Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL

MI · Facility ID 230133 · FY2026

Total HAC Score

-0.1722

Percentile

41.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1722

Hospital score -0.1722. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 4 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -0.486
  • CLABSIN/A
  • CAUTIz 0.955
  • SSIz -1.456
  • CDIz 0.300
  • MRSAN/A

Fragility

Each reported measure moves the score by 0.2500 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-0.4865-0.42140.57720.9986
CAUTI0.9545-0.74050.18570.9262
CDI0.2996-0.61270.30110.9138
SSI-1.4565-0.17220.73480.9070

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 MI (88 scored): 33.5th

Score distributionThreshold 0.3792Hospital -0.1722

Hospital score -0.1722. Penalty threshold 0.3792. Distribution of 88 scored hospitals.

Percentile among hospitals with 4 reported measures (139 scored): 40.6th

Score distributionThreshold 0.3792Hospital -0.1722

Hospital score -0.1722. Penalty threshold 0.3792. Distribution of 139 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1722; threshold 0.3792).

Reported on 4 of 6 measures; each reported measure moves the equal-weighted score by 0.2500 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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