Hospital audit

HAC Penalty Risk Auditor

HAC Penalty Risk Auditor

FY2026 · structural fragility of Total HAC Scores

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Hospital audit

ASCENSION SETON WILLIAMSON

TX · Facility ID 670041 · FY2026

Total HAC Score

-0.3524

Percentile

28.9th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.3524

Hospital score -0.3524. 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 -1.430
  • CLABSIz -0.142
  • CAUTIz -0.559
  • SSIz -0.275
  • CDIz -0.316
  • MRSAz 0.608

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-1.4297-0.36130.30440.6658
CAUTI-0.5593-0.47890.13860.6175
MRSA0.6075-0.6965-0.08280.6137
CDI-0.3160-0.54340.06580.6092
CLABSI-0.1422-0.56310.04470.6078
SSI-0.2745-0.54940.05530.6047

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 TX (255 scored): 42.9th

Score distributionThreshold 0.3792Hospital -0.3524

Hospital score -0.3524. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 23.8th

Score distributionThreshold 0.3792Hospital -0.3524

Hospital score -0.3524. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.3524; 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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