Inaccurate PBJ Staffing Data Submission Due to Incomplete Manual Adjustments
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one of the three quarters reviewed. Specifically, the PBJ report for Quarter 1 of Fiscal Year 2025 showed missing Registered Nurse (RN) hours on several dates and indicated a lack of licensed nursing coverage for 24 hours on multiple days. However, a review of daily staff schedules and nursing staff time detail reports revealed inconsistencies, with some records showing RN presence for at least 8 hours and licensed nursing coverage, while others did not. The discrepancies were particularly noted for specific dates where either RN hours or 24-hour licensed nursing coverage were not properly documented. Interviews with facility leadership revealed that the Administrator and Director of Nursing, both RNs and salaried employees, often worked nursing shifts but did not clock in or out, resulting in their hours not appearing in the time detail reports. Additionally, when nurses from sister facilities worked at this location, their hours were not automatically recorded due to system limitations, requiring manual adjustments by the corporate office. The corporate office was not always consistent in manually inputting these hours, leading to inaccurate PBJ submissions and triggering findings of insufficient RN and licensed nursing coverage.