Failure to Accurately Report Nurse Staffing in PBJ Submissions
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system as required by CMS. Review of PBJ reports for multiple fiscal quarters indicated that there were several dates recorded with no licensed nurse coverage. However, examination of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that nurses were always scheduled for each 12-hour shift, including the use of agency staff when necessary. Interviews with administrative and nursing staff revealed that while scheduling was managed internally, the actual PBJ submission was handled by the corporate team. The facility's policy required accurate electronic reporting of staffing and census information, including agency and contract staff, to CMS. The failure to submit accurate PBJ data resulted in records that did not reflect the actual nurse staffing present in the facility.