Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ST JOSEPH HOSPITAL

WA · Facility ID 500030 · FY2026

Total HAC Score

-0.3308

Percentile

30.3th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3308

Hospital score -0.3308. 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 -0.639
  • CAUTIz -0.260
  • SSIz 0.913
  • CDIz -0.026
  • MRSAz -0.490

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-1.4834-0.33080.33490.6657
CAUTI-0.2604-0.50720.11030.6175
MRSA-0.4896-0.49210.12160.6137
CDI-0.0256-0.57030.03890.6092
CLABSI-0.6386-0.45880.14900.6078
SSI0.9126-0.7257-0.12100.6047

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 WA (46 scored): 22.8th

Score distributionThreshold 0.3792Hospital -0.3308

Hospital score -0.3308. Penalty threshold 0.3792. Distribution of 46 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 25.4th

Score distributionThreshold 0.3792Hospital -0.3308

Hospital score -0.3308. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3308; 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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