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F0851
F

Inaccurate Submission of PBJ Staffing Data

West Chester, Pennsylvania Survey Completed on 06-13-2025

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 electronically submit accurate direct care staffing information for one of the last four quarters, specifically Quarter One of 2025, as required by Section 6106 of the Affordable Care Act (ACA). Review of Payroll Based Journal (PBJ) staffing data reports indicated that the facility was flagged for having no RN hours and for failing to provide licensed nursing coverage 24 hours per day throughout October, November, and December 2024. However, a review of the facility's staffing documentation for these months showed that RN hours and 24-hour licensed nursing coverage were actually provided. During an interview, the Director of Nursing (DON) confirmed that the PBJ report for the quarter was submitted inaccurately, resulting in the deficiency.

See complete original report
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