Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

CHRISTUS SANTA ROSA HOSPITAL-SAN MARCOS

TX · Facility ID 450272 · FY2026

Total HAC Score

-0.3907

Percentile

26.8th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3907

Hospital score -0.3907. 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 -0.918
  • CLABSIz -0.015
  • CAUTIz 0.014
  • SSIz -1.456
  • CDIz -0.235
  • MRSAz 0.265

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-0.9179-0.48500.18070.6658
CAUTI0.0144-0.61290.00460.6175
MRSA0.2648-0.6778-0.06400.6137
CDI-0.2347-0.59530.01390.6092
CLABSI-0.0146-0.6227-0.01490.6078
SSI-1.4565-0.39070.21390.6047

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): 39.8th

Score distributionThreshold 0.3792Hospital -0.3907

Hospital score -0.3907. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 21.4th

Score distributionThreshold 0.3792Hospital -0.3907

Hospital score -0.3907. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3907; 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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