HAC Penalty Risk Auditor
FY2026 · structural fragility of Total HAC Scores
Hospital audit
CHRISTUS MOTHER FRANCES HOSPITAL SULPHUR SPRINGS
TX · Facility ID 450236 · FY2026
Total HAC Score
-0.1291
Percentile
44.0th
Displayed status
No reductionFrom CMS Payment Reduction column (file).
Score vs threshold (0.3792)
Hospital score -0.1291. 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 -0.395
- CLABSIz -1.407
- CAUTIz -0.576
- SSIz 2.172
- CDIz -1.160
- MRSAz 0.591
Fragility
Each reported measure moves the score by 0.1667 points.
| Measure | Current Z | Score @ floor | Score @ cap | Abs swing |
|---|---|---|---|---|
| PSI-90controls fate | -0.3945 | -0.3106 | 0.3551 | 0.6658 |
| CAUTI | -0.5762 | -0.2529 | 0.3646 | 0.6175 |
| MRSA | 0.5908 | -0.4705 | 0.1432 | 0.6137 |
| CDI | -1.1601 | -0.1795 | 0.4297 | 0.6092 |
| CLABSI | -1.4065 | -0.1291 | 0.4787 | 0.6078 |
| SSI | 2.1717 | -0.7338 | -0.1291 | 0.6047 |
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): 60.2th
Hospital score -0.1291. Penalty threshold 0.3792. Distribution of 255 scored hospitals.
Percentile among hospitals with 6 reported measures (1940 scored): 41.3th
Hospital score -0.1291. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.
Plain-language verdict
As scored, the CMS file lists no payment reduction (Total HAC Score -0.1291; 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.