Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

TENNOVA HEALTHCARE-JEFFERSON MEMORIAL HOSPITAL

TN · Facility ID 440056 · FY2026

Total HAC Score

-0.3378

Percentile

29.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3378

Hospital score -0.3378. 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 1.587
  • CLABSIN/A
  • CAUTIz 0.422
  • SSIz -1.456
  • CDIz -0.784
  • MRSAz -1.457

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 fate1.5873-0.9520-0.15310.7989
CAUTI0.4218-0.68590.05510.7410
MRSA-1.4573-0.33780.39860.7365
CDI-0.7845-0.47340.25770.7311
SSI-1.4565-0.33780.38780.7256

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 TN (73 scored): 33.6th

Score distributionThreshold 0.3792Hospital -0.3378

Hospital score -0.3378. Penalty threshold 0.3792. Distribution of 73 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 34.8th

Score distributionThreshold 0.3792Hospital -0.3378

Hospital score -0.3378. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3378; 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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