Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

UMD REHABILITATION & ORTHOPAEDIC INSTITUTE

MD · Facility ID 210058 · FY2026

Total HAC Score

1.9139

Percentile

98.7th

Displayed status

Exempt (Maryland)

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital 1.9139

Hospital score 1.9139. 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 0.267
  • CLABSIImputedz 2.240
  • CAUTIImputedz 2.386
  • SSIImputedz 2.172
  • CDIImputedz 2.193
  • MRSAImputedz 2.225

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 fate0.26681.62222.28790.6657
CAUTI2.38631.29641.91390.6175
MRSA2.22511.30011.91390.6137
CDI2.19311.30461.91390.6092
CLABSI2.24021.30611.91390.6078
SSI2.17171.30921.91390.6047

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.

Imputation exposure

5 reported measures carry footnote 18 (imputed). Compare as-scored vs measured-only mean.

As scored
1.9139
Measured only
0.2668
  • CLABSI imputed
  • CAUTI imputed
  • SSI imputed
  • CDI imputed
  • MRSA imputed

Peer context

Percentile within MD (43 scored): 98.8th

Score distributionThreshold 0.3792Hospital 1.9139

Hospital score 1.9139. Penalty threshold 0.3792. Distribution of 43 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 100.0th

Score distributionThreshold 0.3792Hospital 1.9139

Hospital score 1.9139. 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.

5 reported measure(s) are imputed (footnote 18). As-scored 1.9139 vs measured-only 0.2668 — both compared to threshold 0.3792 as a mechanics illustration only.

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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