Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

UNIVERSITY OF MD ST JOSEPH MEDICAL CENTER

MD · Facility ID 210063 · FY2026

Total HAC Score

-0.0806

Percentile

47.5th

Displayed status

Exempt (Maryland)

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0806

Hospital score -0.0806. 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 -1.483
  • CLABSIz 0.289
  • CAUTIz 1.967
  • SSIz 0.013
  • CDIz 0.187
  • 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-1.4834-0.08070.58510.6657
CAUTI1.9669-0.6282-0.01080.6175
MRSA-1.4573-0.08070.53310.6137
CDI0.1873-0.35560.25360.6092
CLABSI0.2893-0.36330.24450.6078
SSI0.0133-0.32560.27910.6047

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): 40.7th

Score distributionThreshold 0.3792Hospital -0.0806

Hospital score -0.0806. Penalty threshold 0.3792. Distribution of 43 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 44.8th

Score distributionThreshold 0.3792Hospital -0.0806

Hospital score -0.0806. 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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