Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for the first quarter, as required by federal regulations. Specifically, the Payroll Based Journal (PBJ) report for the quarter indicated excessively low weekend staffing, a one-star staffing rating, no RN hours for every day in the quarter, and a lack of licensed nursing coverage 24 hours per day. However, a review of staff timecards for the same period verified that the facility did not have excessively low weekend staffing, had RN coverage for at least 8 hours per day, and maintained licensed nursing coverage 24 hours per day. This discrepancy was due to a clerical error in the PBJ submission process, where staff hours were incorrectly entered as exceeding 24 hours in a single day, resulting in the rejection of all staffing data for the quarter. During an interview, the administrator confirmed responsibility for submitting the PBJ reports and was unaware that the facility was triggering deficiencies in the PBJ report. The administrator acknowledged the clerical error and stated that it caused all PBJ data to be rejected for the quarter. Facility policy required the administrator to review validation reports and ensure corrections were made before the quarterly deadline, but this process was not effectively followed, leading to the submission of incomplete and inaccurate staffing data. This deficiency had the potential to affect all 43 residents in the facility.