Failure to Accurately Report Weekend 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 regarding weekend staffing coverage hours. Although the facility's internal records, including working schedules, time sheets, and posted staffing hours, showed no gaps or loss of hours, the PBJ data submitted for two consecutive fiscal quarters triggered for excessively low weekend staffing. Interviews with staff indicated that while some did not perceive issues with weekend staffing, administrative staff acknowledged occasional gaps and the use of incentives or shift coverage to address open positions. The administrator noted a recent switch to a new tracking system and stated that the facility had been triggered for low weekend staffing multiple times despite being adequately staffed according to their records. Additionally, the facility's most recent Facility Assessment did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed per unit, patient acuity, or census. The assessment also lacked details on staffing levels required for each shift, day, and weekend. The facility's policy requires that staffing and census information be reported electronically to CMS and made available to residents, family members, and the public within 24 hours of a request.