Next Quarterly Payroll-Based Journal Data Submission Due by May 15th
We remind nursing home members that Payroll-Based Journal (PBJ) data submissions covering Jan. 1st through March 31st must be finalized with the Centers for Medicare and Medicaid Services (CMS) by May 15th. PBJ submissions have been the basis for calculating the staffing domain of the Five-Star Quality Rating System for several years, and they are now being used to compute staff turnover and weekend staffing rates currently being displayed on Nursing Home Compare. As of July of this year, CMS expects to incorporate these measures into the Five-Star calculation.
In addition, the State will utilize PBJ data to measure compliance with State staffing level requirements, although penalties will not be assessed based on data due May 15th. (Members can access their 2021 Q4 PBJ data put in context of the State staffing requirements here.) Only data that are successfully submitted by the deadline are used in Five-Star calculations, and inaccurate or missing submissions can result in a home being assigned a single star for the staffing domain for one quarter.
Members should be certain that their homes are accurately reflecting in their reporting the requirement that they have a registered nurse (RN) on site for at least eight consecutive hours, seven days per week. The latest version of the PBJ policy manual and related resources are available for download at the bottom of the dedicated CMS PBJ webpage here. The user guide for uploading data through the CMSNet Secure Access Service is available here.
Based on prior areas of concern identified by CMS, the following reporting items warrant special attention to ensure accurate reporting:
Meal Breaks. Meal breaks must be subtracted from PBJ-reported time regardless of whether staff worked through lunch or actually took the break. When reporting, you must deduct the time allotted for meals from each employee’s daily hours.
RN Staffing. Providers should ensure that they are meeting the requirement to have an RN on site for at least eight consecutive hours, seven days per week; that their reporting accurately reflects the hours; and that they are able to readily provide necessary documentation to back up the reporting.
Varying Roles and Universal Workers. While reporting is based on primary roles, CMS recognizes that staff may completely shift their primary role in a given day, and in those cases, facilities can change the designated job title and split the staff member’s hours into two separate job roles during a shift if warranted. For facilities that use universal care workers, a reasonable methodology must be used to separate the time that the universal care worker spends performing their primary role from their time that is spent performing other activities. The PBJ Frequently Asked Questions (FAQs) provide further examples.
High, Low, and Fluctuating Hours. CMS and their contract auditors appear to focus on reporting that indicates unreasonably high or low work hours, large variations in weekday versus weekend staffing, as well as low weekend staffing.
Calendar Day Reporting. Staff hours must be reported on a calendar day basis. Providers are required to split shifts that straddle midnight into individual calendar days. For example, if an employee works a shift that starts at 11 p.m. and ends at 7 a.m., one hour would need to be reported for day 1 and the remaining six hours for day 2. CMS has indicated its understanding that employees may be paid per shift and not per calendar day and will consider this when conducting audits.
Training Time. Hours for staff who are attending training (either on site or off site) and are not available to perform their primary role, such as providing resident care, should not be reported. If another staff member is called in to fill in for staff participating in training, the hours for the replacement employee should be reported.
Staff Identifiers. With CMS seeking to incorporate turnover rates into the Five-Star Quality Rating System later this year, providers should ensure that the systems they have in place to identify individual workers, including contract staff, are working and that continuity was preserved if providers updated or changed their worker identifier systems.
National Guard. If National Guard members have been deployed to your facility, and they meet the definition of temporary nurse aides (TNAs), the TNA hours worked by these National Guard members may be reported in PBJ. The nursing home should provide the National Guard Non-Commissioned Officer In Charge (NCOIC) with a document with the information that will be reported in PBJ, including the Guard members who worked as TNAs and the dates and times they worked. The NCOICs have been authorized to sign these documents.
CMS recommends that providers take advantage of the verification resources after uploading their data to ensure a successful submission.
Once the data is uploaded, the system will remind the user to:
- Check the My Submissions page. This feature will show the status of the zip file.
- Check the Certification and Survey Provider Enhanced Reporting (CASPER) application for a system-generated PBJ Final File Validation Report (FFVR) within 24 hours. If no FFVR appears, run a PBJ Submitter FFVR to check your file for errors.
- Run the PBJ 1702D (by Employer) or 1703D (by Job Type) Reports to verify that the submitted quarterly PBJ data accurately reflects your records.
Information from CMS describing the various PBJ reports providers may access, including general and detailed Minimum Data Set (MDS) census reports, is available here.
Because daily census is an important component of the PBJ staffing calculation and is derived from MDS submissions, providers should ensure that MDS assessments, including discharge records, are filed in a timely way. Please note that accurate and timely PBJ reporting also has implications for the facility's Nursing Home Quality Initiative (NHQI) score calculation.
The current PBJ Manual (dated November 2018) is available here, and an accompanying FAQ document is here.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841