Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

BOTHWELL REGIONAL HEALTH CENTER

MO · Facility ID 260009 · FY2026

Total HAC Score

-0.7117

Percentile

12.5th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7117

Hospital score -0.7117. 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 -0.465
  • CLABSIz -1.407
  • CAUTIz -0.060
  • SSIz -0.155
  • CDIz -0.727
  • MRSAz -1.457

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-0.4653-0.8814-0.21570.6658
CAUTI-0.0603-0.9215-0.30400.6175
MRSA-1.4573-0.7117-0.09800.6137
CDI-0.7265-0.8344-0.22520.6092
CLABSI-1.4065-0.7117-0.10400.6078
SSI-0.1546-0.9287-0.32400.6047

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 MO (62 scored): 7.3th

Score distributionThreshold 0.3792Hospital -0.7117

Hospital score -0.7117. Penalty threshold 0.3792. Distribution of 62 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 6.6th

Score distributionThreshold 0.3792Hospital -0.7117

Hospital score -0.7117. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7117; 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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