Failure to Accurately Report Direct Care Staffing Data
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journaling (PBJ) system. Review of the PBJ report for all four quarters of Fiscal Year 2024 indicated that the facility triggered for excessively low weekend staffing. However, the administrative nurse stated that weekend staffing levels were the same as during the week and suggested there was an error in the reporting of hours. The facility's policy required direct care staffing information to be submitted to the PBJ system on the schedule specified by CMS, but the submitted data did not accurately reflect actual staffing levels.