Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for Fiscal Year Quarter 2 2025 (January 1 - March 31), as required by federal guidelines. The deficiency was identified through review of the facility's Staffing Data Report, which showed that the facility did not submit the required data for the specified quarter. The submission must include information for agency and contract staff, based on payroll and other verifiable and auditable data, in a uniform format according to CMS specifications. During an interview, the administrator acknowledged the oversight, attributing it to the demands of opening a new building and missing the reporting window when the links for data submission were available. The administrator confirmed that it was her responsibility to ensure the staffing data was reported and stated that the facility did not have a specific policy for reporting staffing data, instead following CMS guidelines. No policy or procedure was in place to ensure timely submission, and the failure was not attributed to any technical or resident-related issue.