The facility failed to submit complete and accurate direct care staffing data to CMS via the PBJ system, resulting in reports that showed excessively low weekend staffing for multiple fiscal quarters. An administrative staff member acknowledged that a former business office manager had submitted the PBJ data incorrectly. This failure occurred despite a facility policy requiring uniform electronic submission of verifiable payroll data for all direct care staff, including agency and contract personnel, and specifying whether staff were employees or contracted workers.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data based on payroll and other verifiable records. CMS PBJ reports for multiple quarters showed excessively low weekend staffing and a one-star staffing rating, even though review of staffing and nursing hours showed adequate coverage. An Administrative Nurse stated salaried nurses did not clock in when they filled in, so their hours were not counted.
Incomplete PBJ Staffing Data Submission: The facility failed to submit complete and accurate PBJ staffing data. CMS PBJ reports for multiple FY 2025 quarters showed excessively low weekend staffing, while schedule review showed adequate staff were on duty. An admin staff member stated the data were pulled from the time clock in corporate, the facility was not short on weekends, did not use agency staff, and several payroll program changes may have caused the issue. The facility policy required timely and accurate staffing data submission through CMS PBJ.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data for weekend nursing coverage. Although payroll and scheduling data reflected similar weekend coverage to other days, the PBJ report showed excessively low weekend staffing because all RNs except the DON were reported under the same category, causing administrative nurses to be counted with floor nursing staff.
The facility did not accurately submit direct care staffing information through PBJ, as required, resulting in reported gaps in licensed nurse coverage that did not reflect actual staffing. The issue was attributed to incomplete documentation of agency nurse hours, despite facility policy requiring all staffing, including agency and contract staff, to be reported.
Incomplete PBJ Staffing Submission: The facility failed to submit accurate direct care staffing data through PBJ. CMS PBJ reports showed no LPN/RN coverage on multiple dates, but payroll records showed a licensed nurse was on duty 24/7. Staff stated the issue may have been related to delayed agency timesheets and noted the facility used 12-hour shifts and agency nurses.
The facility failed to submit complete and accurate PBJ staffing data. CMS PBJ records showed no 24-hour licensed nurse coverage on several dates, but the facility's daily nursing coverage records showed licensed nurse coverage and adequate staffing. An admin staff member stated HR was responsible for PBJ submission during that period, and the facility policy required accurate staffing data to be reported to CMS through PBJ.
Inaccurate PBJ staffing reporting showed excessively low staffing and missing 24-hour LN coverage on multiple days across several quarters, even though review of the Daily Nurse Staffing Form and payroll data showed the days were actually covered with appropriate staff. Administrative staff stated the PBJ report was submitted by an outside firm and expected it to be accurate.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data to CMS. CMS reports showed no RN hours for multiple days in one quarter and no data submitted for several other quarters, even though record review showed an LPN/RN was on duty daily, including weekends. Staff stated the coordinator was responsible for submitting the PBJ using the internal clocking system and agency time reports, and no PBJ policy was provided.
Incomplete PBJ Staffing Submission: CMS PBJ reports for multiple quarters showed excessively low weekend staffing, even though a review of weekend and licensed nurse hours found appropriate coverage. An administrative staff member responsible for PBJ submissions said she used software to verify hours and had made changes related to removing ancillary staff from total hours, while stating the weekend licensed nurse staffing pattern remained the same. The facility’s PBJ policy required timely submission of complete and accurate direct care staffing data, including agency and contract staff, based on payroll and other verifiable records.
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