ASHEVILLE, N.C. (828newsNOW) — A new annual review of HCA Healthcare’s compliance with its obligations under the agreement that governed its purchase of Mission Health has identified two potential areas of non-compliance, according to Dogwood Health Trust and the independent monitor overseeing the process.

Dogwood released the independent monitor’s 2025 compliance report and a letter sent to the North Carolina Attorney General’s Office outlining the concerns identified during the seventh annual review of HCA’s obligations under the Asset Purchase Agreement, the agreement that transferred ownership of Mission Health System to HCA in 2019.

The findings do not represent a final determination that HCA violated the agreement. Instead, they identify areas where the independent monitor found potential compliance concerns that will move through the review and enforcement process outlined in the agreement.

What HCA agreed to when it bought Mission Health

When HCA Healthcare purchased Mission Health System for $1.5 billion in 2019, the company agreed to 15 major commitments designed to maintain health care services and operations across Western North Carolina.

Those commitments included requirements to maintain certain services, continue operations at Mission facilities, meet charity care obligations, maintain quality and safety standards and remain in compliance with Medicare and Medicaid requirements.

Dogwood Health Trust was established as part of the Mission Health sale transaction and is responsible for monitoring HCA’s compliance with those commitments. Affiliated Monitors Inc. became the independent monitor in 2024 and conducts annual reviews of HCA’s performance.

The independent monitor reviews HCA’s compliance with the broader set of commitments outlined in the agreement. As part of that process, the monitor reviews information provided by HCA, examines supporting documentation, gathers input from community members and conducts other reviews before issuing its annual report.

The 2025 report identified two areas requiring further review.

Two potential compliance concerns identified

The 2025 report identifies two areas of potential non-compliance involving Sections 7.13(a) and 7.13(h) of the Asset Purchase Agreement.

The first concern involves HCA’s obligation to continue certain health care services included in the agreement.

The independent monitor’s report cites concerns about the discontinuation of industrial rehabilitation services at CarePartners and concerns about access to certain services at Mission Hospital, Mission Children’s Hospital Reuter Outpatient Center and CarePartners.

The report also references concerns involving emergency and trauma services and oncology services. Those issues are already part of a separate legal challenge filed by the North Carolina Attorney General’s Office in North Carolina Business Court.

Medicare and Medicaid concerns

The second potential compliance issue involves HCA’s obligation to remain “enrolled and in good standing” with Medicare and Medicaid.

According to the report, Mission Hospital received a 23-day notice of termination of its Medicare and Medicaid provider agreement from the Centers for Medicare & Medicaid Services on Oct. 17, 2025.

Mission submitted a revised corrective action plan addressing CMS concerns, and CMS approved an Enhanced Plan of Correction. Mission has continued working under that plan and had until July 26, 2026, to complete implementation.

Dogwood noted that although HCA took steps to return Mission to good standing with CMS, Mission Hospital received another Immediate Jeopardy finding from CMS in January 2026. That finding was later lifted, but federal oversight has continued through the Enhanced Plan of Correction.

Dogwood continues monitoring

Rachel Ryan, general counsel for Dogwood Health Trust, said the annual review focuses on HCA’s compliance during the previous calendar year and considers ongoing issues that could affect future reports.

“The Asset Purchase Agreement guides our monitoring and assessment process, directing us to conduct an annual review of HCA’s compliance with the APA for the previous year,” Ryan said.

Ryan said Dogwood continues to monitor issues in real time and is engaged in discussions with HCA and the Attorney General’s Office.

Gerald Coyne with Affiliated Monitors said the organization understands the concerns many Western North Carolina residents have raised about healthcare access while also recognizing the work being done by Mission employees.

“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,” Coyne said.

Coyne encouraged residents to continue sharing their experiences and concerns with the independent monitor, saying community feedback remains an important part of the review process.

What happens next

The next steps are outlined in the Asset Purchase Agreement.

After receiving Dogwood’s notice, the Attorney General’s Office has 30 days to notify Dogwood if it believes Dogwood has not adequately exercised its enforcement rights under the agreement.

Dogwood must then issue a formal notice of potential non-compliance to HCA by Oct. 28 under the process outlined in the Asset Purchase Agreement.

Throughout the process, Dogwood said it will continue working with HCA to address the concerns identified in the report and seek resolution.

Public Q&A planned

Dogwood Health Trust and the Independent Monitor will host a public Q&A webinar from 9 to 10 a.m. Aug. 4 to discuss the findings, explain the Asset Purchase Agreement and answer questions from residents.

Community members can also submit feedback directly to the Independent Monitor as part of the ongoing compliance review process.

The full compliance report, Dogwood’s letter to the Attorney General’s Office and additional information about HCA’s 15 commitments are available through Dogwood Health Trust.