The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX 79902 Aug. 21, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility documents, facility tour, and staff interviews, the hospital's governing body failed to effectively exercise its oversight responsibilities on the overall operation of the hospital by failing to ensure that the contracted services of the pharmacy permitted the hospital to comply with all applicable conditions of participation and standards.

Findings were:

Based on a review of facility documents, facility tour, and staff interviews, the hospital's governing body failed to effectively exercise its oversight responsibilities of the contracted services of the facility pharmacy. Cross refer: A0083.

The above findings were confirmed in an interview with the facility CEO and Chief Nursing Officer the afternoon of 8/21/13 in the facility break area.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on a review of facility documents, facility tour, and staff interviews, the hospital's governing body failed to effectively exercise its oversight responsibilities of the contracted services of the facility pharmacy.

Findings were:

Based on observation, review of facility documents and staff interviews, the facility failed to have pharmaceutical services that met the needs of the patients as patients were discharged without being provided with their own home medications brought into the facility with them. Cross refer: A0490.

Based on observations, facility documentation and staff interviews, the facility failed to ensure adequate accountability procedures to ensure control of the distribution, use and disposition of all scheduled drugs as the facility's record system did not adequately track the movement of all scheduled drugs from the point of entry into the hospital to the point of departure in a readily retrievable manner, and thus failed to minimize the risk for scheduled drug diversion. Cross refer: A0494.

Review of facility contracts revealed a contract between Comprehensive Pharmacy Services, Inc. and Universal Health Services of Delaware, Inc., the owner of University Behavioral Health, to provide pharmacy services to the facility. In addition, UBH contracts included a current contract with EXP Pharmaceutical Corporation (EXP) for reverse distribution of pharmaceuticals.

The above findings were confirmed in an interview with the facility CEO and Chief Nursing Officer the afternoon of 8/21/13 in the facility break area.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on observation, review of facility documents and staff interviews, the facility failed to have pharmaceutical services administered in accordance with accepted standards of practice as patients' own home medications brought into the facility with them upon admission were not returned to them upon discharge. In addition, the facility failed to accurately track movement of all scheduled drugs from the point of entry into the hospital to the point of disposition in a readily retrievable manner, thereby increasing the potential for scheduled drug diversion within the facility. Past citations in the area of pharmaceutical services at this facility make these findings of increased concern.

Findings were:

Based on observation, review of documents and staff interviews, the facility failed to accurately track movement of all scheduled drugs from the point of entry into the hospital to the point of disposition in a readily retrievable manner, thereby increasing the potential for scheduled drug diversion within the facility. Cross refer: A0494.

Based on observation, review of facility documents and staff interviews, the facility failed to return medications to patients upon discharge who had brought home medications into the facility at the time of admission for 45 of 45 patients [patients #4-48].

A tour of the facility pharmacy revealed a locked metal cabinet at the back of the pharmacy containing patient home medications. This cabinet had five shelves. The top three shelves contained 21 individual plastic containers, each of which was labeled with a different patient name. Staff #3 identified these as controlled home medications of current patients at the facility. On the middle shelf was a closed plastic container containing medications which she said were controlled medications of approximately five discharged patients that were to be picked up by EXP Pharmaceutical Services Corp. for destruction. The bottom shelf contained a plastic container with six alphabetic divisions, each of which contained assorted medication bottles which staff #3 identified as controlled home medications of patients who had been discharged .

A review of the facility current patient census revealed 7 of the 21 patients identified as current patients with controlled medications on the top shelves had been discharged [patients #17-23]. Dates of discharge for these patients ranged from 7/23/13 to 8/19/13.

The assorted medications bottles in the container on the bottom shelf of the cabinet were for 13 discharged patients [patients #4-16]. Staff #3 was asked if other (i.e., non-controlled) medications remained at the facility for these patients. She stated that these patients did have non-controlled medications remaining in the pharmacy. Dates of discharge for these patients ranged from 5/10/13 to 7/25/13. Each patient's medications included, at a minimum, one controlled medication, and anywhere from 1 to 17 additional non-controlled medications left behind by the patient upon discharge.

In addition to the above mentioned patient medications, on a low shelf in the pharmacy were two plastic tubs containing 25 10"x13" envelopes, each identified with a different patient name printed at the top [patients #24-48]. Staff #3 stated these were all non-controlled medications of 25 patients who had been discharged . When asked if they were for the same patients who had medications in the metal cabinet, she stated, "These are other patients' meds."

A facility policy entitiled "Patient Home Medication Administration and Storage," dated 11/2008 and last revised 12/2012, stated in part, "UBH El Paso will utilize patient home medication(s) if/when necessary and will store medications safely for patient while they are admitted and make every reasonable effort to return the medication to patient upon discharge ... Patients who are discharged when the pharmacy is closed will have authorized medications returned to them as follows:

a. Medications will have to be obtained by the nursing supervisor and given to the patient or a representative ...If after pharmacy hours, nurse will notify Director of Pharmacy of patients discharge and arrangements will be made to get pharmacy staff into the pharmacy for controlled medications [facility's bold and underline] to be given to patient ...
Medications not returned to patients will be held for 30 days prior to destruction in accordance with DEA and state requirements. If the need arises, and it is possible, medications which were not picked up may be mailed to the patient ..."

The facility could not provide documented evidence of patient home medications being mailed to patients.

Facility policy entitled "Patient Home Medication Storage," last issued 11/2008 and available in the facility Policies and Procedures notebook, stated in part:

"3. The medications should be logged on the Patient Home Medications form and the sheet attached to the medications.

4. The medications and Patient Home Medications form should be placed in the designated locked cabinet in the back of the nurse's station."

The policy failed to include how patients' home medications brought to the hospital were suppose to be transferred to the pharmacy, thus, patients' home medications could be locked in the back of the nurse's station of the Care Center [admissions]. No mention is made in the policy of returning these home medications back to the patients upon discharge from the hospital.

Facility policy entitled "Discharge," last issued 11/2008, stated in part, "Check medication room [on the unit] for any personal equipment or medication to return ..." This indicates patient home medications may be stored in the medication room of the unit. No mention is made of returning patient home medications from the pharmacy prior to discharge.

Review of the facility form "Continuing Care Discharge Plan" had a section entitled "Medications." Under this section was a checkbox for "Return patient's own medications." In 11 of 11 medical records checked of patient bringing home medications into the facility upon admission [patients #1-11], this box was left blank. The areas for staff signatures on the form included the patient's case manager and nurse.

The above findings were confirmed in an interview with the facility CEO and Chief Nursing Officer the afternoon of 8/21/13 in the facility break area. These practice failed to ensure accountability of all controlled substance within the facility.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, facility documentation and staff interviews, the facility failed to ensure adequate record system was in place which could trace the movement of all scheduled drugs from the point of entry into the hospital to the point of disposition in a readily retrievable manner, and thus failed to minimize the risk for scheduled drug diversion.

Findings were:

Review of facility patient records revealed 1 of 13 patients [patient #5] who had brought home medications into the facility upon admission, did not have a listing of "Home Medications Brought into the Hospital by the Patient" form. A search by pharmacy staff could not locate the medication form, yet patient #5 had medications in the pharmacy. He had been discharged on [DATE]. This created a situation wherein the patient's medications had no inventory listing, thus creating a potential for diversion. The medical record of patient #5 contained a form entitled "Medication Orders and Reconciliation Form" completed on 7/1/13 at 8:10 a.m. by nursing staff upon his discharge. The form listed the patient's home medications the patient had brought into the facility and a column titled "Physician Order" for the medication with "Y=yes continue, N=No discontinue."

The "Medication Orders and Reconciliation Form" completed on 7/1/13 for patient #5 listed the following home medications brought into the facility by the patient upon admission:
Physician Orders
? Lipitor Yes to be continued
? Aricept Yes to be continued
? Lovaza Yes to be continued
? Zoloft Yes to be contined
? Vitamin D Yes to be continued
? Naprosyn Yes to be continued
? Prilosec Yes to be continued
? Ambien 10mg No not to be continued
? Xanax 0.25 mg No not to be continued
? Levemir Yes to be continued
? Novalog Yes to be continued

On 8/21/13, the facility pharmacy had the following home medications for patient #5 which had not been returned to him upon discharge:

? No generic or brand name Lipitor noted
? donepicil (generic Aricept), 5mg tabs
? Lovaza, 1000mg caps
? sertraline (generic Zoloft), 25 mg tabs
? sertraline (generic Zoloft), 50 mg tabs
? No Vitamin D noted
? No naprosyn noted
? omeprazole (generic Prilosec), 20 mg caps
? zolpidem (generic Ambien), 5 mg tabs
? No generic or brand name Xanax noted [a Schedule IV controlled substance]
? No Levemir noted
? Novalog flexpen insulin, 3 mL syringe

In addition, the following non-inventoried home medications were in the pharmacy and were labeled as patient #5's:

? Super B Complex Vitamins approximately 1/3 bottle of 250 tabs
? meclizine, 12.5 mg tabs

Further review of patient records revealed 3 of 13 patients [patients #6, 7, and 11] who had brought home medications into the facility upon admission revealed inconsistencies in pharmacy medication documentation, thus making the disposition of their medications unclear.

1. Review of the medical record of patient #11 revealed that he had brought 16 home medications with him into the facility upon admission on 5/2/13. He was discharged on [DATE]. The facility failed to show evidence that the patient received these medications back upon discharge from the facility. Patient #11's hydrocodone 10/325, quantity #9, was still at the facility on 8/21/13, date of this complaint survey. A facility pharmacy technician [staff #3] stated that the patient's other non-controlled medications had been sent for destruction. The facility could provide no documented evidence of the medications having been sent for destruction.

2. The same situation existed for patient #6. A review of his chart revealed he had brought 6 home medications with him into the facility upon admission on 6/19/13. He was discharged on [DATE]. The facility had no evidence that the patient received these medications back upon discharge from the facility. Patient #6's Ambien, 10mg, quantity #23, was still at the facility on 8/21/13, date of this complaint survey. Staff #3 stated the patient's other non-controlled medications had been sent for destruction. There was no evidence that the medications were sent for destruction.

3. Review of the medical record of patient #7 revealed that she brought baclofen, 10mg and lorazepam 1mg, quantity #5 (Schedule IV controlled medication) with her upon her admission on 6/30/13. She was discharged on [DATE]. These two medications were listed on the form entitled "Home Medications Brought into the Hospital by the Patient." Also on the form was the handwritten note "Returned to pt. upon discharge on 07/05/13." Following that were three signatures, including the patient and two witnesses. Yet on 8/21/13, date of the complaint survey, the facility pharmacy had a prescription bottle for patient #7 with #5 lorazepam 1mg tablets inside. Thus, the documentation of the status of the medication was inaccurate and created an opportunity for diversion of a scheduled medication.

The facility had a contract with a company to provide for the destruction of medications. Facility documentation on 8/13/13 of conveyance on that date of pharmaceuticals to the company providing destruction revealed that medications were listed by type, strength and quantity. The list entitled "Expired Patient Own Medications" of 8/13/13 included 37 different listings of controlled substances. The list did not include the name of the patient the medication had belonged to. The facility could provide no documentation of when a specific patient's medication was destroyed. This made tracking the movement of controlled substances to the point of destruction difficult, and increased the opportunity for diversion of scheduled medications.

The above findings were confirmed in an interview with the facility CEO and Chief Nursing Officer the afternoon of 8/21/13 in the facility break area.