Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ESSENTIA HEALTH ST MARY'S MEDICAL CENTER

MN · Facility ID 240002 · FY2026

Total HAC Score

-0.3161

Percentile

31.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3161

Hospital score -0.3161. 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 -0.695
  • CLABSIz -0.901
  • CAUTIz 0.521
  • SSIz -0.151
  • CDIz -0.444
  • MRSAz -0.226

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-0.6952-0.44750.21830.6657
CAUTI0.5206-0.6227-0.00520.6175
MRSA-0.2263-0.52130.09240.6137
CDI-0.4438-0.48580.12340.6092
CLABSI-0.9008-0.40040.20740.6078
SSI-0.1512-0.53370.07100.6047

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 MN (45 scored): 21.1th

Score distributionThreshold 0.3792Hospital -0.3161

Hospital score -0.3161. Penalty threshold 0.3792. Distribution of 45 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 26.8th

Score distributionThreshold 0.3792Hospital -0.3161

Hospital score -0.3161. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3161; threshold 0.3792).

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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