Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

SENTARA LEIGH HOSPITAL

VA · Facility ID 490046 · FY2026

Total HAC Score

-0.5845

Percentile

16.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.5845

Hospital score -0.5845. 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 -0.251
  • CLABSIz -1.035
  • CAUTIz -0.716
  • SSIz -0.612
  • CDIz -0.792
  • MRSAz -0.101

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-0.2505-0.7900-0.12420.6657
CAUTI-0.7160-0.6849-0.06750.6175
MRSA-0.1009-0.8106-0.19680.6137
CDI-0.7923-0.6962-0.08690.6092
CLABSI-1.0353-0.6464-0.03860.6078
SSI-0.6120-0.7253-0.12060.6047

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): 27.9th

Score distributionThreshold 0.3792Hospital -0.5845

Hospital score -0.5845. Penalty threshold 0.3792. Distribution of 70 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 10.2th

Score distributionThreshold 0.3792Hospital -0.5845

Hospital score -0.5845. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.5845; 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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