Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

INTERMOUNTAIN HEALTH ST. MARY'S REGIONAL HOSPITAL

CO · Facility ID 060023 · FY2026

Total HAC Score

-0.2306

Percentile

36.7th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2306

Hospital score -0.2306. 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 0.064
  • CLABSIz -0.326
  • CAUTIz 0.002
  • SSIz 0.424
  • CDIz -0.746
  • MRSAz -0.803

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 fate0.0640-0.48850.17720.6657
CAUTI0.0023-0.45080.16670.6175
MRSA-0.8031-0.33970.27410.6137
CDI-0.7458-0.35000.25920.6092
CLABSI-0.3255-0.41080.19700.6078
SSI0.4244-0.54410.06060.6047

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): 41.8th

Score distributionThreshold 0.3792Hospital -0.2306

Hospital score -0.2306. Penalty threshold 0.3792. Distribution of 49 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 32.9th

Score distributionThreshold 0.3792Hospital -0.2306

Hospital score -0.2306. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2306; 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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