As early as April 2018, the Centers for Medicare & Medicaid Services was planning to use Payroll Based Journal (PBJ) data in ways other than calculating and reporting a staffing rating on the Five-Star Quality Rating System. In memo QSO 18-17-NH, CMS reported its intention to use PBJ data to inform the survey process to help surveyors identify if a facility’s staffing is an underlying root cause for quality issues.

Little details were given regarding definition of terms or the methodology CMS would use to analyze and then report the PBJ data. Seven months later, in a subsequent memo (QSO 19-02-NH), CMS notified state survey agencies that CMS would be providing them a list of facilities with potential staffing issues. CMS defines facilities with potential staffing issues as those facilities with low nurse staffing levels on weekends.

But what does low nurse staffing levels mean, and how will PBJ data be used to create the list? After posing these questions, CMS clarified how facilities with low nurse staffing levels on weekends will be identified. CMS will be flagging the bottom decile (10%) in each state based on total reported weekend nurse staffing. The list will be forwarded to state survey agencies, who are then charged with increasing the number of weekend surveys. Surveyors will use this list to identify facilities due for survey that have potential staffing issues and schedule their surveys to occur on the weekend.

Prior to the release of memo QSO 19-02-NH, surveyors were required to perform 10% of all surveys on either weekends or off hours. Post release, surveyors are required to hold 50% of all off-hour surveys on weekends. One cannot disregard concerns on the impact of using PBJ data for this purpose. One concern is that CMS is just identifying the bottom decile without risk adjusting for acuity of the resident. Nor does identifying the bottom decile compare a facility’s weekday staffing with its own weekend staffing. This means a facility whose nurse staffing levels are appropriate for its resident population may be targeted and subject to a weekend survey.

Another concern for using PBJ data for this purpose is that facilities may not be submitting accurate or timely data. These facilities may be targeted and subject to weekend surveys when nurse staffing levels aren’t truly in the bottom decile.

Now, more than ever, it is imperative to complete and submit accurate and timely PBJ data. There are several ways this goal can be accomplished:

  • High-level leadership support for the process
  • Creating a PBJ team and convening often
  • Open communication between team members
  • Using redundancy procedures to self-audit data
  • Staying up to date with the latest PBJ software
  • Keeping track of PBJ submission deadlines and creating reminders
  • Reviewing monthly Provider Preview Reports in the Certification and Survey Provider Enhanced Reporting (CASPER) folder
  • Running Reports: 1700D – Employee Report; 1702D – Individual Daily Staffing Report; and 1702S – Staffing Summary Report to verify accuracy of data
  • Correcting any inconsistencies within the data submission window – 45 days after the reporting quarter closes

If you believe the information CMS is posting about your facility is in error, please contact NHStaffing@cms.hhs.gov.

Susan Chenail, RN, CCM, RAC-CT, is a Senior Quality Improvement Analyst at LeadingAge New York Technology Solutions, LLC