Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MEMORIAL REGIONAL HOSPITAL

FL · Facility ID 100038 · FY2026

Total HAC Score

-0.0295

Percentile

51.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0295

Hospital score -0.0295. 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 0.094
  • CLABSIz 0.060
  • CAUTIz 0.340
  • SSIz -0.747
  • CDIz 0.021
  • MRSAz 0.056

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 fate0.0943-0.29250.37330.6658
CAUTI0.3398-0.30590.31160.6175
MRSA0.0558-0.28170.33200.6137
CDI0.0208-0.27670.33250.6092
CLABSI0.0596-0.27380.33390.6078
SSI-0.7473-0.14770.45700.6047

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 FL (165 scored): 66.4th

Score distributionThreshold 0.3792Hospital -0.0295

Hospital score -0.0295. Penalty threshold 0.3792. Distribution of 165 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 49.0th

Score distributionThreshold 0.3792Hospital -0.0295

Hospital score -0.0295. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.0295; 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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