Inaccurate PBJ Staffing Data Submission for Weekend Coverage
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ), specifically regarding weekend staffing coverage hours. A review of the facility's PBJ data for multiple fiscal quarters showed that the facility triggered for excessively low weekend staffing. However, examination of the facility's working schedules, time sheets, and posted staffing hours did not reveal any gaps or loss of hours, and weekend call-offs were documented as being covered by administrative nurses. Further review of the facility's updated Facility Assessment indicated that it did not differentiate required nursing hours for day, evening, and weekend shifts. Interviews with nursing staff and administrative nurses confirmed that the facility was typically well-staffed on weekends, with administrative nurses covering any call-offs. Despite this, the PBJ data submitted to CMS did not accurately reflect the actual staffing coverage, resulting in a deficiency for failing to report complete and accurate staffing information as required by facility policy.