Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

PROVIDENCE QUEEN OF THE VALLEY MEDICAL CENTER

CA · Facility ID 050009 · FY2026

Total HAC Score

-0.3563

Percentile

28.6th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3563

Hospital score -0.3563. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 6 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -0.904
  • CLABSIz 0.633
  • CAUTIz -1.319
  • SSIz 0.330
  • CDIz -0.359
  • MRSAz -0.519

Fragility

Each reported measure moves the score by 0.1667 points.

Score swing if each reported measure were at its Z floor versus Z cap, holding other measures fixed
MeasureCurrent ZScore @ floorScore @ capAbs swing
PSI-90controls fate-0.9043-0.45280.21300.6657
CAUTI-1.3186-0.35630.26120.6175
MRSA-0.5189-0.51270.10110.6137
CDI-0.3586-0.54020.06900.6092
CLABSI0.6326-0.6961-0.08830.6078
SSI0.3302-0.6540-0.04940.6047

Swing is a mechanics illustration: replace one reported Z with that measure’s observed floor or cap while holding others fixed. Ranked by absolute swing.

Peer context

Percentile within CA (277 scored): 28.3th

Score distributionThreshold 0.3792Hospital -0.3563

Hospital score -0.3563. Penalty threshold 0.3792. Distribution of 277 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 23.5th

Score distributionThreshold 0.3792Hospital -0.3563

Hospital score -0.3563. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3563; threshold 0.3792).

Reported on 6 of 6 measures; each reported measure moves the equal-weighted score by 0.1667 points.

Describes scoring mechanics only. Not medical or legal advice. Any “would / would not” language is an illustration against the published threshold, not a CMS prediction.

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