Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ST MARY'S GENERAL HOSPITAL

NJ · Facility ID 310006 · FY2026

Total HAC Score

-0.5603

Percentile

17.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5603

Hospital score -0.5603. 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 -1.041
  • CLABSIz 0.672
  • CAUTIz -0.716
  • SSIz -0.833
  • CDIz -0.885
  • MRSAz -0.559

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-1.0410-0.63400.03170.6657
CAUTI-0.7160-0.6607-0.04320.6175
MRSA-0.5586-0.7101-0.09630.6137
CDI-0.8852-0.6564-0.04720.6092
CLABSI0.6720-0.9067-0.29890.6078
SSI-0.8329-0.6642-0.05950.6047

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 NJ (61 scored): 12.3th

Score distributionThreshold 0.3792Hospital -0.5603

Hospital score -0.5603. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 11.1th

Score distributionThreshold 0.3792Hospital -0.5603

Hospital score -0.5603. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5603; 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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