Piedmont Mountainside Hospital Inc

Hospital in Jasper, GA, Medicare certification number 110225. CMS publishes 50 quality measures for it.

Medicare certification

Provider of Services

CCN: 110225The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Other
Control type: Other
Participating since: Jun 3, 2004
Last certification: Mar 30, 2023
Beds: 35
Overall star rating: 4 of 5Care Compare
Address: 1266 Highway 515 South
Jasper, GA 30143
(706) 301-5269

NPI records for this facility 1

Piedmont Mountainside Hospital, Inc.
- General Acute Care Hospital
- Jasper, GA
- NPI 1780643411
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 3.3 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.46 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse3 of 5
- State average 2.94 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 3.08 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse3 of 5
- State average 3.2 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse3 of 5
- State average 3.27 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse3 of 5
- State average 3.77 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse3 of 5
- State average 3.6 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse3 of 5
- State average 3.15 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 13

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.99
- State average 1.07 (computed here)
- National average 1.06
- No different than the national rate
- 365 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.94
- State average 1.07 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for COPD patients As expected6.7
- State average 8.69 (computed here)
- National average 8.6
- No different than the national rate
- 57 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected8.5
- State average 10.84 (computed here)
- National average 11.1
- No different than the national rate
- 242 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected11.1
- State average 15.21 (computed here)
- National average 15.2
- No different than the national rate
- 279 patients
- Period from 07/01/2022
Death rate for stroke patients As expected14.7
- State average 12.45 (computed here)
- National average 11.9
- No different than the national rate
- 103 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.7
- State average 4.08 (computed here)
- National average 3.9
- No different than the national rate
- 1,603 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.31
- State average 0.22 (computed here)
- National average 0.21
- No different than the national rate
- 2,518 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.29
- State average 0.28 (computed here)
- National average 0.27
- No different than the national rate
- 2,568 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected4.05
- State average 3.81 (computed here)
- National average 3.52
- No different than the national rate
- 222 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.26
- State average 2.36 (computed here)
- National average 2.34
- No different than the national rate
- 196 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.71
- State average 1.74 (computed here)
- National average 1.77
- No different than the national rate
- 75 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.31
- State average 0.68 (computed here)
- National average 0.63
- No different than the national rate
- 2,125 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (7)

Death rate among surgical inpatients with serious treatable complications — 1
Death rate for CABG surgery patients — 5
Death rate for heart attack patients — 1
Postoperative acute kidney injury requiring dialysis rate — 1
Postoperative respiratory failure rate — 1
Postoperative sepsis rate — 1
Rate of complications for hip/knee replacement patients — 1

Infections 3

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected0
- State average 0.39
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected0
- State average 0.61
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.37
- State average 0.26
- National average 1
- Better than the national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (3)

MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 13
SSI - Colon Surgery — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 7.7
- State average 5.62 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 7.8
- State average 6.41 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 0.91
- State average 0.97
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 15

Medicare Care Compare

Antithrombotic Therapy by End of Hospital Day 2 100
- State average 92.46 (computed here)
- National average 92.79 (computed here)
- 75 patients
- Period from 01/01/2024
Appropriate care for severe sepsis and septic shock 52
- State average 63
- National average 65
- 106 patients
- Period from 10/01/2024
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better 156
- State average 169
- National average 168
- 420 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better 564
- State average 322
- National average 287
- 13 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better 153
- State average 162
- National average 162
- 397 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 98
- State average 89
- National average 93
- 47 patients
- Period from 01/01/2024
Head CT results 91
- State average 70
- National average 69
- 11 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 46
- State average 76
- National average 78
- 818 patients
- Period from 10/01/2024
Hospital Harm - Opioid Related Adverse Events 0
- State average 0.08 (computed here)
- National average 0.18 (computed here)
- 2,649 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 100
- State average 95.53 (computed here)
- National average 93.49 (computed here)
- 1,159 patients
- Period from 01/01/2024
Left before being seen 1
- State average 2
- National average 2
- 34,934 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 20
- State average 15
- National average 15
- 1,398 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 45
- State average 73
- National average 73
- 20 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 68
- State average 80
- National average 81
- 106 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 98
- State average 92
- National average 93
- 43 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (15)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better — 1
Discharged on Antithrombotic Therapy — 5
Emergency department volume — medium
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Septic Shock 6-Hour Bundle — 1, 2
ST-Segment Elevation Myocardial Infarction (STEMI) — 1
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 7

Medicare Care Compare

Heart failure (HF) 30-Day Readmission Rate As expected21.3
- State average 21.19 (computed here)
- National average 21.3
- No different than the national rate
- 347 patients
- Period from 07/01/2023
Hospital return days for heart failure patients 26.1
- State average 12.52 (computed here)
- National average 4.02 (computed here)
- Average days per 100 discharges
- 264 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -18
- State average 12.69 (computed here)
- National average 5.65 (computed here)
- Average days per 100 discharges
- 301 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16
- State average 17.41 (computed here)
- National average 17.3
- No different than the national rate
- 444 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected20.3
- State average 19.84 (computed here)
- National average 20
- No different than the national rate
- 122 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12
- State average 12.97 (computed here)
- National average 13
- No different than the national rate
- 400 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected0.9
- State average 0.97 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 371 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (7)

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate — 1
Hospital return days for heart attack patients — 1
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1
Rate of readmission after hip/knee replacement — 1
Rate of readmission for CABG — 5

Mountainside Medical Center CCN 110149, Jasper, GA

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.
NPPES NPI Registry: the NPI records connected to this certification.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.