Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, including data for agency and contract staff, to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024, as required by Payroll Based Journal (PBJ) reporting regulations. Review of the CASPER Payroll-Based Journal Staffing Data Report confirmed that the facility did not report staffing data for the period of July 1, 2024, through September 30, 2024. This omission resulted in CMS having inaccurate data related to the facility's nursing home staffing levels. Interviews with facility staff revealed that the Business Office Manager was responsible for PBJ reporting during the relevant period but could not recall if the report was run or submitted, and was unaware that the submission did not go through. The Director of Business Intelligence at the corporate office confirmed that the CASPER report showed no data was submitted and that a confirmation report should have been received. The current Administrator stated they were not in the role at the time and were unaware of the missing submission until the survey. This is a repeat citation from a previous Statement of Deficiencies.