10.50 No Different Than the National Rate 175
MORT_30_PN 13.50 No Different Than the National Rate 198
MORT_30_STK 12.20 No Different Than the National Rate 50
PSI_03 0.36 No Different Than the National Rate 1,738
PSI_04 — Number of Cases Too Small —
PSI_06 0.19 No Different Than the National Rate 2,368
PSI_08 0.29 No Different Than the National Rate 2,235
PSI_09 2.45 No Different Than the National Rate 541
PSI_10 1.61 No Different Than the National Rate 283
PSI_11 9.42 No Different Than the National Rate 284
PSI_12 3.13 No Different Than the National Rate 580
PSI_13 5.36 No Different Than the National Rate 241
PSI_14 1.71 No Different Than the National Rate 177
PSI_15 0.91 No Different Than the National Rate 461
PSI_90 0.90 No Different Than the National Value —

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 88% —
H_COMP_1_SN_P: Nurses "sometimes" or "never" communicated well 2% —
H_COMP_1_U_P: Nurses "usually" communicated well 10% —
H_COMP_1_LINEAR_SCORE: Nurse communication - linear mean score — —
H_COMP_1_STAR_RATING: Nurse communication - star rating — 5
H_NURSE_RESPECT_A_P: Nurses "always" treated them with courtesy and respect 92% —
H_NURSE_RESPECT_SN_P: Nurses "sometimes" or "never" treated them with courtesy and respect 2% —
H_NURSE_RESPECT_U_P: Nurses "usually" treated them with courtesy and respect 6% —
H_NURSE_LISTEN_A_P: Nurses "always" listened carefully 85% —
H_NURSE_LISTEN_SN_P: Nurses "sometimes" or "never" listened carefully 2% —
H_NURSE_LISTEN_U_P: Nurses "usually" listened carefully 13% —
H_NURSE_EXPLAIN_A_P: Nurses "always" explained things so they could understand 86% —
H_NURSE_EXPLAIN_SN_P: Nurses "sometimes" or "never" explained things so they could understand 3% —
H_NURSE_EXPLAIN_U_P: Nurses "usually" explained things so they could understand 11% —
H_COMP_2_A_P: Doctors "always" communicated well 86% —
H_COMP_2_SN_P: Doctors "sometimes" or "never" communicated well 3% —
H_COMP_2_U_P: Doctors "usually" communicated well 11% —
H_COMP_2_LINEAR_SCORE: Doctor communication - linear mean score — —
H_COMP_2_STAR_RATING: Doctor communication - star rating — 4
H_DOCTOR_RESPECT_A_P: Doctors "always" treated them with courtesy and respect 90% —
H_DOCTOR_RESPECT_SN_P: Doctors "sometimes" or "never" treated them with courtesy and respect 2% —
H_DOCTOR_RESPECT_U_P: Doctors "usually" treated them with courtesy and respect 8% —
H_DOCTOR_LISTEN_A_P: Doctors "always" listened carefully 84% —
H_DOCTOR_LISTEN_SN_P: Doctors "sometimes" or "never" listened carefully 3% —
H_DOCTOR_LISTEN_U_P: Doctors "usually" listened carefully 13% —
H_DOCTOR_EXPLAIN_A_P: Doctors "always" explained things so they could understand 82% —
H_DOCTOR_EXPLAIN_SN_P: Doctors "sometimes" or "never" explained things so they could understand 3% —
H_DOCTOR_EXPLAIN_U_P: Doctors "usually" explained things so they could understand 15% —
H_COMP_5_A_P: Staff "always" explained 68% —
H_COMP_5_SN_P: Staff "sometimes" or "never" explained 16% —
H_COMP_5_U_P: Staff "usually" explained 16% —
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 80% —
H_MED_FOR_SN_P: Staff "sometimes" or "never" explained new medications 7% —
H_MED_FOR_U_P: Staff "usually" explained new medications 13% —
H_SIDE_EFFECTS_A_P: Staff "always" explained possible side effects 56% —
H_SIDE_EFFECTS_SN_P: Staff "sometimes" or "never" explained possible side effects 25% —
H_SIDE_EFFECTS_U_P: Staff "usually" explained possible side effects 19% —
H_COMP_6_N_P: No, staff "did not" give patients this information 11% —
H_COMP_6_Y_P: Yes, staff "did" give patients this information 89% —
H_COMP_6_LINEAR_SCORE: Discharge information - linear mean score — —
H_COMP_6_STAR_RATING: Discharge information - star rating — 4
H_DISCH_HELP_N_P: No, staff "did not" give patients information about help after discharge 11% —
H_DISCH_HELP_Y_P: Yes, staff "did" give patients information about help after discharge 89% —
H_SYMPTOMS_N_P: No, staff "did not" give patients information about possible symptoms 11% —
H_SYMPTOMS_Y_P: Yes, staff "did" give patients information about possible symptoms 89% —
H_CLEAN_HSP_A_P: Room was "always" clean 74% —
H_CLEAN_HSP_SN_P: Room was "sometimes" or "never" clean 9% —
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 — 3
H_QUIET_HSP_A_P: "Always" quiet at night 75% —
H_QUIET_HSP_SN_P: "Sometimes" or "never" quiet at night 4% —
H_QUIET_HSP_U_P: "Usually" quiet at night 21% —
H_QUIET_LINEAR_SCORE: Quietness - linear mean score — —
H_QUIET_STAR_RATING: Quietness - star rating — 5
H_HSP_RATING_0_6: Patients who gave a rating of "6" or lower (low) 3% —
H_HSP_RATING_7_8: Patients who gave a rating of "7" or "8" (medium) 14% —
H_HSP_RATING_9_10: Patients who gave a rating of "9" or "10" (high) 83% —
H_HSP_RATING_LINEAR_SCORE: Overall hospital rating - linear mean score — —
H_HSP_RATING_STAR_RATING: Overall hospital rating - star rating — 5
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 84% —
H_RECMND_PY: "YES", patients would probably recommend the hospital 14% —
H_RECMND_LINEAR_SCORE: Recommend hospital - linear mean score — —
H_RECMND_STAR_RATING: Recommend hospital - star rating — 5
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 854.000 —
HAI_1_ELIGCASES 0.509 —
HAI_1_NUMERATOR 0.000 —
HAI_1_SIR — —
HAI_2_CILOWER — —
HAI_2_CIUPPER — —
HAI_2_DOPC 1292.000 —
HAI_2_ELIGCASES 0.660 —
HAI_2_NUMERATOR 2.000 —
HAI_2_SIR — —
HAI_3_CILOWER 0.012 No Different than National Benchmark
HAI_3_CIUPPER 1.197 No Different than National Benchmark
HAI_3_DOPC 163.000 No Different than National Benchmark
HAI_3_ELIGCASES 4.120 No Different than National Benchmark
HAI_3_NUMERATOR 1.000 No Different than National Benchmark
HAI_3_SIR 0.243 No Different than National Benchmark
HAI_4_CILOWER — —
HAI_4_CIUPPER — —
HAI_4_DOPC 11.000 —
HAI_4_ELIGCASES 0.091 —
HAI_4_NUMERATOR 0.000 —
HAI_4_SIR — —
HAI_5_CILOWER — —
HAI_5_CIUPPER — —
HAI_5_DOPC 13667.000 —
HAI_5_ELIGCASES 0.595 —
HAI_5_NUMERATOR 1.000 —
HAI_5_SIR — —
HAI_6_CILOWER 0.127 No Different than National Benchmark
HAI_6_CIUPPER 1.361 No Different than National Benchmark
HAI_6_DOPC 13667.000 No Different than National Benchmark
HAI_6_ELIGCASES 5.999 No Different than National Benchmark
HAI_6_NUMERATOR 3.000 No Different than National Benchmark
HAI_6_SIR 0.500 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 medium 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 — Electronic Clinical Quality Measure
HH_ORAE — Electronic Clinical Quality Measure
IMM_3 84.0 Healthcare Personnel Vaccination
OP_18a 129.0 Emergency Department
OP_18b 126.0 Emergency Department
OP_18c 196.0 Emergency Department
OP_18d 240.0 Emergency Department
OP_22 1.0 Emergency Department
OP_23 — Emergency Department
OP_29 99.0 Colonoscopy care
OP_31 — Cataract surgery outcome
OP_40 — Electronic Clinical Quality Measure
SAFE_USE_OF_OPIOIDS 16.0 Electronic Clinical Quality Measure
SEP_1 78.0 Sepsis Care
SEP_SH_3HR 76.0 Sepsis Care
SEP_SH_6HR 87.0 Sepsis Care
SEV_SEP_3HR 88.0 Sepsis Care
SEV_SEP_6HR 98.0 Sepsis Care
STK_02 98.0 Electronic Clinical Quality Measure
STK_03 — Electronic Clinical Quality Measure
STK_05 — Electronic Clinical Quality Measure
VTE_1 95.0 Electronic Clinical Quality Measure
VTE_2 99.0 Electronic Clinical Quality Measure

Unplanned Hospital Visits

Readmission and ED return rates within 30 days of discharge.

Measure Score vs. National
EDAC_30_AMI — —
EDAC_30_HF 55.60 More Days Than Average per 100 Discharges
EDAC_30_PN -26.90 Fewer Days Than Average per 100 Discharges
Hybrid_HWR 14.00 No Different Than the National Rate
OP_32 12.80 No Different Than the National Rate
OP_35_ADM — Number of Cases Too Small
OP_35_ED — Number of Cases Too Small
OP_36 1.10 No Different than expected
READM_30_AMI — —
READM_30_CABG — —
READM_30_COPD 17.80 No Different Than the National Rate
READM_30_HF 21.10 No Different Than the National Rate
READM_30_HIP_KNEE 4.30 No Different Than the National Rate
READM_30_PN 15.80 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
0.97

Financial Health (Cost Report — FY 2023)

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 0.18 — metrics.cost_to_charge_ratio
Cost Report Current Ratio 15.93 — metrics.current_ratio
Cost Report Employees per Bed 3.50 — metrics.employees_per_bed
Cost Report fiscal_year 2,023 — fiscal_year
Cost Report Fund Balance ($) $81,045,098 — metrics.fund_balance
Cost Report Net Income ($) $23,415,639 — metrics.net_income
Cost Report Net Patient Revenue ($) $120,865,617 — metrics.net_patient_revenue
Cost Report Operating Margin (%) 18.6% — metrics.operating_margin
Cost Report Total Assets ($) $81,742,327 — metrics.total_assets
Cost Report Total Costs ($) $83,782,257 — metrics.total_costs
Cost Report Total Liabilities ($) $697,229 — metrics.total_liabilities
Cost Report Total Margin (%) 19.2% — metrics.total_margin
Cost Report Uncompensated Care (%) 5.0% — metrics.uncompensated_care_pct
General Information Address 3510 HIGHWAY 17 NORTH SUITE 140 — Address
General Information City/Town MOUNT PLEASANT — City/Town
General Information Count of Facility MORT Measures 4 — 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 7 — Count of Facility READM Measures
General Information Count of Facility Safety Measures 4 — Count of Facility Safety Measures
General Information Count of Facility TE Measures 10 — 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 4 — 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 6 — Count of READM Measures No Different
General Information Count of READM Measures Worse 1 — Count of READM Measures Worse
General Information Count of Safety Measures Better 1 — Count of Safety Measures Better
General Information Count of Safety Measures No Different 3 — Count of Safety Measures No Different
General Information Count of Safety Measures Worse 0 — Count of Safety Measures Worse
General Information County/Parish CHARLESTON — County/Parish
General Information Emergency Services Yes — Emergency Services
General Information Facility ID 420104 — Facility ID
General Information Facility Name MOUNT PLEASANT HOSPITAL — Facility Name
General Information Hospital overall rating 5 — Hospital overall rating
General Information Hospital overall rating footnote — — Hospital overall rating footnote
General Information Hospital Ownership Voluntary non-profit - Private — 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 SC — State
General Information TE Group Footnote — — TE Group Footnote
General Information TE Group Measure Count 12 — TE Group Measure Count
General Information Telephone Number (843) 724-2954 — Telephone Number
General Information ZIP Code 29466 — ZIP Code
HAC Reduction Program fiscal_year 2,026 — fiscal_year
HAC Reduction Program measures — cauti — sir 2.67 — measures.cauti.sir
HAC Reduction Program measures — cdi — sir 0.34 — measures.cdi.sir
HAC Reduction Program measures — clabsi — sir 0 — measures.clabsi.sir
HAC Reduction Program measures — mrsa — sir 1.62 — measures.mrsa.sir
HAC Reduction Program measures — ssi — sir 0.25 — measures.ssi.sir
HAC Reduction Program payment_reduction No — payment_reduction
HAC Reduction Program total_hac_score 0.19 — 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 0.97 — Value
Readmissions (HRRP) Acute Myocardial Infarction (Heart Attack) — Number of discharges 0 — READM-30-AMI-HRRP.num_discharges
Readmissions (HRRP) COPD — Excess readmission ratio 0.98 0.9969 p33 READM-30-COPD-HRRP.excess_readmission_ratio
Readmissions (HRRP) COPD — Expected readmission rate 15.4% — READM-30-COPD-HRRP.expected_readmission_rate
Readmissions (HRRP) COPD — Predicted readmission rate 15.1% — READM-30-COPD-HRRP.predicted_readmission_rate
Readmissions (HRRP) Heart Failure — Excess readmission ratio 1.08 0.9983 p87 READM-30-HF-HRRP.excess_readmission_ratio
Readmissions (HRRP) Heart Failure — Expected readmission rate 17.6% — READM-30-HF-HRRP.expected_readmission_rate
Readmissions (HRRP) Heart Failure — Number of discharges 178 — READM-30-HF-HRRP.num_discharges
Readmissions (HRRP) Heart Failure — Number of readmissions 39 — READM-30-HF-HRRP.num_readmissions
Readmissions (HRRP) Heart Failure — Predicted readmission rate 19.0% — READM-30-HF-HRRP.predicted_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Excess readmission ratio 0.89 0.9916 p23 READM-30-HIP-KNEE-HRRP.excess_readmission_ratio
Readmissions (HRRP) Hip/Knee Replacement — Expected readmission rate 5.1% — READM-30-HIP-KNEE-HRRP.expected_readmission_rate
Readmissions (HRRP) Hip/Knee Replacement — Predicted readmission rate 4.6% — READM-30-HIP-KNEE-HRRP.predicted_readmission_rate
Readmissions (HRRP) Pneumonia — Excess readmission ratio 0.99 0.9955 p44 READM-30-PN-HRRP.excess_readmission_ratio
Readmissions (HRRP) Pneumonia — Expected readmission rate 13.6% — READM-30-PN-HRRP.expected_readmission_rate
Readmissions (HRRP) Pneumonia — Number of discharges 200 — READM-30-PN-HRRP.num_discharges
Readmissions (HRRP) Pneumonia — Number of readmissions 26 — READM-30-PN-HRRP.num_readmissions
Readmissions (HRRP) Pneumonia — Predicted readmission rate 13.4% — READM-30-PN-HRRP.predicted_readmission_rate
Value-Based Purchasing Clinical Outcomes 7.50 5.00 p67 clinical_outcomes_score
Value-Based Purchasing Efficiency & Cost Reduction 5.00 2.50 p56 efficiency_score
Value-Based Purchasing Person & Community Engagement 22.25 8.75 p97 person_community_score
Value-Based Purchasing Safety 13.33 10.00 p70 safety_score
Value-Based Purchasing Total Performance Score 48.08 29.50 p91 total_performance_score
Methodology

Full methodology →