CMS Finds Condition Level Violations Again at University Behavioral of El Paso; Recommends 90 Day Termination Proceeding

El Paso Behavioral Health System, formerly known as University Behavioral Health of El Paso, was found by the Centers for Medicare and Medicaid Services (CMS) as not complying with the conditions of participation in the Medicare program. CMS cited the facility for condition-level deficiencies related to the governing body and pharmaceutical services. The inspection report revealed the “hospital’s governing body failed to effectively exercise its oversight responsibilities on the overall operation of the hospital” and the contracted services of the pharmacy. Medicare conditions for participation require the hospital to have pharmaceutical services that meet the needs of all patients and must have a drug storage area under competent supervision. CMS found that the facility had failed to have “pharmaceutical services administered in accordance with accepted standards of practice” and did not have accountability procedures and processes for patients’ own home medications brought with them at admission to be returned upon discharge. Specifically, CMS found the facility failed to return medications to patients at discharge for 45 of 45 patients. In addition, the facility had failed to “accurately track movement of all scheduled drugs from the point of entry into the hospital to the point of disposition.” CMS wrote: “Past citations in the area of pharmaceutical services as this facility make these findings of increased concern.” In November 2012, CMS cited the facility for violations of conditions of Medicare participation for medication related issues. See the complaint here (link: In response to the condition-level deficiencies found during the inspection, CMS recommended a 90-day termination proceeding. CMS wrote:
“The deficiencies have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care and prevent it from being in compliance with all the applicable Medicare Conditions of Participation.”
The facility submitted a plan of correction to address these deficiencies.