HAC Penalty Risk Auditor
FY2026 · structural fragility of Total HAC Scores
Hospital audit
WELLSPAN EPHRATA COMMUNITY HOSPITAL
PA · Facility ID 390225 · FY2026
Total HAC Score
-0.8406
Percentile
7.3th
Displayed status
No reductionFrom CMS Payment Reduction column (file).
Score vs threshold (0.3792)
Hospital score -0.8406. 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 -0.622
- CLABSIz -0.725
- CAUTIz -1.319
- SSIz -1.020
- CDIz 0.098
- MRSAz -1.457
Fragility
Each reported measure moves the score by 0.1667 points.
| Measure | Current Z | Score @ floor | Score @ cap | Abs swing |
|---|---|---|---|---|
| PSI-90controls fate | -0.6219 | -0.9842 | -0.3185 | 0.6658 |
| CAUTI | -1.3186 | -0.8406 | -0.2231 | 0.6175 |
| MRSA | -1.4573 | -0.8406 | -0.2269 | 0.6137 |
| CDI | 0.0983 | -1.1007 | -0.4915 | 0.6092 |
| CLABSI | -0.7245 | -0.9543 | -0.3465 | 0.6078 |
| SSI | -1.0197 | -0.9134 | -0.3087 | 0.6047 |
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): 2.7th
Hospital score -0.8406. Penalty threshold 0.3792. Distribution of 130 scored hospitals.
Percentile among hospitals with 6 reported measures (1940 scored): 3.6th
Hospital score -0.8406. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.
Plain-language verdict
As scored, the CMS file lists no payment reduction (Total HAC Score -0.8406; 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.