Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SOUTHERN REGIONAL MEDICAL CENTER

GA · Facility ID 110165 · FY2026

Total HAC Score

-0.1426

Percentile

43.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1426

Hospital score -0.1426. 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 -0.023
  • CLABSIz 0.503
  • CAUTIz -1.319
  • SSIz -0.782
  • CDIz -0.858
  • MRSAz 1.623

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-0.0230-0.38600.27980.6657
CAUTI-1.3186-0.14260.47490.6175
MRSA1.6232-0.6560-0.04220.6137
CDI-0.8581-0.24320.36600.6092
CLABSI0.5027-0.46080.14700.6078
SSI-0.7816-0.25500.34970.6047

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): 36.5th

Score distributionThreshold 0.3792Hospital -0.1426

Hospital score -0.1426. Penalty threshold 0.3792. Distribution of 89 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 40.3th

Score distributionThreshold 0.3792Hospital -0.1426

Hospital score -0.1426. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1426; 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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