Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CALIFORNIA PACIFIC MEDICAL CENTER - MISSION BERNAL

CA · Facility ID 050055 · FY2026

Total HAC Score

-0.3667

Percentile

28.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3667

Hospital score -0.3667. 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 -0.824
  • CLABSIz -1.407
  • CAUTIz 0.340
  • SSIz -0.463
  • CDIz -0.208
  • MRSAz 0.361

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-0.8242-0.47660.18910.6658
CAUTI0.3398-0.6431-0.02570.6175
MRSA0.3609-0.6698-0.05610.6137
CDI-0.2076-0.57580.03340.6092
CLABSI-1.4065-0.36670.24100.6078
SSI-0.4629-0.53230.07230.6047

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): 27.3th

Score distributionThreshold 0.3792Hospital -0.3667

Hospital score -0.3667. Penalty threshold 0.3792. Distribution of 277 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 23.0th

Score distributionThreshold 0.3792Hospital -0.3667

Hospital score -0.3667. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3667; 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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