Failure to Accurately Report Staffing Data in PBJ Submissions
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), specifically regarding licensed nurse coverage and weekend staffing hours. CMS reports for two consecutive fiscal quarters indicated the facility was flagged for low weekend staffing and for not providing licensed nurse coverage 24 hours per day. However, a review of the facility's working schedules, time sheets, clock in/out records, and posted staffing hours for the identified dates did not reveal any missed coverage or gaps. During an interview, the administrative nurse confirmed that there were no missed licensed nurse shifts, as agency staff were used to fill any gaps. She acknowledged that some shifts may not have been accurately reported in the PBJ submission, particularly those involving agency and shift fill-ins. The facility's PBJ policy requires submission of complete and accurate payroll data that is verifiable and auditable, but the facility did not ensure the accuracy of the data submitted, specifically related to weekend staffing and licensed nurse coverage.