Failure to Submit Required Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit mandatory direct care staffing information for Fiscal Year Quarter 2, 2025, as required by the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) system. During the entrance conference, the Administrator confirmed that the PBJ report for the specified quarter was not submitted. Interviews revealed that the responsibility for PBJ submissions had shifted after the previous payroll specialist left approximately four months prior, and a new Chief Operations Officer (COO) began in May. The Interim Director of Nursing (IDON) stated that the new COO was not trained on the PBJ submission process. Review of the CMS policy manual confirmed the requirement for quarterly electronic submission of staffing data based on payroll and other auditable sources.