Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SAINT FRANCIS HOSPITAL SOUTH, LLC

OK · Facility ID 370218 · FY2026

Total HAC Score

-0.9175

Percentile

5.2th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.9175

Hospital score -0.9175. 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 -0.440
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIz -0.783
  • CDIz -0.099
  • MRSAz -1.457

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-0.4400-1.0914-0.42560.6657
CAUTI-1.3186-0.9175-0.30000.6175
MRSA-1.4573-0.9175-0.30380.6137
CDI-0.0992-1.1447-0.53540.6092
CLABSI-1.4065-0.9175-0.30970.6078
SSI-0.7833-1.0297-0.42500.6047

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 OK (68 scored): 12.5th

Score distributionThreshold 0.3792Hospital -0.9175

Hospital score -0.9175. Penalty threshold 0.3792. Distribution of 68 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 2.1th

Score distributionThreshold 0.3792Hospital -0.9175

Hospital score -0.9175. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.9175; 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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