Inaccurate PBJ Staffing Data Submission Resulted in Reported Low Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) via the Payroll Based Journal (PBJ) system for the period from July 1, 2024, to March 31, 2025. Despite scheduling the same number of direct care staff on weekends as on weekdays, the PBJ data submitted indicated excessively low weekend staffing for three consecutive fiscal quarters. This discrepancy was identified through review of CASPER 1705D reports and was not supported by the facility's actual staffing schedules or by interviews with the scheduler and the nursing home administrator (NHA), both of whom confirmed that weekend staffing levels did not differ from weekday levels except for the absence of the DON or ADON. The NHA reported that staff hours worked are submitted to the owner through the payroll system and then entered into the PBJ system by the owner. Attempts to verify the data entry process with the owner were unsuccessful. The NHA suspected that some staff hours may have gone unreported in the PBJ system due to incorrect timecard entries, which may have triggered the low weekend staffing reports. The surveyor did not find evidence of actual low weekend staffing during the review, but the inaccurate PBJ data submission constituted a deficiency affecting all 49 residents in the facility.