Failure to Accurately Report Licensed Nurse Coverage in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for the reporting period of October 1st to December 31st. Specifically, the PBJ Staffing Data Report identified that the facility did not have licensed nurse coverage reported for four dates. Upon review, it was found that the Director of Nursing (DON) had covered the nursing shifts on those dates, but the DON's hours were not included in the PBJ submission. The facility census at the time was 18 residents. Interviews with the Administrator confirmed that the DON's hours were not reported to PBJ for the identified dates. The Administrator acknowledged that the omission was due to the use of an outdated reporting system, which led to company-wide errors in PBJ submissions. Facility procedures for PBJ compliance outlined steps for data assembly, validation, and submission, but these were not effectively followed, resulting in incomplete and inaccurate staffing data being reported to CMS.