§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.
|
Observations:
Based on record review and interview, it was determined that the facility failed to submit accurate staffing information in the Payroll-Based Journal (PBJ) system for two of the four quarters reviewed (October 1, 2023, through December 31, 2023, and July 1, 2023, through September 30, 2023).
Findings include:
A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 4 2023 (July 1 - September 30) revealed that the facility's data triggered for no registered nurse (RN) hours on August, 5, 2023, August 6, 2023, August 27, 2023, September 2, 2023 and September 4. 2023.
A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 1 2024 (October 1 - December 31) revealed that the facility's data triggered for no registered nurse (RN) hours on October 1, 2023, October 14, 2023, November 18, 2023, November 19, 2023, November 23, 2023, and November 25, 2023.
A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had RN staffing working on each date that triggered for no RN hours on the PBJ Staffing Data Reports.
During an interview on March 7, 2024, at approximately 10:00 AM, the facility Vice President of Skilled Nursing Operations indicated that the PBJ trigger for no RN hours was due to a coding error that occurred when the facility updated their system to identify charge nurses. He explained that charge nurses were added to the facility's reporting system in July of 2023, but the facility failed to code the charge nurses as registered nurses for submissions through the PBJ system.
28 Pa. Code 201.18 (e)(2) Management
| | Plan of Correction - To be completed: 04/16/2024
1. The facility cannot correct the data submitted for calendar Q3 2023, and calendar Q4, 2023, as the CMS submission / correction deadlines have passed. 2. A system wide audit was completed for all positions currently in the payroll system, to ensure all positions are coded properly to the PBJ table for accurate staffing information data submission to PBJ. 3. Payroll representatives, human resources personnel, and IT staff involved in the coding of staffing data, and the creation of PBJ files for submission, have been re-educated on proper coding of positions for accurate reporting. 4. Prior to each quarterly submission, the facility will audit the payroll system and PBJ lookup table, to ensure all positions are coded properly for accurate staffing information to be submitted to PBJ.
|
|