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 HAYS

TX · Facility ID 670056 · FY2026

Total HAC Score

-0.7218

Percentile

12.1th

Displayed status

No reduction

From CMS Payment Reduction column (file).

Score vs threshold (0.3792)

Score distributionThreshold 0.3792Hospital -0.7218

Hospital score -0.7218. 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 -1.374
  • CLABSIz -0.344
  • CAUTIz -0.097
  • SSIz -0.026
  • CDIz -1.032
  • MRSAz -1.457

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-1.3744-0.7399-0.07420.6657
CAUTI-0.0965-0.9255-0.30800.6175
MRSA-1.4573-0.7218-0.10810.6137
CDI-1.0324-0.7934-0.18420.6092
CLABSI-0.3440-0.8989-0.29110.6078
SSI-0.0261-0.9602-0.35550.6047

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): 20.2th

Score distributionThreshold 0.3792Hospital -0.7218

Hospital score -0.7218. Penalty threshold 0.3792. Distribution of 255 scored hospitals.

Percentile among hospitals with 6 reported measures (1940 scored): 6.3th

Score distributionThreshold 0.3792Hospital -0.7218

Hospital score -0.7218. Penalty threshold 0.3792. Distribution of 1940 scored hospitals.

Plain-language verdict

As scored, the CMS file lists no payment reduction (Total HAC Score -0.7218; 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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