Inaccurate PBJ Submission of RN and Licensed Nurse Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one federal fiscal quarter, specifically related to RN hours and 24-hour licensed nurse coverage. Review of the PBJ data for Quarter 1 of Federal Fiscal Year 2025 showed system triggers indicating no RN hours for an extended period and no licensed nurse coverage on multiple dates. However, detailed review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheets, and nursing staff time detail reports for the same timeframe, conducted with the ADON, showed that an RN was on site for at least 8 hours every 24 hours and that licensed nurse coverage was present 24 hours a day on all of the dates in question. The Administrator reported that she first became aware of a potential PBJ issue when the facility received a 1-star staffing rating, and stated that this rating was the first indication of a problem with the Quarter 1 PBJ submissions. The ADON stated she was responsible for scheduling and staffing and ensured RN and licensed nurse coverage daily, but did not perform the final PBJ submissions. The Controller, who had been submitting PBJ data for eight years, explained that he obtained staffing information from the facility’s online staffing system after the ADON entered it, transferred it to a spreadsheet, and then uploaded it into the staffing system for conversion into a CMS-acceptable file type. He stated he verified nursing hours against payroll and logged into the CMS site only once per quarter to submit data and view validation messages, did not receive CMS alerts by email, and had not contacted CMS because he was unaware of any issue until the survey interview. The Administrator also stated she did not contact CMS after learning of the 1-star rating because she did not know the specific reason for the rating and had not received specific alert messages indicating a problem with RN and licensed nurse coverage.
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