Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

PELHAM MEDICAL CENTER

SC · Facility ID 420103 · FY2026

Total HAC Score

-0.4166

Percentile

25.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.4166

Hospital score -0.4166. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 5 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -0.438
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIz -1.004
  • CDIz 2.085
  • MRSAN/A

Fragility

Each reported measure moves the score by 0.2000 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-0.4384-0.62560.17330.7989
CAUTI-1.3186-0.41660.32440.7410
CDI2.0846-1.1260-0.39490.7311
CLABSI-1.4065-0.41660.31270.7293
SSI-1.0042-0.50710.21860.7256

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 SC (51 scored): 26.5th

Score distributionThreshold 0.3792Hospital -0.4166

Hospital score -0.4166. Penalty threshold 0.3792. Distribution of 51 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 28.9th

Score distributionThreshold 0.3792Hospital -0.4166

Hospital score -0.4166. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.4166; threshold 0.3792).

Reported on 5 of 6 measures; each reported measure moves the equal-weighted score by 0.2000 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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