Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

← All audits

Hospital audit

CHRISTUS SOUTHERN NEW MEXICO

NM · Facility ID 320004 · FY2026

Total HAC Score

-0.7135

Percentile

12.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7135

Hospital score -0.7135. 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 -0.415
  • CLABSIz 0.132
  • CAUTIz -0.776
  • SSIz -1.456
  • CDIz -0.308
  • MRSAz -1.457

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-0.4146-0.8917-0.22590.6657
CAUTI-0.7762-0.8040-0.18650.6175
MRSA-1.4573-0.7136-0.09980.6137
CDI-0.3083-0.9059-0.29670.6092
CLABSI0.1315-0.9699-0.36210.6078
SSI-1.4565-0.7136-0.10890.6047

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 NM (26 scored): 9.6th

Score distributionThreshold 0.3792Hospital -0.7135

Hospital score -0.7135. Penalty threshold 0.3792. Distribution of 26 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 6.5th

Score distributionThreshold 0.3792Hospital -0.7135

Hospital score -0.7135. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7135; 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.

Scan a hospital system →