Off-Site Staffing in Nursing Homes: CMS Clarifies PBJ Reporting and Licensing Requirements
(August 18, 2025) The Centers for Medicare & Medicaid Services (CMS) has issued important clarifications regarding the use of off-site staff, particularly Minimum Data Set (MDS) coordinators. These updates, published in the revised Payroll-Based Journal (PBJ) Policy Manual and FAQs, reinforce compliance expectations for staffing data reporting and resident assessment practices.
CMS has clarified that only hours worked on-site may be recorded in the PBJ system. This applies even to nurses performing administrative duties. While facilities may utilize off-site staff for tasks such as MDS coding and transmission, those hours are not reportable in PBJ submissions.
Facilities must ensure that all PBJ-reported hours reflect direct care or administrative work performed physically within the facility. This policy aims to maintain transparency and accuracy in staffing data used for quality ratings and oversight.
MDS Coordination and Assessment Requirements:
Off-site nurses may assist with coding and transmitting MDS data, but nursing homes must still meet all assessment requirements. These include:
- Direct observation of residents
- Communication with residents
- Collaboration with the interdisciplinary team
These elements are essential to ensure that assessments are accurate, person-centered, and compliant with federal standards.
Licensure Requirements for Off-Site Staff:
Any off-site staff performing duties for a nursing home must be licensed to practice in the state where the facility is located. This means that off-site MDS coordinators must hold valid licensure in each state where they support facilities. This requirement ensures that all staff involved in resident care and assessment meet the professional standards and legal obligations of the jurisdiction in which services are delivered.
For questions regarding MDS tasks, scope of practice, or assessment protocols, providers should contact their State Resident Assessment Instrument (RAI) Coordinator. The most current list of state contacts is available in Appendix B of the MDS 3.0 RAI Manual.
Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 x. 147