Inaccurate PBJ Census Data Submitted to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for Quarter 2 of 2025. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed facilities are required to electronically submit complete and accurate direct care staffing information, including direct care staff, category of work, resident census data, and direct care staff turnover and tenure, by the required deadlines. For Q2 (April through June 2025), the PBJ data submitted by the facility showed a reported census total of 6988. However, review of the facility’s own monthly census records showed 2266 for April, 2242 for May, and 2238 for June, for a total of 6746, revealing a discrepancy of 242 census days. During an interview, the Administrator stated that PBJ submission and census reporting were completed at the corporate level and acknowledged that issues had been identified with prior MDS submissions being timely and accurate. In an email communication, corporate staff later stated that, after reviewing all PBJ submission documents, the accurate census for Q2 was 6789, which still differed from the originally reported PBJ census total. The Administrator stated they would expect complete and accurate PBJ information to be submitted as required. This failure affected the accuracy of nursing home staffing level data collected by CMS and had the potential to impact provisions of resident care and services.
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