Failure to Submit Required Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the period of October 1, 2024, to December 31, 2024, as required by federal regulations. The missing submission included essential details such as the category of work for each direct care staff member, including whether individuals were registered nurses, licensed practical nurses, certified nursing assistants, therapists, or other specified medical personnel. This deficiency was identified through record review, which showed no Payroll Based Journal (PBJ) data was submitted for the specified quarter, and was confirmed during an interview with the Corporate Nurse. During the interview, the Corporate Nurse acknowledged awareness of the missing PBJ submission and stated uncertainty regarding the reason for the failure. She indicated that the previous Administrator, who resigned on July 1, 2025, did not ensure the required data was submitted. The facility's policy on reporting direct care staffing information outlines the requirement for timely and accurate electronic submission of staffing data to CMS, but this process was not followed for the quarter in question.