Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

LAKE REGIONAL HEALTH SYSTEM

MO · Facility ID 260186 · FY2026

Total HAC Score

-0.2858

Percentile

33.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2858

Hospital score -0.2858. 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 -1.026
  • CLABSIz -1.407
  • CAUTIz -0.034
  • SSIz 0.209
  • CDIz 0.381
  • MRSAz 0.162

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-1.0265-0.36200.30380.6657
CAUTI-0.0338-0.49990.11750.6175
MRSA0.1624-0.55580.05800.6137
CDI0.3809-0.59300.01620.6092
CLABSI-1.4065-0.28580.32200.6078
SSI0.2086-0.56330.04140.6047

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): 29.8th

Score distributionThreshold 0.3792Hospital -0.2858

Hospital score -0.2858. Penalty threshold 0.3792. Distribution of 62 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 29.0th

Score distributionThreshold 0.3792Hospital -0.2858

Hospital score -0.2858. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2858; 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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