Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

UPSON REGIONAL MEDICAL CENTER

GA · Facility ID 110002 · FY2026

Total HAC Score

-0.2284

Percentile

36.9th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2284

Hospital score -0.2284. 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 0.360
  • CLABSIz -1.407
  • CAUTIz 0.038
  • SSIz -1.456
  • CDIz -0.610
  • MRSAz 1.705

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 fate0.3598-0.53560.13020.6657
CAUTI0.0385-0.45460.16290.6175
MRSA1.7047-0.7554-0.14160.6137
CDI-0.6103-0.37040.23890.6092
CLABSI-1.4065-0.22840.37940.6078
SSI-1.4565-0.22840.37630.6047

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 GA (89 scored): 30.9th

Score distributionThreshold 0.3792Hospital -0.2284

Hospital score -0.2284. Penalty threshold 0.3792. Distribution of 89 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 33.1th

Score distributionThreshold 0.3792Hospital -0.2284

Hospital score -0.2284. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2284; 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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