HAC Penalty Risk Auditor
FY2026 · structural fragility of Total HAC Scores
Hospital audit
MARY IMMACULATE HOSPITAL
VA · Facility ID 490041 · FY2026
Total HAC Score
-1.0737
Percentile
3.1th
Displayed status
No reductionFrom CMS Payment Reduction column (file).
Score vs threshold (0.3792)
Hospital score -1.0737. 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 -1.483
- CLABSIz -0.107
- CAUTIz -1.319
- SSIz -0.811
- CDIz -1.265
- MRSAz -1.457
Fragility
Each reported measure moves the score by 0.1667 points.
| Measure | Current Z | Score @ floor | Score @ cap | Abs swing |
|---|---|---|---|---|
| PSI-90controls fate | -1.4834 | -1.0737 | -0.4079 | 0.6657 |
| CAUTI | -1.3186 | -1.0737 | -0.4562 | 0.6175 |
| MRSA | -1.4573 | -1.0737 | -0.4600 | 0.6137 |
| CDI | -1.2647 | -1.1066 | -0.4974 | 0.6092 |
| CLABSI | -0.1074 | -1.2902 | -0.6824 | 0.6078 |
| SSI | -0.8107 | -1.1813 | -0.5766 | 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 VA (70 scored): 3.6th
Hospital score -1.0737. Penalty threshold 0.3792. Distribution of 70 scored hospitals.
Percentile among hospitals with 6 reported measures (1940 scored): 0.9th
Hospital score -1.0737. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.
Plain-language verdict
As scored, the CMS file lists no payment reduction (Total HAC Score -1.0737; 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.