Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MERCY SAN JUAN MEDICAL CENTER

CA · Facility ID 050516 · FY2026

Total HAC Score

-0.6809

Percentile

13.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.6809

Hospital score -0.6809. 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 -1.483
  • CLABSIz -0.511
  • CAUTIz -0.287
  • SSIz -0.528
  • CDIz -1.001
  • MRSAz -0.274

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-1.4834-0.6809-0.01510.6657
CAUTI-0.2869-0.8528-0.23530.6175
MRSA-0.2744-0.8780-0.26430.6137
CDI-1.0014-0.7577-0.14840.6092
CLABSI-0.5110-0.8301-0.22230.6078
SSI-0.5280-0.8356-0.23090.6047

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): 11.0th

Score distributionThreshold 0.3792Hospital -0.6809

Hospital score -0.6809. Penalty threshold 0.3792. Distribution of 277 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 7.4th

Score distributionThreshold 0.3792Hospital -0.6809

Hospital score -0.6809. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.6809; 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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