After receiving its third immediate jeopardy designation in less than two years, Asheville, N.C.-based Mission Hospital has outlined a series of corrective actions — including reassessing the “capacity and competency” of its leadership and staff — as part of an enhanced plan of correction submitted to federal regulators.
Here are eight things to know:
1. Hospital leaders outlined several steps in the enhanced plan, including conducting a root cause analysis of care deficiencies and reviewing hospital operations, processes and outcomes to strengthen patient safety and compliance with Medicare Conditions of Participation, according to the enhanced plan of correction obtained by Becker’s.
2. The enhanced plan allows Mission Hospital to address survey findings and complete a comprehensive review of operations, processes and outcomes to ultimately create a sustainable framework that enhances patient safety and quality of care, a Mission Hospital spokesperson said in a March 16 statement shared with Becker’s.
“We are pleased that CMS accepted Mission’s proposed enhanced plan of correction on February 2, 2026, and, with the resources and support from our organization, we are executing it with urgency and discipline,” the spokesperson said. “As noted in the plan, we understand the responsibility we have for the health and safety of our community and the need for our patients to have confidence in their hospital.”
3. CMS placed Mission Hospital in immediate jeopardy in late January after regulators identified patient care and safety deficiencies tied to two patient deaths. Mission submitted its enhanced plan of correction following a Jan. 6-9 survey by state regulators, and CEO Greg Lowe told staff March 4 that CMS had lifted the immediate jeopardy designation.
4. The enhanced plan requires Mission to reevaluate the “capacity and competency” of its leaders and staff and commit the resources needed to ensure they can meet patient care standards, according to the document.
5. The hospital has until July 26 to implement the plan. Responsibility for carrying it out is assigned to the CEO, chief administrative officer, chief nursing officer and chief medical officer.
6. Mission Hospital retained Bryant Healthcare Consultants to help implement the plan as of Feb. 2. The firm will assist with developing processes and procedures, conducting a root cause analysis and establishing monitoring systems to track the hospital’s progress, according to the plan document.
“As part of our plan, we are partnering with an independent consulting firm that is highly respected in the healthcare industry for their comprehensive approach towards quality improvement,” the health system spokesperson said. “Today, Mission offers many industry-leading services to our community, but we recognize there is work to be done and we are determined to use this as an opportunity to improve.”
7. The hospital’s review of surveys conducted by the North Carolina Department of Health and Human Services and The Joint Commission since Jan. 1, 2025, identified six recurring themes affecting patient care:
- Leadership oversight and governance
- Staffing and staffing assignments
- Compliance with protocols, policies and procedures
- Emergency department safety and quality
- Quality outlier performance
- Patient and staff communication
8. The plan also outlines corrective steps tied to incidents cited in the survey findings, including one involving an 88-year-old orthopedic patient who died after not receiving a needed blood transfusion after hip surgery. Mission said it will improve its critical lab value notification process and provide additional staff education on transport and care coordination processes.
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