§483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.
§483.70(q)(1) Direct Care Staff. Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).
§483.70(q)(2) Submission requirements. The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following: (i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS); (ii) Resident census data; and (iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).
§483.70(q)(3) Distinguishing employee from agency and contract staff. When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.
§483.70(q)(4) Data format. The facility must submit direct care staffing information in the uniform format specified by CMS.
§483.70(q)(5) Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.
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Observations:
Based on record review and interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for four of four quarters reviewed. (Quarters one, two, three, and four)
Findings include:
A review of PBJ staffing data reports revealed that the facility did not submit data for quarter two (January 1, through March 31, 2023), quarter three (April 1, through June 30, 2023), quarter four (July 1, through September 30, 2023), and quarter one (October 1, through December 31, 2023).
In an interview on February 6, 2024, at 10:04 a.m., the Administrator confirmed that the facility had not submitted staffing information in the PBJ system.
28 Pa. Code 201.14(a) Responsibility of licensee.
| | Plan of Correction - To be completed: 03/13/2024
1 The facility is unable to retrospectively submit missed staffing data reports by report date of 2/14/2024. The facility does continuously meet and mostly exceeds the minimum staffing ratio required by state regulation. 2 The Administrator, in a combined effort with the Payroll Coordinator and Corporate Office assistance, will continue to gather data as once planned, for composing it to Payroll-Based-Journal specifications for final review and submission. The next Report-By date with the PBJ system is 5/15/2024. 3 The Administrator will be re-educated by the Operations Officer as to the importance and mandatory requirement of electronically reporting employee role and time data to the Payroll Based Journal System in a thorough, complete, and timely manner. To serve as monitor and audit, the Operations Officer will be made aware of progress towards meeting the next Report-By date twice a week for 4 weeks, and once a week until complete submission. 4 Results of our PBJ reporting audit with related progress will be reviewed, and respective data submitted to the Quality Assurance and Performance Improvement Committee until necessary, to determine effectiveness, improvement, or if further measure is necessary to correct any persistence or worsening of facility compliance.
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