Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) as required by CMS. Although CMS PBJ reports for two consecutive fiscal quarters indicated excessively low weekend nurse staffing and a lack of 24-hour licensed nursing coverage on specific dates, a review of the facility's own nursing schedules and coverage records for those periods showed that adequate staffing and licensed nurse coverage were actually maintained. The discrepancy arose because the PBJ data submitted did not accurately reflect the facility's actual staffing levels. Additionally, the facility did not have a policy in place related to PBJ submission, and the process involved corporate staff submitting the data with review by the administrative nurse.