Inaccurate PBJ Staffing Data Submission Due to Unadjusted Staff Hours
Penalty
Summary
The facility failed to submit accurate and complete direct care staffing information to CMS for one reviewed quarter, as required by federal regulations. Payroll Based Journal (PBJ) data submitted for the quarter included total nursing staff hours for various roles, but did not account for time that facility staff spent providing services at the assisted living center during their scheduled shifts at the facility. Documentation, including the 'AL Filling in Time Book,' showed that staff regularly left the facility to assist at the assisted living center, with over 50 hours documented during the quarter. Some entries in the log were illegible or incomplete, making it difficult to determine the exact amount of time spent away from the facility. Interviews with the DON, administrator, and director of human resources confirmed that this practice had been ongoing and that the time spent by staff at the assisted living center was not subtracted from the hours reported to CMS in the PBJ submissions. The director of human resources acknowledged that the PBJ hours submitted were incorrect, as they were based solely on timecard data without adjusting for time spent away from the facility. The facility's PBJ policy was requested but not provided.