Inaccurate PBJ Submission of RN Staffing Hours
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system, specifically related to RN hours for three consecutive quarters of Federal Fiscal Year 2025. For Quarter 2, the PBJ report showed no RN hours on several specific dates, while the daily staff schedules for those same dates showed an RN scheduled for at least 8 hours per day. Similar discrepancies were identified in Quarter 3 and Quarter 4, where the PBJ reports reflected no RN hours on multiple dates, yet the facility’s daily staffing schedules documented that an RN was scheduled for at least 8 hours on each of those dates. During interviews, the Regional Nurse Consultant stated that on each of the dates with zero RN hours reported in PBJ, the facility did in fact have RN coverage for a minimum of 8 consecutive hours, often provided by herself and the MDS nurse, both of whom are salaried RNs who do not clock in or out, resulting in no timecard record of their worked hours. She explained that the corporate office was responsible for manually adjusting and entering hours for salaried nursing staff who covered shifts. The Administrator reported that the corporate office was not always consistent in manually entering these hours, which led to multiple dates with inaccurate RN staffing data in the PBJ submissions for the three reviewed quarters. Attempts by surveyors to contact the Regional Business Office Manager by telephone were unsuccessful, and no return call was received.
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