Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

OUR LADY OF FATIMA HOSPITAL

RI · Facility ID 410005 · FY2026

Total HAC Score

-0.7720

Percentile

10.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7720

Hospital score -0.7720. 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 -0.747
  • CLABSIz -1.407
  • CAUTIz -0.511
  • SSIz -0.179
  • CDIz -1.462
  • MRSAz -0.327

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-0.7474-0.8947-0.22900.6657
CAUTI-0.5111-0.9066-0.28920.6175
MRSA-0.3266-0.9605-0.34680.6137
CDI-1.4622-0.7721-0.16280.6092
CLABSI-1.4065-0.7721-0.16430.6078
SSI-0.1786-0.9850-0.38030.6047

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 RI (10 scored): 15.0th

Score distributionThreshold 0.3792Hospital -0.7720

Hospital score -0.7720. Penalty threshold 0.3792. Distribution of 10 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 4.9th

Score distributionThreshold 0.3792Hospital -0.7720

Hospital score -0.7720. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7720; 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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