Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ASCENSION RIVER DISTRICT HOSPITAL

MI · Facility ID 230241 · FY2026

Total HAC Score

2.3133

Percentile

100.0th

Displayed status

Payment reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital 2.3133

Hospital score 2.3133. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 2 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90N/A
  • CLABSIImputedz 2.240
  • CAUTIImputedz 2.386
  • SSIN/A
  • CDIN/A
  • MRSAN/A

Fragility

Each reported measure moves the score by 0.5000 points.

Score swing if each reported measure were at its Z floor versus Z cap, holding other measures fixed
MeasureCurrent ZScore @ floorScore @ capAbs swing
CAUTIcontrols fate2.38630.46082.31331.8524
CLABSI2.24020.48992.31331.8234

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

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

As scored
2.3133
Measured only
N/A
  • CLABSI imputed
  • CAUTI imputed

Peer context

Percentile within MI (88 scored): 99.4th

Score distributionThreshold 0.3792Hospital 2.3133

Hospital score 2.3133. Penalty threshold 0.3792. Distribution of 88 scored hospitals.

Percentile among hospitals with 2 reported measures (252 scored): 99.8th

Score distributionThreshold 0.3792Hospital 2.3133

Hospital score 2.3133. Penalty threshold 0.3792. Distribution of 252 scored hospitals.

Plain-language verdict

As scored, the CMS file lists payment reduction Yes (Total HAC Score 2.3133; threshold 0.3792).

Reported on 2 of 6 measures; each reported measure moves the equal-weighted score by 0.5000 points.

Penalized as scored on imputed values only (footnote 18); excluding imputation leaves no measured Z-scores — a mechanics illustration, not a CMS prediction.

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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