Failure to Accurately Report Direct Care Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing data to CMS for Quarter 2, Quarter 3, and Quarter 4 of 2024, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Reports for these quarters revealed excessively low weekend staffing and a one-star staff rating for Quarter 3. Further examination of direct care staffing records, including facility census and per patient day (PPD) calculations, showed that on five randomly selected Saturdays, the facility reported PPD values greater than 2.7, which were still considered excessively low for weekend staffing during the reviewed quarters. Interviews with the Staffing Director and Administrator confirmed awareness of low weekend staffing, attributed to staff call-ins, and indicated that agency staff were included in the reported numbers. The Administrator also acknowledged that direct care hours for a Certified Nursing Assistant who worked in multiple roles were not properly coded, contributing to inaccuracies in the PBJ submissions. No specific residents or patient conditions were mentioned in relation to the deficiency.