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 DULUTH

MN · Facility ID 240019 · FY2026

Total HAC Score

-0.3317

Percentile

30.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3317

Hospital score -0.3317. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 5 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -0.377
  • CLABSIz -0.311
  • CAUTIz 0.354
  • SSIN/A
  • CDIz 0.133
  • MRSAz -1.457

Fragility

Each reported measure moves the score by 0.2000 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-0.3773-0.55300.24590.7989
CAUTI0.3543-0.66630.07470.7410
MRSA-1.4573-0.33170.40470.7365
CDI0.1331-0.65080.08030.7311
CLABSI-0.3115-0.55070.17860.7293

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): 16.7th

Score distributionThreshold 0.3792Hospital -0.3317

Hospital score -0.3317. Penalty threshold 0.3792. Distribution of 45 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 35.2th

Score distributionThreshold 0.3792Hospital -0.3317

Hospital score -0.3317. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3317; threshold 0.3792).

Reported on 5 of 6 measures; each reported measure moves the equal-weighted score by 0.2000 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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