Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ST JOSEPH HOSPITAL

NH · Facility ID 300011 · FY2026

Total HAC Score

-0.6098

Percentile

15.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.6098

Hospital score -0.6098. 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 -0.447
  • CLABSIz -1.014
  • CAUTIz -0.962
  • SSIz -0.913
  • CDIz -0.804
  • MRSAz 0.482

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-0.4472-0.7825-0.11670.6657
CAUTI-0.9619-0.6692-0.05170.6175
MRSA0.4822-0.9330-0.31930.6137
CDI-0.8039-0.7195-0.11030.6092
CLABSI-1.0144-0.6751-0.06730.6078
SSI-0.9135-0.7003-0.09560.6047

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 NH (13 scored): 11.5th

Score distributionThreshold 0.3792Hospital -0.6098

Hospital score -0.6098. Penalty threshold 0.3792. Distribution of 13 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 9.3th

Score distributionThreshold 0.3792Hospital -0.6098

Hospital score -0.6098. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.6098; 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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