Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ST LUKE'S WARREN HOSPITAL

NJ · Facility ID 310060 · FY2026

Total HAC Score

-0.1917

Percentile

39.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1917

Hospital score -0.1917. 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 -0.433
  • CLABSIz -0.590
  • CAUTIz -0.793
  • SSIz 1.920
  • CDIz -0.808
  • MRSAz -0.446

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-0.4333-0.36670.29910.6657
CAUTI-0.7931-0.27920.33820.6175
MRSA-0.4458-0.36030.25350.6137
CDI-0.8078-0.30070.30850.6092
CLABSI-0.5899-0.32780.28000.6078
SSI1.9199-0.7544-0.14970.6047

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): 48.4th

Score distributionThreshold 0.3792Hospital -0.1917

Hospital score -0.1917. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 36.3th

Score distributionThreshold 0.3792Hospital -0.1917

Hospital score -0.1917. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1917; 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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