Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

PRESENCE ST MARYS HOSPITAL

IL · Facility ID 140155 · FY2026

Total HAC Score

-0.8662

Percentile

6.5th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.8662

Hospital score -0.8662. 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 -0.630
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIz -1.456
  • CDIz -0.928
  • MRSAz 0.543

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-0.6305-1.0083-0.34260.6658
CAUTI-1.3186-0.8662-0.24870.6175
MRSA0.5428-1.1995-0.58580.6137
CDI-0.9278-0.9553-0.34600.6092
CLABSI-1.4065-0.8662-0.25840.6078
SSI-1.4565-0.8662-0.26150.6047

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 IL (112 scored): 4.0th

Score distributionThreshold 0.3792Hospital -0.8662

Hospital score -0.8662. Penalty threshold 0.3792. Distribution of 112 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 3.0th

Score distributionThreshold 0.3792Hospital -0.8662

Hospital score -0.8662. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.8662; 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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