Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

VIRTUA MOUNT HOLLY HOSPITAL

NJ · Facility ID 310057 · FY2026

Total HAC Score

-0.2206

Percentile

37.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2206

Hospital score -0.2206. 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 0.056
  • CLABSIz -0.604
  • CAUTIz -0.311
  • SSIz 0.191
  • CDIz -0.595
  • MRSAz -0.061

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 fate0.0559-0.47710.18860.6658
CAUTI-0.3110-0.38850.22900.6175
MRSA-0.0612-0.45330.16050.6137
CDI-0.5948-0.36520.24410.6092
CLABSI-0.6038-0.35440.25340.6078
SSI0.1914-0.49520.10950.6047

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): 43.4th

Score distributionThreshold 0.3792Hospital -0.2206

Hospital score -0.2206. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 33.7th

Score distributionThreshold 0.3792Hospital -0.2206

Hospital score -0.2206. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2206; 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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