Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHRISTUS MOTHER FRANCES HOSPITAL

TX · Facility ID 450102 · FY2026

Total HAC Score

-0.2100

Percentile

38.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2100

Hospital score -0.2100. 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 -1.061
  • CLABSIz 1.347
  • CAUTIz -0.321
  • SSIz -0.502
  • CDIz -0.413
  • MRSAz -0.310

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-1.0612-0.28030.38540.6658
CAUTI-0.3207-0.37630.24120.6175
MRSA-0.3099-0.40120.21250.6137
CDI-0.4128-0.38490.22430.6092
CLABSI1.3471-0.6689-0.06110.6078
SSI-0.5023-0.36900.23570.6047

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 TX (255 scored): 53.5th

Score distributionThreshold 0.3792Hospital -0.2100

Hospital score -0.2100. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 34.7th

Score distributionThreshold 0.3792Hospital -0.2100

Hospital score -0.2100. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2100; 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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