Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

← All audits

Hospital audit

CJW MEDICAL CENTER

VA · Facility ID 490112 · FY2026

Total HAC Score

-0.2262

Percentile

37.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.2262

Hospital score -0.2262. 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 0.872
  • CLABSIz -0.286
  • CAUTIz -0.559
  • SSIz -0.369
  • CDIz -1.028
  • MRSAz 0.014

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 fate0.8716-0.61870.04710.6658
CAUTI-0.5593-0.35270.26480.6175
MRSA0.0140-0.47140.14240.6137
CDI-1.0285-0.29840.31080.6092
CLABSI-0.2860-0.41290.19490.6078
SSI-0.3687-0.40740.19730.6047

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): 53.6th

Score distributionThreshold 0.3792Hospital -0.2262

Hospital score -0.2262. Penalty threshold 0.3792. Distribution of 70 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 33.4th

Score distributionThreshold 0.3792Hospital -0.2262

Hospital score -0.2262. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.2262; 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.

Scan a hospital system →