Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

STARR REGIONAL MEDICAL CENTER ATHENS

TN · Facility ID 440068 · FY2026

Total HAC Score

-0.1093

Percentile

45.4th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1093

Hospital score -0.1093. 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 -0.435
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIz 0.421
  • CDIz 2.193
  • 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-0.4355-0.31890.48000.7989
CAUTI-1.3186-0.10930.63170.7410
CDI2.1931-0.8404-0.10930.7311
CLABSI-1.4065-0.10930.62000.7293
SSI0.4210-0.48480.24080.7256

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): 55.5th

Score distributionThreshold 0.3792Hospital -0.1093

Hospital score -0.1093. Penalty threshold 0.3792. Distribution of 73 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 45.7th

Score distributionThreshold 0.3792Hospital -0.1093

Hospital score -0.1093. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1093; 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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