Failure to Submit Staffing Data for Fiscal Quarter
Penalty
Summary
The facility failed to electronically submit direct care staffing information for the first quarter of the fiscal year 2025, covering the period from October 1, 2024, to December 31, 2024. This deficiency was identified through a review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and confirmed during an interview with the Director of Nursing. The report indicated that the facility did not meet the mandatory submission requirements as outlined in Section 6106 of the Affordable Care Act (ACA) and the State Operations Manual, which mandates the electronic submission of complete and accurate direct care staffing information, including agency and contract staff, based on payroll and other verifiable data. The failure to submit the required staffing data was further highlighted by the facility's triggering for 'Failed to Submit Data for the Quarter' in the PBJ staffing data report. During the interview, the Director of Nursing, identified as Employee E2, was unable to provide any additional information or documentation to account for the missing submission. This lack of compliance with the CMS requirements for staffing data submission could potentially impact the facility's ability to report on staff levels, turnover, and tenure, which are critical for assessing the quality of care provided to residents.
Plan Of Correction
1. The Director of Nursing and Administrator will be in-serviced on CMS, 483.70 Mandatory submission of staffing based on payroll data in a uniform format that Long Term Care facilities must electronically submit to CMS direct care staffing information according to the CMS submission schedule. 2. The Director of Nursing along with the Administrator will be reviewing the direct care staffing data monthly for electronic submission. 3. The administrator will monitor that the facility submits the direct care staffing data electronically in the uniform format for each quarter as directed by CMS for Payroll Based Journal. Data submission will be reported by the Director of Nursing or the Administrator through the Quality Assurance meeting and/or the Facilities Governing Body meetings for compliance.