Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHRISTUS SPOHN HOSPITAL KLEBERG

TX · Facility ID 450163 · FY2026

Total HAC Score

-0.1486

Percentile

42.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.1486

Hospital score -0.1486. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 4 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z 0.394
  • CLABSIN/A
  • CAUTIz 0.106
  • SSIz -0.209
  • CDIz -0.885
  • MRSAN/A

Fragility

Each reported measure moves the score by 0.2500 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 fate0.3941-0.61800.38060.9986
CAUTI0.1060-0.50480.42140.9262
CDI-0.8852-0.29290.62090.9138
SSI-0.2094-0.46040.44660.9070

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): 57.8th

Score distributionThreshold 0.3792Hospital -0.1486

Hospital score -0.1486. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 4 reported measures (139 scored): 42.8th

Score distributionThreshold 0.3792Hospital -0.1486

Hospital score -0.1486. Penalty threshold 0.3792. Distribution of 139 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.1486; threshold 0.3792).

Reported on 4 of 6 measures; each reported measure moves the equal-weighted score by 0.2500 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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