Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

JOHN RANDOLPH MEDICAL CENTER

VA · Facility ID 490020 · FY2026

Total HAC Score

-0.6711

Percentile

13.6th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.6711

Hospital score -0.6711. 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 -0.357
  • CLABSIz 0.477
  • CAUTIz -1.319
  • SSIz -0.199
  • CDIz -1.172
  • MRSAz -1.457

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-0.3571-0.8588-0.19310.6658
CAUTI-1.3186-0.6711-0.05360.6175
MRSA-1.4573-0.6711-0.05740.6137
CDI-1.1718-0.7195-0.11030.6092
CLABSI0.4772-0.9851-0.37730.6078
SSI-0.1991-0.8807-0.27600.6047

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 VA (70 scored): 26.4th

Score distributionThreshold 0.3792Hospital -0.6711

Hospital score -0.6711. Penalty threshold 0.3792. Distribution of 70 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 7.7th

Score distributionThreshold 0.3792Hospital -0.6711

Hospital score -0.6711. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.6711; 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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