Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering the period from October 1 to December 31. The PBJ report indicated that the facility did not have licensed nursing coverage for 24 hours per day on 65 dates within the quarter, which triggered a deficiency for failing to meet the required staffing levels. However, a review of the facility's daily staffing sheets, nurse schedules, and time cards for the infraction dates showed that nursing services were provided for 24 hours per day, with coverage by the DON and several RNs. The deficiency was attributed to discrepancies in the PBJ data submission process. The facility underwent a change in management and corporation during the reporting period, resulting in a lack of access to staffing information for the earlier part of the quarter. After the management change, the process involved the Business Office Manager and Administrator submitting staffing data to the corporate PBJ software, with the corporation responsible for final submission. The facility relied on weekly detailed reports and corporate review to identify discrepancies, but the submitted PBJ data did not accurately reflect the actual staffing provided, leading to the deficiency.