Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

BAYSHORE MEDICAL CENTER

NJ · Facility ID 310112 · FY2026

Total HAC Score

-0.6258

Percentile

14.7th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.6258

Hospital score -0.6258. 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 -0.763
  • CLABSIz -1.407
  • CAUTIz -0.576
  • SSIz 1.043
  • CDIz -1.017
  • MRSAz -1.035

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-0.7628-0.7459-0.08010.6658
CAUTI-0.5762-0.7495-0.13200.6175
MRSA-1.0351-0.6961-0.08240.6137
CDI-1.0169-0.7000-0.09080.6092
CLABSI-1.4065-0.6258-0.01800.6078
SSI1.0428-1.0423-0.43760.6047

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): 7.4th

Score distributionThreshold 0.3792Hospital -0.6258

Hospital score -0.6258. Penalty threshold 0.3792. Distribution of 61 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 8.8th

Score distributionThreshold 0.3792Hospital -0.6258

Hospital score -0.6258. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.6258; 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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