Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ST JOSEPHS HOSPITAL

FL · Facility ID 100075 · FY2026

Total HAC Score

-0.4870

Percentile

21.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4870

Hospital score -0.4870. 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 -0.818
  • CLABSIz -0.555
  • CAUTIz -0.012
  • SSIz -0.425
  • CDIz -0.727
  • MRSAz -0.385

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-0.8178-0.59790.06780.6657
CAUTI-0.0121-0.7047-0.08720.6175
MRSA-0.3851-0.6657-0.05190.6137
CDI-0.7265-0.6096-0.00040.6092
CLABSI-0.5551-0.6289-0.02110.6078
SSI-0.4252-0.6589-0.05410.6047

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): 27.0th

Score distributionThreshold 0.3792Hospital -0.4870

Hospital score -0.4870. Penalty threshold 0.3792. Distribution of 165 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 15.4th

Score distributionThreshold 0.3792Hospital -0.4870

Hospital score -0.4870. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4870; 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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