HAC Penalty Risk Auditor
FY2026 · structural fragility of Total HAC Scores
Hospital audit
MOUNT ST. MARY'S HOSPITAL & HEALTH CENTER
NY · Facility ID 330188 · FY2026
Total HAC Score
-1.0615
Percentile
3.4th
Displayed status
No reductionFrom CMS Payment Reduction column (file).
Score vs threshold (0.3792)
Hospital score -1.0615. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.
Data completeness
Reported on 5 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.
- PSI-90z -0.089
- CLABSIz -1.407
- CAUTIz -1.319
- SSIN/A
- CDIz -1.036
- MRSAz -1.457
Fragility
Each reported measure moves the score by 0.2000 points.
| Measure | Current Z | Score @ floor | Score @ cap | Abs swing |
|---|---|---|---|---|
| PSI-90controls fate | -0.0891 | -1.3404 | -0.5415 | 0.7989 |
| CAUTI | -1.3186 | -1.0615 | -0.3206 | 0.7410 |
| MRSA | -1.4573 | -1.0615 | -0.3251 | 0.7365 |
| CDI | -1.0362 | -1.1467 | -0.4157 | 0.7311 |
| CLABSI | -1.4065 | -1.0615 | -0.3322 | 0.7293 |
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 NY (126 scored): 2.8th
Hospital score -1.0615. Penalty threshold 0.3792. Distribution of 126 scored hospitals.
Percentile among hospitals with 5 reported measures (220 scored): 4.8th
Hospital score -1.0615. Penalty threshold 0.3792. Distribution of 220 scored hospitals.
Plain-language verdict
As scored, the CMS file lists no payment reduction (Total HAC Score -1.0615; threshold 0.3792).
Reported on 5 of 6 measures; each reported measure moves the equal-weighted score by 0.2000 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.