Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

DEBORAH HEART AND LUNG CENTER

NJ · Facility ID 310031 · FY2026

Total HAC Score

-0.1407

Percentile

43.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1407

Hospital score -0.1407. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 5 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z 2.511
  • CLABSIz -0.165
  • CAUTIz -1.319
  • SSIN/A
  • CDIz -0.273
  • MRSAz -1.457

Fragility

Each reported measure moves the score by 0.2000 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 fate2.5111-0.9396-0.14070.7989
CAUTI-1.3186-0.14070.60030.7410
MRSA-1.4573-0.14070.59580.7365
CDI-0.2734-0.37850.35260.7311
CLABSI-0.1654-0.38890.34040.7293

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): 53.3th

Score distributionThreshold 0.3792Hospital -0.1407

Hospital score -0.1407. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 43.9th

Score distributionThreshold 0.3792Hospital -0.1407

Hospital score -0.1407. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1407; threshold 0.3792).

Reported on 5 of 6 measures; each reported measure moves the equal-weighted score by 0.2000 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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