F0851

F

Failure to Timely Submit PBJ Direct Care Staffing Data

Bronx, New York Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to submit required direct care staffing and census data to CMS through the Payroll-Based Journal (PBJ) system within the mandated timeframe for fiscal Quarter 4, 2025 (July 1–September 30). The facility’s policy on Reporting Direct-Care Staffing Information, dated 11/20/2022, states that staffing and census information will be reported electronically to CMS via PBJ in compliance with Section 6106 of the Affordable Care Act, and that this information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. CMS’s PBJ Policy Manual similarly requires that direct care staffing and census data, including agency and contract staff, be submitted electronically and received by CMS by the end of the 45th calendar day after the last day of each fiscal quarter to be considered timely. A CMS PBJ Staffing Data Report documented that the facility failed to submit data for Quarter 4, 2025.

An email from the facility’s PBJ vendor to the Director of Payroll, dated 11/17/2025, documented that a PBJ submission attempted on that date failed because CMS was no longer accepting submissions for the reporting quarter of 07/01/2025–09/30/2025, indicating the submission was late. During an interview, the Director of Payroll stated they were responsible for ensuring all time management records were completed and that PBJ was submitted on time, acknowledged awareness of the submission deadline, and could not explain why the report was not submitted on time. The Director of Staffing reported they were not aware until the day of the interview that the staffing and census data had not been submitted. The Assistant Administrator also stated they could not explain why the Quarter 4, 2025 direct care staffing data was not submitted and described the failure as an oversight.