By Ted Clifford
A report from the independent monitor tasked with supervising Mission Hospital has found two areas of “potential noncompliance” with the agreement HCA Healthcare signed when buying the hospital in 2019.
The potential violations were a warning from federal regulators in October 2025 that Mission stood to lose Medicaid and Medicare funding due to threats to patient safety, and what the monitor said was the hospital’s decision to discontinue and “degrade” services, including the emergency and oncology departments, certain pediatric subspecialties and industrial rehabilitation.
This report comes at a critical time for Mission Hospital. The hospital is not currently in “good standing” with the federal Centers for Medicare and Medicaid Services and is currently under an “Enhanced Plan of Correction” following repeated failures to address system threats to patient safety. Mission had until Sunday, July 26, 2026, to demonstrate that it is in substantial compliance with the Enhanced Plan of Correction in order to prevent its termination from Medicare and Medicaid programs.
The Asheville Watchdog reached out to Mission Hospital for comment on the report’s findings.
The hospital also faces a battery of lawsuits, most significantly one from the North Carolina Attorney General’s Office. It alleges that Mission and Nashville-based HCA have not lived up to the conditions of the Asset Purchase Agreement, which for-profit HCA signed before taking over the formerly nonprofit hospital.
Among the 15 commitments made as part of the agreement were requirements that Mission Hospital maintain a certain level of service and continue to provide charity care. It also established an oversight role occupied by Dogwood Health Trust, a nonprofit created with the $1.5 billion proceeds of the sale of Mission with a mission to improve and expand access to health care in Western North Carolina.
Enforcement options are limited
The report, prepared by Affiliated Monitors, was released Friday by Dogwood Health Trust. It accompanied a letter from Dogwood to the North Carolina Attorney General’s Office describing the areas of potential noncompliance.
Enforcement of the Asset Purchase Agreement falls to the state Attorney General’s Office. However, their tools are ultimately limited to filing a lawsuit in order to obtain a court ruling that would force Mission and HCA to abide by the agreement.
The Attorney General currently has a lawsuit (originally brought by now-Gov. Josh Stein in December 2023) against Mission and HCA. The lawsuit focuses on claims that Mission reduced the levels of services in its emergency and oncology departments to the extent that they were virtually nonexistent.
In their report, Affiliated noted that while they would defer to the court on the questions of law, “the factual issues at the heart of this litigation remain essentially unchanged.”
In community meetings earlier this year, representatives of Affiliated called it unusual for a hospital to remain out of compliance with the same issues for several years in a row.
In their report, Affiliated noted that certain, unspecified pediatric subspecialties along with industrial rehabilitation services had declined at Mission, despite being required services under the purchase agreement.
“We remain hopeful that HCA Healthcare will engage in further dialogue to explain the issues leading to the service reduction noted. If such a dialogue does not resolve those concerns, or does not occur, we recommend that further action be taken to seek specific performance of the APA,” the monitors wrote.
While Dogwood noted that Mission had taken efforts to restore its good standing with federal regulators in 2025, the organization said it would “be remiss not to state” that in January of this year Mission received its fourth Immediate Jeopardy warning from CMS.
Immediate Jeopardy is one of the most severe sanctions that can be handed down by the federal Centers for Medicare and Medicaid Services. It warns that a facility is in danger of losing Medicare and Medicaid reimbursements because noncompliance with federal standards has threatened patient safety.
But assuming Mission returns to good standing following the July 26 deadline when the Enhanced Plan of Correction expires, Affiliated recommended that no corrective action be taken.
“While we do not minimize the challenges facing Mission Hospital, it is important to realize that the overwhelming majority of those who staff the hospital remain singularly focused on providing the best medical care possible to those they encounter, sometimes under the most challenging of circumstances,” said Gerald Coyne, co-lead of the team from Affiliated Monitors reviewing Mission.
Difficulty obtaining records from Mission
In their report Coyne did note that in 2025 Mission was no longer out of compliance with regulations around providing charity care. Mission, the report said, also committed to participate in the Healthcare Access and Stabilization Program, which provides additional funding through CMS to help close the gap in reimbursement between Medicare and commercial insurance. The aim of the program is to help stabilize so-called safety net hospitals, but it also requires those hospitals agree to conditions like forgiving medical debt, capping payment plans and providing financial assistance to low-income patients.
Earlier this year, the monitors described their difficulty in obtaining the records from Mission that they needed in order to perform their review. During the time Affiliated was conducting its 2025 review, Mission asserted that certain records were privileged or proprietary, said Coyne, a former Rhode Island deputy attorney general.
“They have the right to do that,” Coyne said at the time. But, he added, “there’s other areas where they have just declined to produce it. So far, we have found ways to work around it, because we are not going to allow that to frustrate the process.”
In a statement at the time, HCA spokesperson Nancy Lindell said that Mission had provided all documents requested by the independent monitor.
“This report is similar to previous reports in that it cites multiple areas of potential non-compliance with the Agreement, namely the issues under litigation and the hospital again being cited for Immediate Jeopardy in 2025 (and 2026). Those failures are, for most of us, old news,” Julie Mayfield, a leader of the Reclaim Healthcare WNC activist group and a state senator representing Asheville and much of Buncombe County, said.
“What was new,” Mayfield said, “was discussion about dramatic drops in utilization of other services provided, which the IM suspects might be due to an effective discontinuation of those services. That HCA would not share information with the IM either at all or that can be made public shows its ongoing lack of transparency. HCA knows that the IM prepares this annual report, and its continued failure to share sufficient information for the IM to inform the public about compliance is inexcusable. But to be expected from a company that is interested mainly in its stock price rather than having a positive relationship with the community it serves.”
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Ted Clifford is The Watchdog’s investigative reporter focusing on healthcare. He can be reached at tclifford@avlwatchdog.org. The Watchdog’s local reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.
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