Failure to Submit Accurate Staffing Data via PBJ
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ), as required by federal regulations. Review of the PBJ report for all four quarters of Fiscal Year 2024 indicated the facility triggered for low weekend staffing. However, interviews with administrative staff revealed that they believed weekend staffing was not low, despite occasional call-ins, and that the information submitted was based on payroll hours. The facility's policy required submission of accurate staffing data, including agency and contract staff, using verifiable and auditable data, but the submitted information did not reflect actual staffing levels, particularly on weekends.