Q: After submitting our quarterly PBJ file we discovered there were hours for agency nursing staff that we omitted. Are we able to correct this omission? Will the omission impact our Five Star rating?
A: The ability to correct depends on whether the submission window is still open or not. The deadline for each reporting period is as follows:
| Reporting Period | Due Date |
| October 1- December 31 | February 14 |
| January 1- March 31 | May 15 |
| April 1- June 30 | August 14 |
| July – September 20 | November 14 |
If the error was noted in the PBJ file for the quarter from October 1 – December 31, you have until February 14th to make the identified corrections. After the submission period has closed no additional payroll data or corrections will be accepted.
In situations where the omission is identified and corrected timely, the quarterly data reported and used for calculating staffing measures will be accurate. The facility’s Five Star staff rating should be an accurate reflection of the facility’s staffing for the quarter. If the issue is not identified timely, the inability to submit the agency hours could lower the facility’s staffing rating since the nursing hours reported for the quarter are less than the actual hours worked.
Facilities should focus on putting processes in place to prevent these types of omissions and error from occurring.
Strategies to ensure accurate timely PBJ data is submitted to CMS include:
- Strengthen the timekeeping and data integrity
- Ensure staff clock in/out in real time rather than relying on manual edits
- Implement a process for time reconciliation to identify and resolve missed punches early
- Limit the ability to make edit to the time entry system and validate there is documented justification for each change made
- Monitor Agency and Contracted hours
- Require agency and other contracted vendors to provide PBJ data in a CMS compatible format, if possible
- Confirm that the agency and therapy job codes are consistent with CMS PBJ job codes
- you may want to add agency staff to the payroll system with the appropriate job codes and allow them the ability to clock in/out to the timekeeping system rather than relying on sign in sheets requiring a manual entry into the system
- Maintain accurate job codes and employee classifications
- Map each employee to the correct CMS PBJ job code and review the accuracy of this information at least quarterly
- Be sure to update the job code if the employee’s status changes (i.e. an LPN as completed the RN program and is now employed as an RN)
- Validate that the hours for employees who work multiple roles are assigned to the correct PBJ codes for each role and the hours are correctly assigned
- Establish a PBJ workflow
- Create a PBJ calendar with internal deadlines that occur prior to the CMS submission deadline
- Assign clear roles and delegate responsibilities to appropriate team members
- Data preparer – responsible for pull the hours to the PBJ file
- Reviewer – responsible for validating the accuracy and completeness of the file
- Submitter – responsible for the final sign off and submission of the PBJ date and reviewing the final validation reports
- Be sure to have a backup submitter identified in the event the primary is not available to complete PBJ related duties in a timely manner
- Conduct Internal Audits
- On a monthly basis conduct an audit to compare timekeeping hours to payroll hours
- Validate that meal breaks, PTO and other non-worked hours are excluded as required
- Review overtime, agency, and exempt staff hours for accuracy
Contact Proactive for 5 Star Support including mock surveys, Quality Measure Improvement consultation and PBJ Staffing data compliance assistance.
Written By:
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Senior Consultant
Proactive LTC Consulting
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