Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ASCENSION ST VINCENT'S SOUTHSIDE

FL · Facility ID 100307 · FY2026

Total HAC Score

-0.4089

Percentile

25.6th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4089

Hospital score -0.4089. 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 -0.348
  • CLABSIz 0.946
  • CAUTIz -0.832
  • SSIz -0.838
  • CDIz -0.877
  • MRSAz -0.504

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-0.3476-0.59820.06750.6657
CAUTI-0.8317-0.49010.12740.6175
MRSA-0.5043-0.56770.04600.6137
CDI-0.8775-0.50630.10290.6092
CLABSI0.9458-0.8010-0.19320.6078
SSI-0.8381-0.51200.09270.6047

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): 39.1th

Score distributionThreshold 0.3792Hospital -0.4089

Hospital score -0.4089. Penalty threshold 0.3792. Distribution of 165 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 20.3th

Score distributionThreshold 0.3792Hospital -0.4089

Hospital score -0.4089. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4089; 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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