Mission Hospital meets federal deadline for submitting plan to correct immediate jeopardy

Mitchell Black, Asheville Citizen Times
Updated ·4 min read

ASHEVILLE – Mission Hospital submitted a plan to correct serious deficiencies identified by the Centers for Medicare and Medicaid Services, meeting a critical deadline provided by the federal government.

Mission Hospital spokesperson Nancy Lindell told the Citizen Times in a Feb. 7 statement that the hospital met the deadline.

CMS informed Mission Hospital Chief Executive Officer Chad Patrick that conditions at the hospital created an “immediate jeopardy” situation in a Feb. 1 letter. It is the most serious deficiency regulators can assign.

More: NC investigators cite 9 'Immediate Jeopardy' incidents at Mission Hospital

Mission Hospital met the federal government's deadline for submitting its "Plan of Correction" to remediate immediate jeopardy conditions at the hospital.
Mission Hospital met the federal government's deadline for submitting its "Plan of Correction" to remediate immediate jeopardy conditions at the hospital.

According to the federal government, Mission is not in compliance with regulations regarding its governing body, patients’ rights, quality assessment and performance improvement, nursing, laboratory and emergency services. The North Carolina Department of Health and Human Services identified these deficiencies in a Dec. 9 survey.

CMS required Mission to submit a plan for correcting the specific deficiencies cited in the report by Feb. 6, known as a “Plan of Correction.” According to the letter to Patrick, an acceptable plan must include:

  • The plan of correcting the specific deficiencies cited. The plan should address the processes that led to the deficiencies cited;

  • The procedure for implementing the acceptable PoC for the specific deficiencies cited;

  • The monitoring and tracking procedure to ensure that the PoC is effective, that specific deficiencies cited remains corrected, and that the hospital maintains its compliance with the regulatory requirements;

  • The title of the person responsible for implementing the acceptable PoC; and

  • A completion date for correction of each deficiency cited.

Submitting the Plan of Corrections is the first step to Mission avoiding the federal government canceling its Medicare and Medicaid reimbursements.

Mission Hospital CEO Chad Patrick.
Mission Hospital CEO Chad Patrick.

"You may avert the termination by removing the immediate jeopardy conditions or coming into compliance with the hospital Conditions of Participation within 23 days from the date of this notice," the letter read. "In order to do so you must submit a Plan of Correction (PoC) by no later than 5 days from the date of this notice."

HCA Healthcare, a Nashville-based for-profit company, bought the Mission Health system in 2019 for $1.5 billion.

Medicare-certified providers like Mission are required to provide detailed reports to federal contractors. These reports are known as Medicare Cost Reports. HCA has made $177.3 million and $60.8 million in Medicaid and Medicare operating profits respectively between taking over Mission in 2019 and September 2022, according to the National Academy for State Health Policy, which analyzes some of the data in these reports. This is the most recent data available.

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Mission submitting the Plan of Correction to CMS initiated a multi-step process to ensuring the hospital has the opportunity to come into compliance with federal regulations, according to a Feb. 7 email from a CMS spokesperson.

If the federal government accepts the Plan of Correction, NCDHHS will survey the hospital again to evaluate whether the hospital removed the “immediate jeopardy” condition and is back in compliance with federal regulations, according to the letter to Patrick.

NCDHHS spokesperson Charles Epstein told the Citizen Times Feb. 6 that a report detailing the findings of the December survey will be available either March 3, or after the federal government receives an acceptable plan of correction, whatever comes first.

During a Feb. 6 news conference to discuss the immediate jeopardy conditions, State Sen. Julie Mayfield expressed her dismay that the public is in the dark about the findings of the report. She explained that NCDHHS is effectively a contractor for the federal government and cannot submit reports without CMS' blessing.

State Sen. Julie Mayfield speaks at a press conference after the federal government declared that conditions at Mission Hospital create an “immediate jeopardy” situation, the most serious deficiency regulators can assign.
State Sen. Julie Mayfield speaks at a press conference after the federal government declared that conditions at Mission Hospital create an “immediate jeopardy” situation, the most serious deficiency regulators can assign.

"We will continue to put pressure on both DHHS and CMS to release all of the documents going forward," Mayfield said at the news conference, referring to a community coalition of physicians, clergy members and elected officials working to improve health care in Western North Carolina.

Mayfield said that the group would comb through the Plan of Correction once they receive it because "the people of this community will be able to look at that plan and know whether it is band-aid or whether it is going to fix the problems."

More: Mission Hospital to implement new ambulance patient handoff policy. HCA gives no details.

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Mitchell Black covers Buncombe County and health care for the Citizen Times. Email him at mblack@citizentimes.com or follow him on Twitter @MitchABlack. Please help support local journalism with a subscription to the Citizen Times.

This article originally appeared on Asheville Citizen Times: Mission Hospital files 'Plan of Correction' to fix immediate jeopardy