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 JOSEPH'S MEDICAL CENTER

MN · Facility ID 240075 · FY2026

Total HAC Score

-0.0732

Percentile

48.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0732

Hospital score -0.0732. 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 1.644
  • CLABSIz -1.407
  • CAUTIz -0.545
  • SSIz 0.301
  • CDIz -0.452
  • MRSAz 0.018

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 fate1.6444-0.59450.07120.6657
CAUTI-0.5448-0.20220.41530.6175
MRSA0.0182-0.31910.29460.6137
CDI-0.4516-0.24160.36760.6092
CLABSI-1.4065-0.07320.53460.6078
SSI0.3011-0.36610.23860.6047

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): 43.3th

Score distributionThreshold 0.3792Hospital -0.0732

Hospital score -0.0732. Penalty threshold 0.3792. Distribution of 45 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 45.5th

Score distributionThreshold 0.3792Hospital -0.0732

Hospital score -0.0732. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.0732; 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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