University Behavioral Health of El Paso was cited by the Texas Department of State Health Services for violations related to the facility’s dietary services, governing body, and nursing services. State surveyors found that the facility failed to ensure its food and dietetic service requirements were met, as evidenced by failures in providing a current food license (which was expired for 12 days) and an up-to-date therapeutic dietary manual. The manual was last revised in 2006, which violated the facility’s policy of reviewing the diet manual annually.
State surveyors also faulted the facility’s governing body for failing to ensure its policies and regulations were properly implemented and enforced. A surveyor tour of the facility found that some specimen refrigerators contained patient urine samples that were not properly labeled. It was also found that the facility’s policies and procedures for handling controlled substance medications were inadequate, since patients’ personal prescriptions were not properly accounted for or secured. When the state surveyor requested to view the facility’s controlled substance policy, a policy could not be located and a new one was written that day.
The facility was also cited for failing to verify that five of its contracted, staffing agency nurses had valid and current licensure. The facility failed to obtain proof of licensure for these nurses prior to their working in the facility. An interview with the Chief Nursing Officer revealed that the facility did not have a procedure in place to monitor the current licensure of agency nurses.