Failure to Accurately Report Staffing Data to CMS
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). Specifically, the PBJ Staffing Data Report (CASPER Report 1705D) for two consecutive fiscal quarters showed that the facility did not report registered nurse (RN) hours on several dates and failed to demonstrate licensed nurse coverage 24 hours a day on multiple occasions. The report identified specific dates where no RN hours were documented and additional dates where there was no evidence of 24-hour licensed nurse coverage. Administrative staff confirmed that, except for one date, the facility did have 24-hour licensed nurse coverage, but the correct hours were not always submitted to CMS due to issues with the reporting process. The facility did not have a policy in place regarding PBJ reporting, which contributed to the inaccurate submission of staffing data. The administrative nurse stated that all nursing hours were sent to a corporate human resources person at a sister facility, and acknowledged there had been problems with submitting the correct hours to CMS. The lack of a formal policy and the reliance on external staff for reporting led to discrepancies in the reported staffing data, resulting in a one-star staffing rating and multiple triggered deficiencies in the CMS report.