PBJ Policy Manual & FAQs Updated
Updates were posted to the PBJ Policy Manual and FAQs on June 30, 2025.
New Additions to the policy manual include:
- Facilities should run the staffing and census reports that are available in CASPER to verify the accuracy and completeness of their final submission and the accuracy of their resident census prior to the submission deadline.
- Registration information for the PBJ system through QIES is available through the following websites: • https://qtso.cms.gov/providers/cmsnet-submission-access • https://web.qiesnet.org/qiesmds/mds_home.html • https://qtso.cms.gov/training-materials/payroll-based-journal-pbj
- NOTE: In no case should a single employee ID or a single system ID have more than 22.5 hours for a single day entered. This is the maximum number of hours allowed per day to comply with the meal break policy.
- l) Nursing Staff All nursing hours must be worked onsite to be reported in PBJ. Off-site hours are not reportable, even for nursing positions with administrative duties. All nursing staff must be available to provide direct care to residents, if required.
New Additions to the PBJ FAQs include:
- Q4: If the employee takes less than a 30-minute meal break, do I still need to deduct the full 30 minutes? If I do need to deduct the full 30 minutes, then my payroll will show more time paid then worked. Would this be an issue in the case of an audit? A: Yes. While an employee may take a shorter meal break, the policy is that a 30-minute meal break must be deducted for each 8-hour shift worked. If an audit were to occur, the facility would be compliant with PBJ policy by deducting the full meal break and the auditors would not penalize the facility for the timekeeping records showing shorter breaks than the payroll records.
- Q8: If our facility hires a nurse consultant, can the hours of the nurse consultant be reported? A: If the consultant is paid by the facility to be onsite and available to provide direct care to residents, and are not performing monitoring tasks, such as helping the facility prepare for a survey or resident chart reviews, then those hours may be reported in PBJ. They would use the code for RN or RN with administrative duties, depending on the primary duties assigned.
- Q15: Can hours for nursing staff who work remotely be reported? A: No. Hours for nursing staff can only be reported if they are worked onsite, as they must be available to provide direct care if needed.
- Q18: If a provider can prove that they had an RN onsite for 8 consecutive hours and in PBJ they report 7.5 hours after removing 30 minutes for lunch, will that adversely impact them when surveyors review RN coverage? A: Surveyors should be aware of the PBJ meal break policy. A facility should be able to show a surveyor that they deducted time for meals when submitting hours in PBJ. The facility should not be cited if they can show proof that there was an RN onsite for 8 consecutive hours a day, 7 days a week.
- Q19: If there are facilities that have an RN waiver for having an RN onsite 8 hours a day, 7 days a week, are they able to share this information with CMS for consideration in the PBJ submissions? A: The facility would need to contact CMS so CMS can verify they have the RN waiver. Once this is verified, the facility would not be downgraded to a 1 star for staffing as long as they have an RN onsite for a minimum of 40 hours per week as is required by regulation when an RN waiver is granted.
- Q20: I know that only the hours paid for a salaried employee shall be submitted. Can you clarify if I can submit the hours for an extra shift that my salaried employee works, if I pay them a bonus for these additional hours? Is there a cap to the hours that can be reported for salaried employees or can hours be reported if they are worked and paid? A: The hours shall be reported under the following conditions: The payment must be directly correlated to the hours worked and must be distinguishable from other payments. (e.g., cannot be a performance-based or holiday bonus). Additionally, the bonus payment must be reasonable compensation for the services provided. Also, if an employee’s salary is based on more than 40 hours a week, and this is supported in their contract, then the total hours specified in their contract, minus meal breaks, may be reported.
- Q22: When entering data manually, how do I know my data has been submitted? A: The “Save and Submit” button serve the same purpose. Once you click the “Save” button, you will receive a “Save Successful” message, which means your data has been successfully entered. You can go back to the Manual Data Entry section and see that data immediately. In addition, running the staffing reports in CASPER will show what was included in the final PBJ submission.
- Q25: If a provider fails a PBJ audit and would like to appeal the decision, is there a way for them to do so? A: Yes. Providers are given instructions on how to file for a reconsideration in their audit results letter. There are some reasons why a facility would fail an audit where no reconsideration would be available. For example, if an audit reveals that a facility grouped contract employees under one ID instead of creating a unique ID for each contract employee, the audit is not completed. Grouped IDs will cause a significant variance because turnover cannot be calculated accurately. In that case, the results letter would not contain reconsideration instructions.
- Q26: Our understanding is that a “significant variance between the hours reported and verified” would trigger a failed PBJ audit. Is that correct? Are there any other conditions that would trigger a PBJ audit failure? A: Yes, a significant variance between the hours that were reported in PBJ and the hours that were verifiable back to payroll would result in an audit failure. A significant variance could also occur if a facility did not complete all MDS discharge assessments timely, resulting in an inaccurate census calculation. In addition, a failure to respond to an audit request or to submit all required documentation would also trigger a failed PBJ audit.
- Q27: Can you clarify that all communication regarding the audit and appeal is through the auditors and not directly from CMS? A: The audit request and all subsequent communication regarding the audit would come directly from the current audit contractor and not from CMS. This includes the final results letter and, if a reconsideration is requested, the results of that request. Please note that all reconsiderations are sent to CMS for review and final decision, however, the final decision would be communicated by the audit contractor.
Written By:
Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CPC, CLNC
Director of Regulatory Services
Proactive LTC Consulting
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