Failure to Accurately Report Direct Care Staffing in PBJ Submission
Penalty
Summary
The facility failed to ensure that its Payroll Based Journal (PBJ) submissions to CMS accurately reflected direct care staffing hours, as required. Review of CASPER reporting data showed the facility triggered for excessively low weekend staffing for one of four quarters. Examination of monthly schedules indicated that both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who are salaried employees, worked as supervisors and on the floor during weekends in the quarter in question. However, they did not clock in or out during this period, and their work hours were only documented on assignment sheets, not in the PBJ data submitted to CMS. Interviews with facility staff revealed that the DON and ADON only began clocking in and out within the last two weeks, and prior to that, there was no verifiable or auditable record of their hours worked on the floor. The staffing coordinator was responsible for correcting staff punches and updating codes when staff worked outside their usual roles, but the PBJ data sent to the corporate office did not include the DON and ADON's hours for the quarter in question. The Administrator and Director of Payroll were unaware that the facility had triggered for low weekend staffing, and the PBJ submission was accepted by CMS despite the incomplete data.