CMS Removes Immediate Jeopardy, Gives Mission Hospital July Deadline to Comply

The Centers for Medicare & Medicaid Services removed the immediate jeopardy designation for Mission Hospital after a February survey, but a Feb. 27 CMS letter, filed under CCN 340002, says the Asheville hospital remains out of compliance on multiple Medicare conditions and must fix them by late July. The letter lists patient rights, nursing services and infection prevention and antibiotic stewardship among the outstanding areas the hospital must correct.

“Immediate Jeopardy, the most serious warning imposed by CMS for violations of health and safety regulations that endanger patients, was imposed in late January and lifted by the agency on Feb. 9, the statement said,” according to the CMS removal notice. The removal followed CMS approval of Mission’s Enhanced Plan of Correction on Jan. 29, a step Mission cited as part of its effort to resolve the federal findings.

The Feb. 27 letter to Mission Health CEO Greg Lowe gives the hospital until the end of July to reach “substantial compliance.” “Mission Hospital has until July 29 to comply, according to the letter,” the document states; separately, 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 letter warns that failure to meet the deadline could trigger termination of Mission’s Medicare provider agreement.

CMS and state surveyors identified contributing problems that fed the deficiencies. “In its initial report, CMS cited factors contributing to the deficiencies at Mission, including inadequate staffing, poor controls and insufficient follow-up to quality of care concerns,” the removal notice says. State inspection reports that preceded the federal action cited patient-safety incidents including two patient deaths, a measles exposure and an episode in which a nurse was choked by a patient in Mission’s behavioral health “Blue Pod.”

Mission Hospital is the region’s largest hospital and Western North Carolina’s only Level I trauma center, making the agency’s findings consequential for patients across Buncombe County and surrounding communities. With the immediate jeopardy designation lifted, Mission will continue to receive Medicare and Medicaid payments while it works to meet CMS requirements: “With the Immediate Jeopardy lifted, Mission will continue to be able to receive payments from Medicare and Medicaid, a crucial source of funding for the hospital,” the removal notice says.

Mission leadership told staff and the public it has mobilized outside help and internal action plans. “Since that time, we have been working diligently to strengthen our patient safety and quality programs. This work has included collaboration with experienced healthcare and quality consultants, as well as focused internal efforts to ensure meaningful and sustainable improvements,” Greg Lowe wrote in a March 4 press release. “Our teams already have action plans in place to address remaining items identified during the original survey,” Lowe added in an email.

Hospital spokeswoman Nancy Lindell did not respond to requests for comment on the CMS letter. The coming months will determine whether Mission implements the corrective actions CMS requires: if the hospital fails to reach substantial compliance by the July deadline, federal officials have warned the Medicare provider agreement for the hospital may be terminated, a step that would carry major financial consequences for Asheville’s primary trauma and acute-care center.