Inaccurate Reporting of Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing data to CMS, as required. Review of the Payroll Based Journal (PBJ) report, staff schedules, and interviews revealed that staffing data submitted for the period in question did not accurately reflect actual staffing levels. Specifically, a Certified Nurse Assistant (CNA) who also performed activities duties worked on the floor providing direct care, but her hours were not coded correctly in the data submitted to CMS. Additionally, on certain weekend night shifts, only one CNA was present along with two nurses, resulting in lower direct care hours compared to weekday averages. These discrepancies led to the facility triggering for excessively low weekend staffing in the PBJ report, potentially affecting all 31 residents in the facility. No concerns were identified from the provider regarding the average direct care hours, but the inaccurate reporting of staffing data constituted a deficiency in compliance with CMS requirements.