Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MEDSTAR SAINT MARY'S HOSPITAL

MD · Facility ID 210028 · FY2026

Total HAC Score

-0.7125

Percentile

12.5th

Displayed status

Exempt (Maryland)

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7125

Hospital score -0.7125. 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 -0.733
  • CLABSIz -0.671
  • CAUTIz -1.319
  • SSIz 0.555
  • CDIz -0.649
  • MRSAz -1.457

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-0.7334-0.8375-0.17170.6658
CAUTI-1.3186-0.7125-0.09500.6175
MRSA-1.4573-0.7125-0.09870.6137
CDI-0.6490-0.8480-0.23880.6092
CLABSI-0.6711-0.8350-0.22720.6078
SSI0.5546-1.0476-0.44290.6047

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 MD (43 scored): 3.5th

Score distributionThreshold 0.3792Hospital -0.7125

Hospital score -0.7125. Penalty threshold 0.3792. Distribution of 43 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 6.5th

Score distributionThreshold 0.3792Hospital -0.7125

Hospital score -0.7125. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

Displayed status is Exempt (Maryland) under the CMS Payment Reduction column.

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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