DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

CMS Atlanta, Survey & Operations Group
61 Forsyth Street, SW, Suite 4T20
Atlanta, Georgia 30303-8909

Ref: Memorial Mission Hospital and Asheville Surgery Center _ CCN 34-0002_90 Day Notice

IMPORTANT NOTICE – PLEASE READ CAREFULLY

SENT VIA INTERNET EMAIL TO: Chad.Patrick@HCAHealthcare.com
(Receipt of this notice is presumed to be March 14, 2024 – date notice e-mailed)

March 14, 2024

Mr. Chad Patrick, CEO

509 Biltmore Ave.
Asheville, NC 28801

RE: Mission Memorial Hospital and Asheville Surgery Center

CMS Certification Number (CCN): 34-0002
EMTALA Complaint Control Number: NC209495

Dear Mr. Patrick:

A hospital must meet the requirements established under Title XVIII of the Social Security Act
(the Act) and the regulations established by the Secretary of Health and Human Services under the
authority contained in section 1861(e) of the Act to participate in the Medicare program. Hospitals
with an emergency department also must meet the requirements of the Emergency Medical
Treatment & Labor Act (EMTALA) that are mandated and enforced through section 1867 of the
Act and Title 42 of Code of Federal Regulations (C.F.R.) at sections 489.20 and 489.24. Section
1866(b) of the Act authorizes the Secretary to terminate the Medicare provider agreement of a
hospital that fails to substantially comply with these provisions.

On November 27, 2023, the North Carolina State Agency concluded a survey at Memorial Mission
Hospital and Asheville Surgery Center based on a reported allegation of noncompliance with the
EMTALA requirements. The survey found that the hospital failed to comply with the following
requirements:

42 C.F.R. § 489.24(a) & 489.24(c): Medical Screening Exam (Tag 2406); and
42 C.F.R. § 489.20(l): Compliance with 489.24 (Tag 2400)

These deficiencies are further set out in the enclosed Form CMS-2567, Statement of Deficiencies.
Under 42 C.F.R. § 489.53, a hospital that violates the provisions of 42 C.F.R. § 489.24 is subject
to termination of its Medicare provider agreement. Consequently, unless Memorial Mission
Hospital and Asheville Surgery Center has achieved substantial compliance within 90 days
(June 5, 2024) of the date of this notice, the Medicare provider agreement between
Chad Patrick, CEO
Page 2

Memorial Mission Hospital and Asheville Surgery Center and the Secretary of the
Department of Health and Human Services may be terminated. This preliminary
determination letter serves to notify you of the EMTALA violation.

Memorial Mission Hospital and Asheville Surgery Center must submit an acceptable Plan of
Correction (PoC), or credible evidence that the deficiencies did not exist, to CMS and North
Carolina State Agency by no later than March 24, 2024, describing in detail the specific corrective
measures taken to resolve these deficiencies. If you do not submit a PoC, we will assume that the
deficiencies have not been corrected.

An acceptable PoC must contain the following elements:

1. The plan for correcting each deficiency cited;

2. The plan for improving the processes that led to each deficiency cited, including how the
hospital is addressing specific improvements in its systems in order to prevent the
recurrence of the deficient practice;
3. 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;
4. The title of the person responsible for implementing the acceptable PoC; and
5. A completion date for correction of each deficiency cited.

Copies of the Form CMS-2567, including copies containing the hospital’s PoC, are releasable to
the public in accordance with the provisions of Section 1864(a) of the Act and 42 C.F.R.
§ 401.133(a). As such, the PoC should not contain personal identifiers, such as patient names, and
you may wish to avoid the use of staff names. It must, however, be specific as to what corrective
action the hospital will take to achieve compliance, as indicated above.

Please send your PoC to the attention of William Sims at William.Sims@cms.hhs.gov and to Azzie
Conley at Azzie.Conley@dhhs.nc.gov.

If your PoC is accepted, the North Carolina State Agency will conduct a revisit survey to determine
whether the hospital is back in compliance with the EMTALA requirements. If CMS does not
receive a timely PoC or the revisit survey determines that the hospital continues to be in
noncompliance, CMS will send you a Notice of Termination at least 15 days prior to the projected
termination date of June 5, 2024, and provide the information on how to appeal the termination
decision to the Departmental Appeals Board. At the same time, CMS will publish a notice on the
CMS website to inform the public of the hospital’s termination from the Medicare program.

If you have any questions concerning this preliminary determination letter, please contact William
Sims in our CMS Atlanta at William.Sims@cms.hhs.gov.
Chad Patrick, CEO
Page 3

Sincerely,

Linda Smith
Director
Division of Atlanta Survey and Enforcement
Centers for Medicare and Medicaid Services

Enclosure: Form CMS-2567 Statement of Deficiencies

cc: ACTS # NC209495