Hospital record · FY2026CCN 150104

1Hospital

Witham Health Services

2Location

Lebanon, IN (Indiana’s hospitals on the map and in the table) 46052

Boone County

3Type

Not a teaching hospital · 52 beds · Government · Urban

4Care Compare stars

4 of 5 stars

Overall rating, CMS Care Compare data of July 22, 2026
Open on Care Compare (opens in a new tab)

5Total HAC Score

−0.3138

As CMS reports it

6Payment reduction

No cut

CMS’s value: No

7Estimated cut

A cut would have been $80K, likely $59⁠–⁠100K estimate

No cut

from this program

For fiscal year 2026, CMS reports a Total HAC Score of −0.3138 for Witham Health Services and a payment reduction decision of No.

A cut would have taken about $80K estimate 1% of about $8.0M, this site’s estimate of what traditional Medicare pays it for inpatient stays in a year. Its score was 0.6937 under 0.3799, the lowest score CMS cut.

Likely range $59–100K

Its score was at or below CMS’s line, so this program did not cut its Medicare payments for the year. The score compares hospitals with each other; it is not a grade of the quality of care.

CMS cut scores of 0.3799 and above.

Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.

Higher than 31% of the other 2,928 scores CMS published (higher is worse).

Its record, fiscal years 2015 to 2026 Cut in 3 of 11 years

15Cut
16No
17No
18No
19No
20No
21No
22No
23—
24Cut
25Cut
26No

Where the score came from

CMS scored this hospital on 3 of the 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.

Bringing CDI down to the national median (0.346) would lower the score the most: by 0.3820, to −0.6958. Try it in the what-if

Figure 1. Of its 3 measures with a value, this hospital is above the national median on 1; CDI added the most to its score.

This hospital
National median
Scores the same as CMS’s floor or cap

PSI 90 (what it counts)
Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.
Patient safety and adverse events composite
Better than 68% of the other 2,808 hospitals
estimate

This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates

CMS value0.9156

Z-score−0.5087

Part of score−0.1696
CLABSI (what it counts)
Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Central line–associated bloodstream infections
Not scored on this measure
CMS footnote 13: Results cannot be calculated for this reporting period.
CMS footnote 5: Results are not available for this reporting period.

CMS valueno value published

Z-scoreno value published

Part of scoreno value published
CAUTI (what it counts)
Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Catheter-associated urinary tract infections
Not scored on this measure
CMS footnote 13: Results cannot be calculated for this reporting period.
CMS footnote 5: Results are not available for this reporting period.

CMS valueno value published

Z-scoreno value published

Part of scoreno value published
SSI (what it counts)
Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
Surgical site infections after colon surgery or abdominal hysterectomy
Better than 87% of the other 2,269 hospitals

CMS value0.000

Z-score−1.4565

Part of score−0.4855
CDI (what it counts)
C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
added the most
Clostridioides difficile (C. diff) infections
Worse than 84% of the other 2,766 hospitals
estimate

This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0071. How this site estimates

CMS value0.642

Z-score1.0237

Part of score+0.3412
MRSA (what it counts)
Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.
MRSA bloodstream infections
Not scored on this measure
CMS footnote 13: Results cannot be calculated for this reporting period.
CMS footnote 5: Results are not available for this reporting period.

CMS valueno value published

Z-scoreno value published

Part of scoreno value published

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Measure	CMS value	National median	Z-score	Part of the score	Among hospitals
PSI 90	0.9156	0.9623	−0.5087	−0.1696	Better than 68% of the other 2,808 hospitals
CLABSI	no value published	0.559	no value published	no value published	Not scored on this measure
CAUTI	no value published	0.489	no value published	no value published	Not scored on this measure
SSI	0.000	0.795	−1.4565	−0.4855	Better than 87% of the other 2,269 hospitals
CDI	0.642	0.346	1.0237	+0.3412	Worse than 84% of the other 2,766 hospitals
MRSA	no value published	0.641	no value published	no value published	Not scored on this measure

How the parts add up

CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 3; a bar right of zero raised the score and one left of zero lowered it.

(−0.5087PSI 90−1.4565SSI+1.0237CDI)÷3measures=−0.3138Total HAC Score

Added from the rounded z‑scores CMS published, the parts make −0.3138; CMS reports −0.3138. The small difference is rounding.

This hospital’s score is 0.6937 below 0.3799, the lowest score CMS marked Yes. (This site recomputes.)

Figure 2. The parts add up to −0.3138, below CMS’s line.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Measure	Z-score	Part of the score	Running total
PSI 90	−0.5087	−0.1696	−0.1696
SSI	−1.4565	−0.4855	−0.6551
CDI	1.0237	+0.3412	−0.3139
Total HAC Score			−0.3138
CMS’s line		0.3792	0.3799

The money is a cliff

This program’s cut doesn’t grow with the score. Over CMS’s line, CMS cuts 1% of what traditional Medicare pays a hospital for inpatient stays that year; at or under the line, this program cuts nothing.

The chart draws what the cut would be for this hospital at any Total HAC Score, from this site’s estimate of its payments, with its own score marked.

Figure 3. The cut is a cliff, not a slope: this hospital’s score, 0.6937 under the lowest score CMS cut, costs it nothing; 0.6937 higher, the cut would have been about $80K by this site’s estimate, the same as at CMS’s highest score, 2.3133.

Under the axis, every Total HAC Score CMS published: 306 of the 2,929 scored within 0.1 of CMS’s line, on one side or the other.

Estimate · Source: this site’s arithmetic on CMS’s FY2026 IPPS final rule files (the impact file, the rate tables and the value-based factors), its FY2026 HRRP supplemental file and HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Score	Total HAC Score	Estimated HAC cut (whole dollars)
Any score up to 0.3792	0.3792	$0
Any score from 0.3799	0.3799	−$80,113
This hospital	−0.3138	$0
CMS’s highest score	2.3133	−$80,113

The money, line by line

This site estimates what traditional Medicare pays the hospital for a year of inpatient stays, from CMS’s FY2026 payment files, then applies Medicare’s three hospital quality programs: the readmissions and value-based adjustments to the base payment, and the HAC cut last, as the law sets.

The readmissions and value-based programs adjust only the base payment: the DRG rates times the hospital’s cases, and a Medicare-dependent hospital’s add-on. The HAC cut comes last and takes 1% of everything left, teaching, low-income-patient, outlier, capital and uncompensated care payments included.

($8,038,071payment−$48,409readmissions+$21,592value-based)×1%the cut=$80,113at stake

$80,113at stake÷616traditional Medicare stays=$130per traditional Medicare stay

Figure 4. No HAC cut this year; 1% of the hospital’s whole inpatient payment would have been about $80K by this site’s estimate. The readmissions and value-based adjustments, on the base alone, came to −$48K and +$22K.

Estimated Medicare inpatient payments · FY2026 estimate

What traditional Medicare pays it for inpatient stays
DRG payments at the federal rates the base	$5,695,133
Many low-income patients (disproportionate share)	$119,313
Low-volume adjustment	$878,654
Capital: buildings and equipment	$442,535
Uncompensated care	$902,436
Total, before the three programs	$8,038,071
The three programs: two on the base, the HAC cut last
Readmissions (HRRP) base × (0.9915 − 1)	−$48,409
Value-based purchasing (HVBP) base × (1.0038 − 1)	+$21,592
After these two	$8,011,254
HAC Reduction Program no cut; 1% would have been $80,113	$0
Net of the three programs likely −$34K to −$19K	−$26,817

Not paid to this hospital: a Medicare-dependent hospital add-on, teaching payments, outlier payments, and a sole community hospital rate difference.

Whole dollars, so every line adds up; the estimate is not that precise. Each likely range spans the middle 80% of the misses this site’s estimate made for similar hospitals (or for a wider group, where there were too few) when it was checked against their FY2024 cost reports: one year’s check, not a promise of how often a hospital’s actual figure lands inside.

Show table

Line	Amount (whole dollars)
DRG payments at the federal rates (the base)	$5,695,133
Many low-income patients (disproportionate share)	$119,313
Low-volume adjustment	$878,654
Capital: buildings and equipment	$442,535
Uncompensated care	$902,436
Total, before the three programs	$8,038,071
Readmissions (HRRP) (base × (0.9915 − 1))	−$48,409
Value-based purchasing (HVBP) (base × (1.0038 − 1))	+$21,592
After these two	$8,011,254
HAC Reduction Program (no cut; 1% would have been $80,113)	$0
Net of the three programs (likely −$34K to −$19K)	−$26,817

What if a measure were different?

Change a measure’s value to see how this site recomputes the Total HAC Score, the payment reduction decision and, by its estimate, the money, starting from CMS’s values. The money doesn’t slide with the score: it drops off a cliff at CMS’s line.

The what-if needs JavaScript. Without it, the values below stay as they are.

Show table

	CMS reports	Hypothetical
Total HAC Score	−0.3138	same
Payment reduction decision	No	same
Payment cut	0%	same
Estimated HAC cut estimate	$0	same

CMS’s line: between 0.3792 and 0.3799

The faint ticks are CMS’s line in earlier years under the same formula, from about 0.300 (FY2022) to about 0.375 (FY2024). The line moves every year, so a hospital can cross it without changing anything.

CMS reports a Total HAC Score of −0.3138 and a payment reduction decision of No.

A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.

How much cushion?

Staying at or under CMS’s line keeps about $80K out of this program’s cut, this site estimates: a score a hair over would cost all of it.

From CMS’s values, one measure at a time, with every other measure held at CMS’s value.

Measure	Highest value that keeps No
PSI 90	up to 1.2133
SSI	up to 1.213
CDI	any value: every CDI value past the cap (0.944) scores the same

Each measure weighs 1 ÷ 3 of the score.

Measure values

SIR 1.0 = as many infections as predicted · Lower is better

On each track the tick is the national median; shaded values score the same as the floor or cap, as this site fits them to CMS’s values.

Patient safety and adverse events composite PSI 90

PSI 90 value

CMS 0.9156 · median 0.9623 · floor 0.7760 · cap 1.3482 · each 0.1 = 0.2327

Surgical site infections after colon surgery or abdominal hysterectomy SSI

SSI value

CMS 0.000 · median 0.795 · cap 2.118 · each 0.1 = 0.0571

Clostridioides difficile (C. diff) infections CDI

CDI value

CMS 0.642 · median 0.346 · cap 0.944 · each 0.1 = 0.1291

Have your NHSN predicted counts? (optional, stays in your browser)

Stays in your browser; never sent.

Optional: your NHSN predicted infections for SSI, January 1, 2023 to December 31, 2024

Optional: your NHSN predicted infections for CDI, January 1, 2023 to December 31, 2024

Figure 5. CDI added the most to this hospital’s Total HAC Score of −0.3138 among its measured results: +0.3412.

PSI 90 −0.1696
SSI −0.4855
CDI +0.3412

A measure adds its z‑score divided by 3, the number of measures scored. Bars right of the center line raise the score. Hatched: assigned by CMS.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Measure	Z-score	Part of the score	Hypothetical
PSI 90	−0.5087	−0.1696	same
SSI	−1.4565	−0.4855	same
CDI	1.0237	+0.3412	same

Interactive what-if at https://paidandpenalized.org/hacrp/hospital/150104/

Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.

Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.

Year by year

Where this hospital’s score fell among every hospital’s, each year CMS published one. A score near the top is among the highest; the shaded band is where CMS cut. Places compare across years even where CMS changed how it builds the score.

Its longest run: cut 2 years in a row.

Figure 6. CMS cut this hospital in 3 of the 11 years it made a decision.

● Red: a year CMS cut it ○ Hollow: a year it didn’t

This site recomputes · Source: CMS, HACRP hospital files for fiscal years 2015 to 2026 (Provider Data Catalog, its archives and, for the oldest years, the Internet Archive’s copies), and CMS’s cut lists for FY2015 and FY2016.

Show table

Fiscal year	Total HAC Score	Higher than this share of scores	Payment reduction
FY2015	8.0000	88.5%	cut
FY2016	4.0000	22.1%	not cut
FY2017	3.8500	23.0%	not cut
FY2018	−0.6296	16.0%	not cut
FY2019	−1.5668	2.7%	not cut
FY2020	−0.9070	8.4%	not cut
FY2021	−0.5309	18.4%	not cut
FY2022	−0.5401	18.0%	not cut
FY2023			no decision
FY2024	0.6809	86.0%	cut
FY2025	0.5209	82.1%	cut
FY2026	−0.3138	31.4%	not cut

Its infections, year by year

This hospital’s infection rate against prediction for each calendar year Care Compare published one, on each measure with at least two years of results (black), over the nation’s middle hospital (gray). Below the dashed line at one, fewer infections than predicted. Each year is measured against the same fixed baseline, not against other hospitals, so unlike the score they can all improve at once.

Figure 7. 0 of its 1 infection measures ended lower than they started.

Source: CMS Care Compare, healthcare-associated infections by hospital, calendar years 2017 to 2024 (Provider Data Catalog archives; the oldest year through the Internet Archive’s copy).

Show table

Calendar year	C. diff
2017	0.000
2018	0.353
2019	0.341
2021	0.000
2022	1.094
2023	0.755
2024	0.523

Among hospitals like it

Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.

In Indiana, its score is higher than 34% of the other 79 scored there.

In Indianapolis-Carmel-Greenwood, IN area, its score is higher than 39% of the other 23 scored there.

Figure 8. Its score is below the middle in all 8 groups it belongs to; the share cut runs from 13% (Indiana) to 35% (Government).

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Group	With a decision	Hospitals cut	Share cut	Middle score	Hospital higher than
All hospitals	2,886	718	25%	−0.0453	31%
Midwest region	683	174	25%	−0.0268	29%
Indiana	80	10	13%	−0.1841	34%
Indianapolis-Carmel-Greenwood, IN area	24	3	13%	−0.1841	39%
Not teaching	1,563	389	25%	−0.1053	36%
Fewer than 100 beds	805	225	28%	−0.1154	38%
Government	401	140	35%	0.1602	23%
Urban	2,241	510	23%	−0.0574	31%
This hospital				−0.3138
CMS’s line				0.3792	0.3799

The nearest hospitals

The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.

Figure 9. CMS cut none of the 8 nearest hospitals; the closest is 14 miles away.

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table

Hospital	Miles	Score	Decision
Orthoindy Hospital, Indianapolis, IN	14	−1.1355	not cut
Ascension St Vincent Hospital, Indianapolis, IN	17	−0.0480	not cut
Indiana University Health North Hospital, Carmel, IN	17	−0.2277	not cut
Franciscan Health Orthopedic Hospital Carmel, Carmel, IN	17	−0.4321	not cut
Ascension St Vincent Carmel, Carmel, IN	17	−0.1839	not cut
St Vincent Heart Center, Carmel, IN	18	0.3776	not cut
IU Health West Hospital, Avon, IN	19	0.0266	not cut
Hendricks Regional Health, Danville, IN	20	−0.3589	not cut

#	Hospital	Miles	Score	Decision	Est. cut ($, modeled)	Measures
1	Orthoindy HospitalIndianapolis, IN	14	−1.1355	No cut	$0	Above the national median on 0 of 1 measures
2	Ascension St Vincent HospitalIndianapolis, IN	17	−0.0480	No cut	$0	Above the national median on 3 of 6 measures
3	Indiana University Health North HospitalCarmel, IN	17	−0.2277	No cut	$0	Above the national median on 4 of 6 measures
4	Franciscan Health Orthopedic Hospital CarmelCarmel, IN	17	−0.4321	No cut	$0	Above the national median on 0 of 1 measures
5	Ascension St Vincent CarmelCarmel, IN	17	−0.1839	No cut	$0	Above the national median on 2 of 5 measures
6	St Vincent Heart CenterCarmel, IN	18	0.3776	No cut	$0	Above the national median on 3 of 4 measures
7	IU Health West HospitalAvon, IN	19	0.0266	No cut	$0	Above the national median on 2 of 6 measures
8	Hendricks Regional HealthDanville, IN	20	−0.3589	No cut	$0	Above the national median on 2 of 6 measures

Download all hospitals’ data (CSV) · Data dictionary · CMS’s dataset page

CMS’s footnotes on this page

13: Results cannot be calculated for this reporting period.
5: Results are not available for this reporting period.

How the program works, and how to find another hospital

A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.

Cite this page

Paid & Penalized. Witham Health Services, Lebanon, IN: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/150104/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.