Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ASCENSION SAINT THOMAS HOSPITAL

TN · Facility ID 440082 · FY2026

Total HAC Score

-0.2453

Percentile

35.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2453

Hospital score -0.2453. 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 -1.483
  • CLABSIz 0.148
  • CAUTIz -0.195
  • SSIz 0.342
  • CDIz -0.053
  • MRSAz -0.231

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-1.4834-0.24530.42040.6657
CAUTI-0.1953-0.43250.18490.6175
MRSA-0.2305-0.44980.16390.6137
CDI-0.0527-0.48020.12900.6092
CLABSI0.1478-0.50440.10340.6078
SSI0.3422-0.54510.05960.6047

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): 45.9th

Score distributionThreshold 0.3792Hospital -0.2453

Hospital score -0.2453. Penalty threshold 0.3792. Distribution of 73 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 31.9th

Score distributionThreshold 0.3792Hospital -0.2453

Hospital score -0.2453. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2453; 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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