Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CLARA MAASS MEDICAL CENTER

NJ · Facility ID 310009 · FY2026

Total HAC Score

-0.6214

Percentile

14.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.6214

Hospital score -0.6214. 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 -0.275
  • CLABSIz -0.182
  • CAUTIz -0.926
  • SSIz -0.951
  • CDIz -1.087
  • MRSAz -0.308

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-0.2754-0.8227-0.15700.6657
CAUTI-0.9257-0.6869-0.06940.6175
MRSA-0.3078-0.8129-0.19920.6137
CDI-1.0866-0.6840-0.07470.6092
CLABSI-0.1816-0.8255-0.21770.6078
SSI-0.9511-0.7056-0.10090.6047

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): 9.0th

Score distributionThreshold 0.3792Hospital -0.6214

Hospital score -0.6214. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 8.9th

Score distributionThreshold 0.3792Hospital -0.6214

Hospital score -0.6214. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.6214; 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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