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F0851
F

Failure to Accurately Report Agency Staffing Data in PBJ Submissions

Ada, Minnesota Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit complete and accurate direct care staffing information to CMS for the first quarter reviewed. Specifically, agency staff were not punching in for their shifts, resulting in their hours not being included in the Payroll Based Journal (PBJ) submissions. This omission was confirmed through a review of agency staff timecards and the PBJ report, which identified excessively low weekend staffing. The corporate submitter responsible for PBJ submissions acknowledged that she was unaware of the low weekend staffing trigger and confirmed that agency staff who did not punch in were excluded from the PBJ data sent to CMS. The administrator also verified that agency staff had not been punching in during the first quarter, which led to incomplete staffing data being reported. The facility's policy required that all direct care staffing information, including agency and contracted staff, be submitted to CMS according to the specified schedule. The failure to ensure agency staff were properly recorded resulted in inaccurate staffing information being reported for all 39 residents in the facility.

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