Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

DUKE REGIONAL HOSPITAL

NC · Facility ID 340155 · FY2026

Total HAC Score

-0.3071

Percentile

31.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3071

Hospital score -0.3071. 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 -0.042
  • CLABSIz 0.308
  • CAUTIz -0.246
  • SSIz -0.824
  • CDIz -0.784
  • MRSAz -0.254

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-0.0422-0.54730.11840.6657
CAUTI-0.2459-0.48590.13160.6175
MRSA-0.2535-0.50780.10600.6137
CDI-0.7845-0.42010.18910.6092
CLABSI0.3078-0.59280.01500.6078
SSI-0.8244-0.41250.19220.6047

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): 22.2th

Score distributionThreshold 0.3792Hospital -0.3071

Hospital score -0.3071. Penalty threshold 0.3792. Distribution of 79 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 27.3th

Score distributionThreshold 0.3792Hospital -0.3071

Hospital score -0.3071. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3071; 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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