Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2025, specifically for the period from October 1, 2024, to December 31, 2024. This included a failure to report Payroll Based Journal (PBJ) data, which encompasses information for agency and contract staff, as required by CMS specifications. Record review confirmed that no PBJ data was submitted for the specified quarter. During interviews, the Administrator (ADM) and Regional Clinical Nurse (RCN) acknowledged awareness of the missing PBJ submission but were initially unsure of the reason for the failure. The ADM indicated that responsibility for submission lay with the corporate office and was awaiting further clarification from corporate staff. The ADM later reported that the facility had only recently received its federal number from CMS in mid-October, and the next scheduled reporting date had not yet occurred since receiving the number. No policy regarding PBJ data reporting was provided by the facility prior to the survey exit.