Failure to Timely Submit PBJ Staffing Data Due to Payroll Processing Issues
Summary
The facility failed to submit complete and accurate Payroll Based Journal (PBJ) staffing data for the first quarter of 2025 within the required timeframe. According to the CMS PBJ Staffing Data Report, the facility did not submit staffing data for the period from January 1, 2025, to March 31, 2025, by the designated deadline. The Payroll Coordinator reported that there were three errors in the staffing data report for this quarter. Additionally, the Payroll Coordinator stated that the facility's previous payroll processing company had closed for an unknown reason, and a new payroll company was not engaged until the end of May 2025. As a result, the required staffing data was not submitted on time and was only accepted by CMS after the deadline. The facility's policy and procedure required that staffing and census information be reported electronically to CMS through the PBJ system no later than 45 days after the end of each reporting quarter. The policy also specified that the Payroll Coordinator was responsible for preparing, verifying, and submitting the quarterly PBJ. The Administrator, who began working at the facility in June 2025, was not aware of the failure to submit the staffing data report for the first quarter and indicated that the Payroll Coordinator should have informed the previous Administrator about the payroll company closure to prevent the delay.
Plan Of Correction
Immediate Corrective Action: On 6/16/25, the Payroll Coordinator sought help with the new payroll software in familiarizing themselves with the system in preparation for future submissions. Corrective Action for Others Affected: On 6/16/25, the Payroll Coordinator reviewed all reports from the quarterly Payroll Base Journal reports for the past year and did not find any other quarter affected by the deficient practice. Measures Taken to Prevent Recurrence: The Administrator in-serviced the Payroll Coordinator on 06/16/25 regarding the significance of regularly and promptly submitting the quarterly Payroll Base Journal, as it affects reporting of the facility’s direct care staffing compliance. Performance Monitoring to Ensure that Solutions are Sustained: Starting 7/01/25, the administrator will review with the Payroll Coordinator the preparation of the monthly labor reports that will comprise the quarterly Payroll Base Journal submission. Starting 7/01/25, the administrator will review with the Payroll Coordinator on a quarterly basis the submission of the Payroll Base Survey to ensure prompt submission. Starting 7/01/25, the administrator will discuss during the QAPI meeting issues encountered during the monthly and quarterly Payroll Base Journal reviews for the next 3 months. Starting 7/01/25, all findings will be presented by the administrator during the monthly QAPI Meeting for the next 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Inaccurate PBJ Staffing Data Submission: The facility failed to submit complete and accurate direct care staffing data to CMS for a quarter of PBJ reporting. The PBJ report showed an excessively low weekend staffing trigger, and the ADM stated she compiled the data, sent it to corporate, and a third-party company submitted it to CMS, while also acknowledging she did not know why the low weekend staffing was triggered.
Failure to Submit Required Payroll Base Journal Staffing Data: The facility failed to electronically submit complete and accurate direct care staffing data to CMS for Q2 2026, including payroll and other verifiable auditable data for agency and contract staff. The CASPER report showed the required PBJ data was not submitted, and the Administrator said the omission was due to a transition in HR personnel. The HR Director stated she did not know why the PBJ was not submitted, and the facility policy assigned submission responsibility to the HR Director or designee.
Failure to Submit PBJ Staffing Data: The facility failed to submit PBJ direct care staffing data to CMS for a quarter after corporate payroll staff believed a TPV had submitted it. The CPC stated the omission was not discovered until later, he did not check the CASPER report because he did not know he could access it, and the ADM stated the facility had no policy or procedure for PBJ submission.
The facility failed to submit complete and accurate PBJ staffing data to CMS for a quarterly reporting period. HR, the DON, and the ADMIN described a process where staffing hours were gathered from invoices, adjusted, entered into Workday, and then pulled by the Home Office service center for CMS submission. Record review showed the submission failed because one employee did not match after a software change, creating a fatal coding error in the file, and the issue was not discovered until after the deadline had passed.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate direct care staffing information through PBJ. CMS data for FY 2026 Q2 showed excessive low weekend staffing, but staffing sheets showed the same number of direct care staff worked on weekends and weekdays. Administrative Staff A confirmed the facility did not have low weekend staffing and stated the DON, ADON, and MDS Nurse worked weekends as needed.
Failure to Submit Quarterly PBJ Staffing Data: The facility failed to submit complete and accurate PBJ staffing data to CMS for one quarter. Record review showed no staffing submission for the quarter, and the Quality Director stated the prior coordinator had said she was submitting the data, but the facility later learned it had not been submitted and that she no longer worked at the facility.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for the quarter of 01/01/2026 through 03/31/2026. The PBJ report for that quarter documented a staffing data concern for excessively low weekend staffing, and the report stated that this metric was triggered because the submitted weekend staffing data was excessively low. During an interview on 06/25/2026, the Administrator stated she was responsible for submitting staffing data to CMS, did not know why the low weekend staffing was triggered for the second quarter of 2026, and explained that she compiled the data, sent it to corporate, and a third-party company submitted it to CMS. She also stated that if incorrect data was submitted, CMS would not have accurate information concerning staffing.
Failure to Submit Required Payroll Base Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS, including payroll and other verifiable and auditable data for agency and contract staff, for the second quarter of 2026. Record review of the CMS Payroll Base Journal Staffing Data Report (CASPER Report 1705D, Fiscal Year Quarter 2-2026) showed that the facility did not submit the required data for January 1 through March 31, 2026. During interview, the Administrator stated he had been at the facility since 2018 and said the Payroll Base Journal for the second quarter of 2026 was not submitted because of a transition in human resource personnel. He stated human resources was responsible for submitting the Payroll Base Journal. The Human Resource Director, who said she had worked at the facility for three weeks, stated she did not know why the Payroll Base Journal was not submitted and confirmed that human resources was responsible for ensuring it was completed. Record review of the facility policy titled Payroll Base Journal-Staffing, revised in August 2023, stated that the Human Resource Director or designee was responsible for submitting the Payroll Base Journal according to the CMS schedule.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) for the first quarter, covering 10/1/2025 through 12/31/2025. A review of the CMS PBJ Staffing Data Report dated 6/16/2026 showed that the facility did not submit staffing data for that quarter. During an interview on 6/24/2026, the Corporate Payroll Consultant stated the facility's corporate payroll staff used a third-party vendor to submit PBJ data and believed the data for the first quarter had been submitted to the vendor, but later discovered in March 2026 that it had not been submitted to CMS. The Corporate Payroll Consultant also stated he did not check the CASPER Report because he did not know he could access it. The Administrator stated he was aware the first quarter PBJ had not been submitted after speaking with the Corporate Payroll Consultant, and stated the facility did not have any policy and procedure for PBJ submission.
PBJ Staffing Data Not Submitted
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2026, including agency and contract staff, using payroll and other verifiable and auditable data in the required uniform format. Review of the CMS PBJ report showed the facility did not submit staffing data for the quarter. The report identified that the submission failure was tied to the facility’s PBJ reporting process and the quarter ending December 31, 2025. During interviews, HR stated staffing hours were gathered from invoices, adjusted through time adjustment forms, entered into the Workday payroll tracking system, and then pulled by the Home Office service center for submission to CMS. The DON gave a similar account, stating nursing hour reports were received from HR, verified, entered into Workday, and then submitted by the service center. The ADMIN also stated that nursing hours were compiled through HR and DON review, entered into Workday, and submitted by the service center. The ADMIN said the report would be pulled to determine whether any nursing hours were missing. Record review of the facility’s internal investigation showed the PBJ data was submitted by the facility payroll vendor, but CMS loaded a report showing a failed submission. The investigation stated that one employee did not match due to new software that went live on 1/1/26, causing a fatal error. The facility identified a coding error attached to employee positions in the file, and the contracted service did not discover the issue until after the submission deadline had passed. CMS later denied the facility’s appeal to resubmit the PBJ data. The ADMIN stated the facility did not have a PBJ policy other than following CMS guidelines, and the CMS policy manual required quarterly direct care staffing and census data to be timely and accurate.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system based on payroll and other verifiable and auditable data. The CMS PBJ Staffing Data Report for FY 2026 Quarter 2 showed excessive low weekend staffing, but review of the facility staffing sheets showed the same number of direct care staff worked on weekends and weekdays. During interview, Administrative Staff A verified the facility did not have low weekend staffing and stated that the DON, ADON, and MDS Nurse worked on weekends as needed. The facility policy titled Reporting Direct Care Staffing Information (Payroll Based Journal), revised August 2022, stated that direct care staffing information was reported electronically to CMS through the PBJ system.
Failure to Submit Quarterly PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS no less frequently than quarterly based on payroll and other verifiable and auditable data. Record review of the PBJ Staffing Data Report for Quarter 2 of 2026, generated on 6/17/26, showed that the facility did not submit staffing data for that quarter. During an interview on 6/17/26 at 5:30 pm, the Quality Director stated that the coordinator was responsible for submitting staffing data to CMS and that the previous coordinator had told the facility she was submitting the data, but the facility later discovered that she had not submitted it and she no longer worked at the facility.
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