Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ASCENSION ST FRANCIS HOSPITAL

WI · Facility ID 520078 · FY2026

Total HAC Score

-0.0992

Percentile

46.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.0992

Hospital score -0.0992. Penalty threshold 0.3792. Distribution of 2929 scored hospitals.

Data completeness

Reported on 4 of 6. Missing measures show N/A with the CMS footnote; footnote 18 values are imputed worst-case, not measured performance.

  • PSI-90z -0.188
  • CLABSIz -0.307
  • CAUTIz -0.101
  • SSIN/A
  • CDIz 0.199
  • MRSAN/A

Fragility

Each reported measure moves the score by 0.2500 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-0.1876-0.42320.57550.9986
CAUTI-0.1013-0.40350.52270.9262
CDI0.1990-0.51450.39930.9138
CLABSI-0.3069-0.37410.53760.9117

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 WI (62 scored): 33.1th

Score distributionThreshold 0.3792Hospital -0.0992

Hospital score -0.0992. Penalty threshold 0.3792. Distribution of 62 scored hospitals.

Percentile among hospitals with 4 reported measures (139 scored): 44.2th

Score distributionThreshold 0.3792Hospital -0.0992

Hospital score -0.0992. Penalty threshold 0.3792. Distribution of 139 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.0992; threshold 0.3792).

Reported on 4 of 6 measures; each reported measure moves the equal-weighted score by 0.2500 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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