Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MARYMOUNT HOSPITAL

OH · Facility ID 360143 · FY2026

Total HAC Score

-0.4236

Percentile

24.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4236

Hospital score -0.4236. 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 -1.217
  • CLABSIz 0.264
  • CAUTIz -0.639
  • SSIz 0.125
  • CDIz -0.428
  • MRSAz -0.646

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-1.2166-0.46810.19770.6657
CAUTI-0.6388-0.53690.08060.6175
MRSA-0.6464-0.55880.05500.6137
CDI-0.4283-0.59590.01330.6092
CLABSI0.2638-0.7020-0.09420.6078
SSI0.1246-0.6871-0.08240.6047

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 OH (114 scored): 19.7th

Score distributionThreshold 0.3792Hospital -0.4236

Hospital score -0.4236. Penalty threshold 0.3792. Distribution of 114 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 19.6th

Score distributionThreshold 0.3792Hospital -0.4236

Hospital score -0.4236. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4236; 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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