Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

LUTHERAN MEDICAL CENTER

CO · Facility ID 060009 · FY2026

Total HAC Score

-0.1697

Percentile

41.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1697

Hospital score -0.1697. 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 0.099
  • CLABSIz -1.165
  • CAUTIz 0.142
  • SSIz 0.137
  • CDIz -0.060
  • MRSAz -0.170

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 fate0.0987-0.43340.23240.6657
CAUTI0.1422-0.41310.20430.6175
MRSA-0.1699-0.38430.22950.6137
CDI-0.0605-0.40330.20590.6092
CLABSI-1.1652-0.20990.39790.6078
SSI0.1366-0.43520.16950.6047

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 CO (49 scored): 45.9th

Score distributionThreshold 0.3792Hospital -0.1697

Hospital score -0.1697. Penalty threshold 0.3792. Distribution of 49 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 38.2th

Score distributionThreshold 0.3792Hospital -0.1697

Hospital score -0.1697. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1697; 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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