Failure to Accurately Report Agency Staffing Hours in PBJ Submission
Penalty
No penalty information released
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 data to CMS for one of four quarters reviewed, specifically Quarter 2 of 2025. According to facility policy, all direct care staffing information, including staff hired directly, agency staff, and contract employees, must be reported electronically through the Payroll-Based Journal (PBJ) system. Review of the PBJ Staffing Data Report for the specified quarter revealed a one-star staffing rating and excessively low weekend staffing. During an interview, the Administrator confirmed that agency staff hours were not included in the PBJ submission for that quarter, as these hours must be manually entered and were omitted, resulting in inaccurate reporting.