Failure to Submit Required PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not submit the required Payroll Based Journal (PBJ) staffing data for three consecutive quarters: the third and fourth quarters of federal fiscal year 2024 and the first quarter of federal fiscal year 2025. This deficiency was identified through a review of PBJ staffing data reports from the Certification and Survey Provider Enhanced Reports (CASPER) database, which confirmed the absence of submissions for the specified periods. Interviews with facility staff revealed that the responsibility for submitting PBJ data rested with the corporate payroll department. The Administrator stated that payroll information from the facility was sent to the corporate office, which was responsible for the actual submission. The Administrator further confirmed that the corporate office had stopped submitting PBJ data due to the facility's low census numbers, believing that the facility would not receive a staffing star rating. The corporate Director of Workforce Management, who became responsible for PBJ submissions in early 2025, also confirmed that the data for the three quarters in question had not been submitted and that it was too late to submit the missing data after contacting CMS.