From Staff Reports

ASHEVILLE, N.C. — “Immediate jeopardy” at Mission Hospital has been removed, “but persisting issues have prompted the Centers for Medicare and Medicaid Services to set a new deadline by which the hospital must achieve compliance,” the Asheville Citizen Times reported on March 6.

“If it does not meet the deadline, the hospital could have its Medicare provider agreement terminated,” the ACT added. 

“In a Feb. 27 letter to Mission Hospital CEO Greg Lowe, CMS officials indicated that the ‘immediate jeopardy’ status placed on the hospital in late January had been removed Feb. 13. However, the hospital remained noncompliant with Medicare conditions of participation in the areas of patient rights, nursing services and infection prevention and antibiotic stewardship programs.”

Regarding “immediate jeopardy,” the ACT noted that it “is among the most severe federal citations that can be placed against a hospital. Mission Hospital is Western North Carolina’s only Level I trauma center, the highest recognition a trauma provider can receive in the United States.

CMS Division of Atlanta Survey and Enforcement Branch Manager Jill Jones wrote that, if the hospital does not achieve “substantial compliance” with CMS requirements by July 26, the provider agreement “may be terminated,” 

The ACT added that “the termination of the hospital’s provider agreement could lead to a disastrous loss of Medicare funding for the region’s largest hospital.

“The January ‘immediate jeopardy’ citation came after North Carolina Department of Health and Human Services inspectors identified issues with patient care related to two deaths, a measles exposure and an incident when a nurse was choked by a patient in Mission’s ‘Blue Pod’ behavioral health unit were found at the hospital, among other issues.

“It was at least the fourth immediate jeopardy citation at Mission Hospital since 2019, when the Nashville-based HCA Healthcare bought the hospital. Critics of the hospital’s management, including local lawmakers, union nurses and regional health professionals, have frequently said that unsafe staffing levels have significantly contributed to the immediate jeopardy citations.”

Jones also wrote in her Feb. 27 letter the following:

“In addition, if there are new allegations of non-compliance, CMS retains the authority to investigate those concerns. Any additional deficiency findings must be incorporated into the ongoing EPoC and corrected to ensure that there is sustained compliance with the Medicare Conditions of Participation.”

Meanwhile, Lowe wrote in an March 4 email to Mission Health staff obtained by the ACT that the hospital has been “working diligently to strengthen our patient safety and quality programs. The effort has included Mission welcoming “several of HCA Healthcare’s most experienced clinical and quality leaders to support us in the months ahead.”

The January “immediate jeopardy” citation led CMS to require the hospital to submit an enhanced plan of correction, which was approved on Jan. 29, CMS confirmed.

“CMS has approved the hospital’s enhanced plan of correction and will continue to closely monitor the facility’s progress, including conducting additional oversight activities to ensure sustained compliance,” the ACT noted.