Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE

NC · Facility ID 340002 · FY2026

Total HAC Score

-0.4110

Percentile

25.5th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4110

Hospital score -0.4110. 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 -1.483
  • CLABSIz 0.285
  • CAUTIz -0.648
  • SSIz -0.316
  • CDIz -0.355
  • MRSAz 0.052

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-1.4834-0.41100.25470.6657
CAUTI-0.6485-0.52270.09480.6175
MRSA0.0516-0.6625-0.04880.6137
CDI-0.3548-0.59560.01360.6092
CLABSI0.2846-0.6929-0.08510.6078
SSI-0.3156-0.60120.00350.6047

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 NC (79 scored): 17.1th

Score distributionThreshold 0.3792Hospital -0.4110

Hospital score -0.4110. Penalty threshold 0.3792. Distribution of 79 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 20.1th

Score distributionThreshold 0.3792Hospital -0.4110

Hospital score -0.4110. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4110; 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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