Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit the required Payroll-Based Journal (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS) for one quarter of the 2025 Fiscal Year. According to the facility's policy, staffing and census data must be collected, validated, and submitted to CMS on a quarterly basis, with confirmation of receipt and validation reports reviewed and retained. However, a review of the facility's PBJ Staffing Data Report revealed that the report for the first quarter of fiscal year 2025 was not submitted. Interviews with facility staff indicated that the previous Assistant Administrator, who was responsible for PBJ submissions, left the position in late December 2024. The Staffing Coordinator stated she had not been trained to submit PBJ data but would assume responsibility moving forward. The Director of Nursing was unsure who was currently responsible for the submission, and the Administrator confirmed that there was no evidence the required data had been submitted for the specified quarter. The deficiency resulted from a lack of clarity and follow-through regarding staff responsibilities for PBJ data submission after the departure of the Assistant Administrator.