Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate electronic submission of direct care staffing information to CMS, as required by federal regulations. During the review of Payroll Based Journal (PBJ) data for the second quarter, surveyors found discrepancies in the reported staffing levels, particularly noting excessively low weekend staffing and a one-star staffing rating. Upon review of the facility's weekend schedules and minimum staffing requirements, no discrepancies were found between scheduled and required staff. However, it was discovered that a Licensed Practical Nurse who had recently graduated and obtained licensure was still being reported as an aide in the PBJ submission, which contributed to the inaccurate data. Additionally, the facility had recently changed payroll vendors, and the reporting error was not corrected as intended for the first quarter. Interviews with the scheduler and the Nursing Home Administrator (NHA) revealed confusion regarding the reporting process and the source of the staffing data errors. The NHA acknowledged a reporting error and indicated that all hours, including agency staff, were supposed to be sent to corporate for submission. The scheduler described how staffing was managed during call-ins and confirmed that minimum staffing levels were maintained according to the facility assessment. Despite these efforts, the inaccurate reporting of staff roles led to the submission of incorrect staffing data to CMS, affecting the facility's reported staffing levels and ratings.