Failure to Accurately Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for the first quarter of fiscal year 2025. The PBJ Staffing Data Report indicated multiple dates where there was a lack of licensed nursing coverage for 24 hours per day, despite a review of nursing schedules and timesheets showing that nurses were on duty on those dates. The Administrator confirmed that the PBJ report was being managed by a third-party entity and described the process as unorganized and confusing, resulting in incorrect submissions, such as overreporting nurse staffing on some days and showing no nurses on others. The facility's policy required timely and accurate submission of staffing data, but this was not followed, leading to the deficiency.