Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

MORRISTOWN HAMBLEN HOSPITAL ASSOCIATION

TN · Facility ID 440030 · FY2026

Total HAC Score

-0.2186

Percentile

37.5th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2186

Hospital score -0.2186. 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 -0.044
  • CLABSIz -1.017
  • CAUTIz 0.820
  • SSIz -0.120
  • CDIz -1.218
  • MRSAz 0.269

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-0.0445-0.45840.20740.6657
CAUTI0.8195-0.57490.04260.6175
MRSA0.2690-0.50630.10750.6137
CDI-1.2182-0.25920.35000.6092
CLABSI-1.0168-0.28350.32430.6078
SSI-0.1203-0.44120.16350.6047

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 TN (73 scored): 49.3th

Score distributionThreshold 0.3792Hospital -0.2186

Hospital score -0.2186. Penalty threshold 0.3792. Distribution of 73 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 33.9th

Score distributionThreshold 0.3792Hospital -0.2186

Hospital score -0.2186. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2186; 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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