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F0851
F

Inaccurate PBJ Staffing Data Submission Due to Payroll System Transition

Sylva, North Carolina Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) for one reviewed federal fiscal quarter. Specifically, the PBJ report indicated there were no Registered Nurse (RN) hours reported for several dates and the entire month of March, as well as a lack of 24-hour licensed nursing coverage for multiple days. However, review of daily staff schedules and time clock reports showed that an RN was onsite for at least 8 hours each day and licensed nursing coverage was present 24 hours a day during the period in question. For one date, the Director of Nursing (DON), a salaried employee, was onsite but did not appear in the time clock records due to not clocking in or out. The Human Resources (HR) Director, responsible for PBJ submissions, confirmed that the data for the quarter was submitted without a thorough review for accuracy, citing a transition between two payroll systems as a contributing factor. The HR Director prioritized timely submission over data verification due to the payroll system change. The Corporate Nurse Consultant also confirmed that RN coverage was consistently provided, and attributed the inaccurate PBJ data to the payroll system transition, which resulted in missing or incorrect staffing information being reported to CMS.

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