Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SAINT MICHAEL'S MEDICAL CENTER

NJ · Facility ID 310096 · FY2026

Total HAC Score

-0.4521

Percentile

23.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4521

Hospital score -0.4521. 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 0.211
  • CLABSIz -1.031
  • CAUTIz 0.612
  • SSIz -0.708
  • CDIz -1.284
  • MRSAz -0.513

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 fate0.2106-0.7344-0.06860.6657
CAUTI0.6122-0.7739-0.15640.6175
MRSA-0.5126-0.60950.00420.6137
CDI-1.2840-0.48180.12750.6092
CLABSI-1.0307-0.51470.09310.6078
SSI-0.7079-0.57680.02790.6047

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): 23.8th

Score distributionThreshold 0.3792Hospital -0.4521

Hospital score -0.4521. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 18.1th

Score distributionThreshold 0.3792Hospital -0.4521

Hospital score -0.4521. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4521; 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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