Failure to Accurately Report Weekend Staffing in PBJ Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ) by not properly documenting weekend staffing coverage hours. During the review period, the facility reported a census of 36 residents and a sample of 12 residents was included. Although the facility's working schedules, time sheets, and posted staffing hours showed no gaps or loss of hours, the submitted PBJ data triggered for excessively low weekend staffing for the first quarter of the fiscal year. An administrative nurse confirmed that agency staff were used during the period in question, but their hours may not have been appropriately documented in the PBJ reporting. The facility's policy required accurate electronic reporting of staffing and census information to CMS and mandated that this information be made available to residents, family members, and the public within 24 hours of a request.