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 VIRGINIA

MN · Facility ID 240084 · FY2026

Total HAC Score

-0.7918

Percentile

9.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7918

Hospital score -0.7918. 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 -0.353
  • CLABSIz -1.407
  • CAUTIz 0.270
  • SSIz -1.456
  • CDIz -1.013
  • MRSAN/A

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-0.3530-1.0179-0.21900.7989
CAUTI0.2699-1.1095-0.36850.7410
CDI-1.0130-0.8817-0.15060.7311
CLABSI-1.4065-0.7918-0.06250.7293
SSI-1.4565-0.7918-0.06620.7256

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): 1.1th

Score distributionThreshold 0.3792Hospital -0.7918

Hospital score -0.7918. Penalty threshold 0.3792. Distribution of 45 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 10.2th

Score distributionThreshold 0.3792Hospital -0.7918

Hospital score -0.7918. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7918; 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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