Failure to Accurately Report Licensed Nurse Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll Based Journaling (PBJ) as required. The PBJ report for a specific fiscal quarter indicated that there was no licensed nurse coverage on five dates. However, a review of the facility's licensed nurse payroll data for those dates showed that a licensed nurse was on duty 24 hours a day, seven days a week. Administrative staff confirmed that the discrepancies were likely due to the use of agency nurses whose hours were not properly documented in the PBJ system. The facility's policy required the submission of complete staffing information, including agency and contract staff, but this was not followed, resulting in inaccurate data being reported to CMS.