Failure to Accurately Report RN Staffing Hours in PBJ Submissions
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ). Specifically, the facility did not report registered nurse (RN) coverage hours for multiple dates across several fiscal quarters, resulting in a one-star staffing rating and documentation of missing RN hours. On several occasions, the facility was unable to provide requested RN clock in and out times for staff hours, and in some instances, although documentation of RN coverage was available, it was not submitted in the PBJ as required. Additionally, there were periods when the facility lacked a method to log hours for administrative or corporate float RNs, leading to further omissions in PBJ submissions. The facility also failed to provide a policy regarding PBJ reporting when requested. The census at the time was 23 residents. The deficiency was identified through interviews and record reviews, which confirmed the absence of required staffing data and the lack of a systematic process to ensure all RN hours, including those worked by administrative and float staff, were accurately captured and reported to CMS.