Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

EASTERN NEW MEXICO MEDICAL CENTER

NM · Facility ID 320006 · FY2026

Total HAC Score

-0.7555

Percentile

10.7th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7555

Hospital score -0.7555. 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 -0.740
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIz -0.799
  • CDIz -0.618
  • MRSAz 0.348

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-0.7396-0.8795-0.21370.6657
CAUTI-1.3186-0.7555-0.13800.6175
MRSA0.3484-1.0565-0.44270.6137
CDI-0.6181-0.8962-0.28700.6092
CLABSI-1.4065-0.7555-0.14770.6078
SSI-0.7987-0.8651-0.26050.6047

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): 5.8th

Score distributionThreshold 0.3792Hospital -0.7555

Hospital score -0.7555. Penalty threshold 0.3792. Distribution of 26 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 5.3th

Score distributionThreshold 0.3792Hospital -0.7555

Hospital score -0.7555. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7555; 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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