Failure to Timely Submit PBJ Staffing Data Due to Payroll Processing Issues
Penalty
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.