The Centers for Medicare and Medicaid Services (CMS) have strict regulations for reporting direct care staffing and census information through the Payroll-Based Journal (PBJ) system.
Nursing facilities are required to report on this information on a quarterly basis. CMS publishes the data and uses it to determine star ratings on the staffing component of the Nursing Home Compare website.
Star ratings are obviously important for your facility’s reputation and ability to attract new patients and residents, but there are other reasons that you should ensure that the data you submit on your PBJ is accurate and complete. The data you provide can be accessed by other regulatory agencies, including state licensing agencies, and may be used for licensing and complaint investigation surveys, with any identified non-compliance resulting in citations, fines, or penalties. We have also heard from our clients that some state Medicaid agencies utilize PBJ data in a variety of ways, such as to validate paid nursing hours reported on Medicaid cost reports. Facilities need to be aware of a wide range of potential data uses and have comprehensive internal data review procedures to help ensure the public use file reflects accurate reporting and that the facility is prepared for an audit.
Here are eight ways you can prepare:
1. Less might be more
PBJ reporting includes required and optional elements. The optional data may include hire and termination dates and worked hours for other service workers. Evaluate whether you should report optional data elements. If you opt to report this type of data, be sure that it is accurate and complete.
2. Plan ahead and consider more frequent submissions
Allow your team enough time for review after the quarter ends but prior to the cut-off date. It is a requirement to file quarterly, but you may also submit data more frequently. Some of our clients chose to submit PBJ data after processing each pay period. This approach allows for more timely identification of employee classification issues or technical challenges. It also gets responsible staff into the habit of maintaining records on an ongoing basis, rather than as a quarterly event.
3. Don't forget to verify your submission
Do not skip the confirmations and available reports review prior to the deadline. Once the final data file is uploaded, SNF/NFs need to check their Final File Validation Report in their CASPER folder to verify that the data was submitted successfully. Please be aware that it may require up to 24 hours for the validation report to be available and allow for time to correct any errors and resubmissions, if needed.
4. Easily find a needle in a haystack
Carefully review and summarize data as described in the PBJ Report User Guide (Section 12 – Reports). We recommend obtaining all related CASPER reports (“D” in the end of the report number indicates detailed reports and “S” summary reports):
Report Number |
Report Title |
Description |
Available formats |
Use for |
1700D |
Employee Report |
Lists the active and/or terminated employees associated with a facility during a specified period |
PDF or CSV |
Verify all employees have a unique ID |
1702D |
Individual Daily Staffing Report |
Details facility staffing information during a specified period by Employee ID |
PDF or CSV |
Use pivot table to summarize and review hours by employee or position / category and period (recommend daily, weekly, and monthly reports) |
1702S |
Staffing Summary Report |
Summarizes staffing information by job title for a facility during a specified period |
PDF or CSV |
Review summary of hours reported for the quarter to help ensure staff or contractor reports are submitted. Consider comparing this report to the prior quarter |
1703D |
Job Title Report |
Details by work date the staffing hours submitted for select job title(s) during a specified period |
CSV/Excel |
Review hours by job title and classification |
1704S |
Daily MDS Census Summary Report |
Provides daily facility census counts for a specified period |
PDF or CSV |
Use to reconcile to your internal total daily census |
1704D |
Daily MDS Census Detail Report |
Lists the IDs of the residents included in daily facility census counts for a specified period |
PDF or CSV |
Use to help ensure all residents’ MDS assessments were submitted (including admissions and discharges) |
1705D |
PBJ Staffing Data Report |
Identifies areas of concern that may trigger follow-up during the survey including:
- Failed to submit data for the quarter.
- Excessively low weekend staffing
- One Star staffing rating
- No RN hours
- Failed to have licensed nursing coverage 24 hours/day
|
PDF |
Review compliance and error triggers summary (triggered or not triggered, metric suppressed due to invalid data, new facility, special focus facility) |
FFVR |
PBJ Final File Validation Report |
Indicates whether the submitted file was accepted or rejected and details the warning and fatal errors applicable to the data or the data file structure submitted |
PDF |
Use to confirm submission and acceptance |
Review these reports to help ensure the quarterly PBJ data reflects your records. Most of the detail reports (D) are available as a .csv file download, which is instrumental with the assistance of Excel templates to simplify and expedite your review. We recommend the utilization of pivot tables, data filtering, and conditional formatting rules to bring attention to potential errors, omissions, or high audit risk areas, including:
- Any days without at minimum 8 RN hours. Please note the mandatory staffing rule requires RN services 24 hours a day, 7 days per week. Facilities have up to 3 years to implement.
- Exempt staff with >40 reported worked hours per week.
- Non-exempt (hourly) staff with more than 80 hours per week or >300 hours per month.
- High or low average total nurse (aides, LPNs, and RNs) staffing (less than 2 and more than 5 hours per patient day. Refer to BerryDunn’s annual national benchmarks report for comparison to your peers).
- Changes in total average nurse staff hours per patient day by over 10% compared to the previous quarter(s).
5. Spread the knowledge
Educate your PBJ reporting and management oversight team, discuss and gain clarity on your internal record-keeping policies and procedures. Obtain the most recent manuals (we recommend electronic bookmarks to the CMS site rather than printed paper copies, as the guidance may change).
6. Trust but verify
While you may have complete trust in your team, nobody is immune to an occasional mistake or omission. Responsibility for PBJ compliance is with the facility leadership. Review the reports carefully and make timely corrections.
7. Keep a close eye on Nursing Home Compare website
Check CMS nursing home compare information for your facility regularly to help ensure information is correct.
8. Don't panic: It is fixable!
If you have an unfavorable PBJ audit, there are actions you can take to remedy the situation and avoid it in the future. We suggest that your team:
- Include PBJ program compliance review in your QAPI initiatives, which makes it a multi-departmental challenge to get back on track and prevent any future non-compliance.
- Engage your communications team in crafting a meaningful response to any potential community inquiries if you receive a 1-star rating in staffing. Be prepared to describe the issue objectively and without blame, while outlining the steps the facility is taking to improve.
- Take an objective look at your systems. Consider an external consultant to help with identification of the process gap and ideas for a sustainable remediation.
If you have any questions, please reach out to Olga Gross-Balzano or any other members of BerryDunn’s Senior Living team of experts.