Inaccurate PBJ Reporting of Licensed Nursing Coverage
Summary
The facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This issue has the potential to affect all 11 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting, which triggered deficiencies for five fiscal year quarters due to the failure to have licensed nursing coverage 24 hours a day. The facility's policy on PBJ reporting involves pro-rating staff hours based on the number of beds and workload, which led to discrepancies in the reported data. The CMS PBJ Staffing Data Reports for fiscal year quarters 3 and 4 of 2023 and quarter 1 of 2024 indicated multiple days with less than 24 hours of licensed nursing coverage. Specific dates and the reported licensed nursing hours were provided, showing significant shortfalls on several days. Interviews with the Business Office Manager (BOM), Director of Nursing (DON), Payroll Coordinator, Rehabilitation Specialist, and Social Worker confirmed that there is always a licensed nurse on the unit, but the reported data did not reflect this due to the pro-rating method used. The BOM indicated that she uses an equation to divide the licensed nursing hours among the different licensed entities within the home, which results in the reported hours not accurately representing the actual coverage. The DON and other staff members confirmed that the unit is never left without a licensed nurse, but the data reported to CMS does not accurately reflect the 24-hour coverage due to the pro-rating of hours. This discrepancy in reporting has led to the facility being flagged for not having licensed nursing coverage 24 hours a day, despite the actual presence of licensed staff on the unit at all times.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not submit required direct care staffing data to CMS for a reporting period, as confirmed by review of PBJ Staffing Data and interviews with the CEO. The CEO indicated that a change of ownership and reliance on a contracted company contributed to the lack of submission, with no documentation available to verify that the data was sent. This affected all residents in the facility.
The facility did not accurately report direct care staffing data to CMS, as required, due to incorrect coding of a CNA's hours and lower weekend staffing levels. This resulted in the facility being flagged for low weekend staffing, potentially affecting all residents.
The facility did not submit required direct care staffing information to CMS for a full quarter, as shown by review of the PBJ Staffing Data Report. The Administrator confirmed the omission and stated that Human Resources was responsible for the submission, but it was not completed. This failure had the potential to affect all 68 residents in the facility.
The facility submitted inaccurate staffing data to CMS, as revealed by discrepancies between staffing sheets and time punches for several dates. The administrator identified missing time punches for former employees, which may have led to incomplete data submission. This issue was found during a complaint investigation.
The facility did not submit required staffing data for the fourth quarter of 2024 to the PBJ, affecting all residents with a census of 46. The review showed a one-star staffing rating, low weekend staffing, no RN hours, and lack of 24-hour licensed nursing coverage. The Administrator indicated that corporate handles submissions but had not provided proof of submission despite multiple requests.
The facility failed to submit complete and accurate staffing information to CMS, as the schedule did not specify which staff were assigned to the Assisted Living (AL) area. The SNF and AL used the same schedule, and the Administrator confirmed that the same staff cared for both areas, but this was not reflected in the schedule. One resident in the AL required minimal care, and the staff hours for the SNF did not include hours for this resident.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2025, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed that staffing data for the period from October 1st to December 31st, 2025, was not submitted, resulting in the facility receiving a one-star staff rating. During interviews, the Chief of Operation (CEO) confirmed there was no documented evidence that the required staffing data had been reported to CMS. The CEO explained that the facility underwent a change of ownership in December 2024, and it was the previous owner's responsibility to report the staffing data. The CEO also stated that the previous owner had sent the data to a contracted company, which was responsible for submitting it to CMS, but there was no documentation to confirm that this submission occurred. This deficiency had the potential to affect all 72 residents in the facility.
Inaccurate Reporting of Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing data to CMS, as required. Review of the Payroll Based Journal (PBJ) report, staff schedules, and interviews revealed that staffing data submitted for the period in question did not accurately reflect actual staffing levels. Specifically, a Certified Nurse Assistant (CNA) who also performed activities duties worked on the floor providing direct care, but her hours were not coded correctly in the data submitted to CMS. Additionally, on certain weekend night shifts, only one CNA was present along with two nurses, resulting in lower direct care hours compared to weekday averages. These discrepancies led to the facility triggering for excessively low weekend staffing in the PBJ report, potentially affecting all 31 residents in the facility. No concerns were identified from the provider regarding the average direct care hours, but the inaccurate reporting of staffing data constituted a deficiency in compliance with CMS requirements.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit required direct care staffing information to CMS for Quarter Four of 2024, as mandated by federal regulations. Review of the Payroll-Based Journal (PBJ) Staffing Data Report showed that the facility did not submit staffing data for the period of July 1 to September 30, 2024. During an interview, the Administrator confirmed that the data was not submitted and stated that Human Resources was responsible for the submission, but it was not completed. The Administrator was unable to provide a reason for the failure to submit the required data. The facility's policy indicated that staffing data should be collected and submitted monthly before the 15th of each month. This deficiency had the potential to affect all 68 residents in the facility, as reflected by the facility census.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accuracy of direct care staffing information submitted to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. During a review of the PBJ report for the fourth quarter of 2024, it was found that the facility had a one-star staff rating and excessively low weekend staffing. A detailed examination of staffing sheets and time punches revealed discrepancies on several dates, where the time punch detail report did not match the schedules. The administrator identified an issue with time punches of employees no longer working for the facility not appearing in the time punch detail. The administrator, who was not employed during the fourth quarter of 2024, indicated that the time punches submitted to corporate accountants were used for PBJ submission, and it was possible that some employee hours were not submitted. This deficiency was discovered incidentally during a complaint investigation.
Failure to Submit Staffing Data to PBJ
Penalty
Summary
The facility failed to submit the required staffing information for the fourth quarter of 2024 to the Payroll Based Journal (PBJ) data, which had the potential to affect all residents, with a census of 46. A review of the PBJ staffing report for the period from July 1st, 2024, through September 30th, 2024, revealed that the facility did not submit the necessary data. This resulted in a one-star staffing rating, excessively low weekend staffing, no registered nurse (RN) hours, and a lack of licensed nursing coverage 24 hours per day. During an interview, the Administrator stated that the corporate office is responsible for submitting the staffing data. Despite reaching out to corporate multiple times for proof of submission, the Administrator had not received any evidence. A subsequent interview confirmed that corporate was unable to provide evidence that the facility had submitted the required staffing information for the specified quarter.
Incomplete Staffing Information Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified during a review of the State Tested Nursing Assistant (STNA) assignments from January 7, 2025, through February 5, 2025. The review revealed that the schedule did not specify which nurse and aide were assigned to care for residents in the attached Assisted Living (AL) area, as the Skilled Nursing Facility (SNF) and AL used the same schedule. The Administrator confirmed that the nurse and aides assigned to the SNF premium nursing unit were also responsible for residents in the AL area, but the schedule did not reflect this dual assignment. During an interview, the Administrator stated that there was one resident residing in the AL area who required minimal care and was independent, with no need for dressing changes. The Administrator also mentioned contacting the corporate office regarding the lack of a separate schedule for the SNF and AL. The corporate auditor indicated that the AL was not a separate building but part of someone's unit, and the staff hours calculated for the SNF did not include the hours needed to care for the resident in the AL. This deficiency was identified incidentally while investigating several complaint numbers.
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