Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system as required. The PBJ reports for Fiscal Year 2024, Quarters 2 and 3, indicated excessively low weekend staffing, and the Quarter 4 report showed a lack of licensed nurse coverage for 24 hours on seven days in August and one day in September. However, a review of the facility's own records for those dates revealed that appropriate weekend and licensed nurse coverage was actually provided. During an interview, the administrative nurse indicated that the discrepancies may have been due to inaccuracies from the vendor used to submit PBJ data to CMS. The facility's policy requires electronic submission of complete and accurate staffing information, including agency and contracted staff, in accordance with CMS specifications. The deficiency was identified through a comparison of PBJ data submitted to CMS and the facility's internal staffing records.