Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHI HEALTH BERGAN MERCY

NE · Facility ID 280060 · FY2026

Total HAC Score

-0.5216

Percentile

19.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5216

Hospital score -0.5216. 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 0.023
  • CLABSIz -0.268
  • CAUTIz -1.234
  • SSIz -0.770
  • CDIz -0.576
  • MRSAz -0.306

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 fate0.0227-0.7726-0.10690.6657
CAUTI-1.2342-0.53570.08180.6175
MRSA-0.3057-0.7136-0.09980.6137
CDI-0.5755-0.6694-0.06020.6092
CLABSI-0.2675-0.7115-0.10370.6078
SSI-0.7696-0.6361-0.03140.6047

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 NE (24 scored): 27.1th

Score distributionThreshold 0.3792Hospital -0.5216

Hospital score -0.5216. Penalty threshold 0.3792. Distribution of 24 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 13.2th

Score distributionThreshold 0.3792Hospital -0.5216

Hospital score -0.5216. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5216; 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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