CMS found Mission Hospital in Asheville, N.C., to be operating in “substantial compliance” with agency requirements following a July 9 validation and complaint survey, according to an Aug. 3 CMS notice reviewed by Becker’s.
Six things to know:
1. In an Aug. 3 notice addressed to hospital CEO Greg Lowe, CMS said a federal survey team concluded a validation and complaint survey on July 9 and found the hospital in substantial compliance with Medicare conditions of participation, though standard-level deficiencies were identified. Based on those findings, CMS rescinded its termination action against the hospital and restored its deemed status.
2. Mr. Lowe informed staff the hospital was found to be operating in substantial compliance in an internal Aug. 4 email shared with Becker’s, and said CMS requires no additional surveys related to the January 2026 survey.
3. A CMS spokesperson confirmed to Becker’s the hospital has achieved “substantial compliance” with Medicare conditions of participation.
“CMS is continuing to engage with the hospital and is monitoring its ongoing implementation of the Enhanced Plan of Correction,” the spokesperson said.
4. In January, Mission Hospital, part of Nashville, Tenn.-based HCA Healthcare, was placed in immediate jeopardy in January for the fourth time since 2019. A CMS survey concluded Jan. 9 found the hospital out of compliance with Medicare conditions of participation, including requirements regarding nursing services, infection prevention and control, and patient rights, and that the noncompliance posed immediate jeopardy to patients’ health and safety. CMS extended the hospital’s termination date to July 26 to give it time to achieve substantial compliance, and the hospital’s enhanced plan of correction was approved Jan. 29. Regulators later lifted the immediate jeopardy status, but the hospital remained under enhanced monitoring and out of compliance with Medicare conditions of participation in the months that followed.
5. While not required by CMS, Mission Hospital will continue to be supported by Bryant Healthcare Consultants through the end of 2026, Mr. Lowe said. The hospital retained the firm Feb. 2 to help implement its enhanced plan, including conducting a root cause analysis and establishing monitoring systems to track the hospital’s progress, according to the plan document.
6. The changes are improving patient care and experience while helping teams work more effectively, Mr. Lowe said in the Aug. 4 email.
“While we should take pride in reaching this milestone, our work is not finished,” he said. “Our responsibility is to sustain this progress and continue raising the standard for the care we deliver. We will continue the efforts that brought us here including the daily operational reviews, enhanced staff training, additional leadership and Environment of Care rounding, more responsive feedback mechanisms such as our 24/7 Patient Care Line and our Excellence ALWAYS commitments.”
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