Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SAINT PETER'S UNIVERSITY HOSPITAL

NJ · Facility ID 310070 · FY2026

Total HAC Score

-0.5369

Percentile

18.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5369

Hospital score -0.5369. 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 0.057
  • CLABSIz -0.495
  • CAUTIz -0.660
  • SSIz -0.494
  • CDIz -0.994
  • MRSAz -0.636

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 fate0.0574-0.7937-0.12790.6658
CAUTI-0.6605-0.6466-0.02910.6175
MRSA-0.6359-0.6738-0.06000.6137
CDI-0.9936-0.6150-0.00570.6092
CLABSI-0.4948-0.6888-0.08100.6078
SSI-0.4938-0.6973-0.09260.6047

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): 17.2th

Score distributionThreshold 0.3792Hospital -0.5369

Hospital score -0.5369. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 12.2th

Score distributionThreshold 0.3792Hospital -0.5369

Hospital score -0.5369. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5369; 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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