Failure to Accurately Report Staffing Data in PBJ Submissions
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system as required by CMS. Specifically, PBJ reports for multiple fiscal quarters indicated missing licensed nursing coverage for several days, including a lack of Registered Nurse (RN) hours and incomplete documentation of licensed nursing staff coverage. Upon review, it was found that the facility did have adequate licensed nursing staff and RN coverage on the days in question, but these hours were not properly recorded or reported. The deficiency was attributed to several factors, including the failure of salaried staff such as the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to document their worked hours, incorrect calculation of hours for staff working shifts that crossed midnight, and inconsistent accounting for hours worked by agency staff from three different agencies. The facility's own PBJ policy requires accurate and timely submission of staffing and census data, including hours worked and paid for each staff member. However, the audit and interviews revealed that the facility's reporting practices did not align with these requirements, resulting in incomplete and inaccurate data being submitted to CMS. This led to the facility being assigned a one-star rating in the PBJ report and placed residents at risk for unidentified and ongoing inadequate nurse staffing, as the reported data did not reflect the actual staffing levels present in the facility.