Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHI ST LUKE'S HEALTH BRAZOSPORT

TX · Facility ID 450072 · FY2026

Total HAC Score

-0.7907

Percentile

9.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7907

Hospital score -0.7907. 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 -0.558
  • CLABSIz -1.407
  • CAUTIz -1.319
  • SSIN/A
  • CDIz 0.787
  • 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 fate-0.5585-0.9757-0.17680.7989
CAUTI-1.3186-0.7907-0.04970.7410
MRSA-1.4573-0.7907-0.05420.7365
CDI0.7875-1.2406-0.50960.7311
CLABSI-1.4065-0.7907-0.06130.7293

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 TX (255 scored): 15.1th

Score distributionThreshold 0.3792Hospital -0.7907

Hospital score -0.7907. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 5 reported measures (220 scored): 10.7th

Score distributionThreshold 0.3792Hospital -0.7907

Hospital score -0.7907. Penalty threshold 0.3792. Distribution of 220 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7907; 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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