Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CLEVELAND CLINIC MARTIN NORTH HOSPITAL

FL · Facility ID 100044 · FY2026

Total HAC Score

-0.4827

Percentile

21.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4827

Hospital score -0.4827. 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 -0.598
  • CLABSIz -1.195
  • CAUTIz -0.470
  • SSIz -0.699
  • CDIz 0.280
  • MRSAz -0.214

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-0.5981-0.63030.03550.6657
CAUTI-0.4701-0.6241-0.00670.6175
MRSA-0.2138-0.6900-0.07620.6137
CDI0.2803-0.7731-0.16390.6092
CLABSI-1.1954-0.51790.08990.6078
SSI-0.6993-0.6089-0.00420.6047

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): 27.6th

Score distributionThreshold 0.3792Hospital -0.4827

Hospital score -0.4827. Penalty threshold 0.3792. Distribution of 165 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 15.9th

Score distributionThreshold 0.3792Hospital -0.4827

Hospital score -0.4827. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4827; 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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