Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MEMORIALCARE SADDLEBACK MEDICAL CENTER

CA · Facility ID 050603 · FY2026

Total HAC Score

-0.0013

Percentile

52.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0013

Hospital score -0.0013. 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 0.006
  • CLABSIz -0.332
  • CAUTIz 0.827
  • SSIz -0.713
  • CDIz 0.594
  • MRSAz -0.389

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 fate0.0062-0.24960.41620.6657
CAUTI0.8267-0.35890.25860.6175
MRSA-0.3893-0.17930.43440.6137
CDI0.5939-0.34400.26520.6092
CLABSI-0.3324-0.18030.42750.6078
SSI-0.7130-0.12520.47950.6047

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): 51.1th

Score distributionThreshold 0.3792Hospital -0.0013

Hospital score -0.0013. Penalty threshold 0.3792. Distribution of 277 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 51.0th

Score distributionThreshold 0.3792Hospital -0.0013

Hospital score -0.0013. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.0013; 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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