Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

DOYLESTOWN HOSPITAL

PA · Facility ID 390203 · FY2026

Total HAC Score

-0.0574

Percentile

49.0th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0574

Hospital score -0.0574. 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 -0.112
  • CAUTIz -0.246
  • SSIz 0.560
  • CDIz 0.896
  • MRSAz 0.041

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-1.4834-0.05740.60830.6657
CAUTI-0.2459-0.23620.38130.6175
MRSA0.0412-0.30720.30660.6137
CDI0.8959-0.45040.15880.6092
CLABSI-0.1120-0.27320.33460.6078
SSI0.5597-0.39350.21130.6047

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 PA (130 scored): 35.8th

Score distributionThreshold 0.3792Hospital -0.0574

Hospital score -0.0574. Penalty threshold 0.3792. Distribution of 130 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 46.7th

Score distributionThreshold 0.3792Hospital -0.0574

Hospital score -0.0574. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.0574; 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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