Other·February 2, 2024

42 CFR §483.70(q) Mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. §483.70(q)(2) Submission requirements. The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following: (i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS); (ii) Resident census data; and (iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual). §483.70(q)(4) Data format. The facility must submit direct care staffing information in the uniform format specified by CMS. §483.70(q)(5) Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. On 12/15/2023, the California Department of Public Health made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022. As a result, CMS was unable to timely collect the facility’s direct care staffing information for 2022 and release the report to the public. On 12/18/2023 at 6:30 p.m., during a concurrent interview with the Finance Coordinator (FC) and a review of the Payroll-Based Journal (PBJ) Staffing Report for quarter four (4) of 2022 (from 7/1/2022 to 9/30/2022 end of Federal Fiscal Year [FFY]), the FC stated that around this time the facility was using another software and there was no record and she had no recollection if the PBJ Staffing Report had been submitted based on the submission timeframe. The FC stated that the current software they are using has no capability to pull up the record beyond the previous 150 days. The FC stated that she could not verify if the submission was done timely. A review of the facility's policy and procedure titled, "Reporting Direct Care Staffing Information: PBJ," dated 1/27/2021, indicated that staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Staffing information is collected daily and for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: - Fiscal Quarter 4: Date Range July 1-September 30. Submission Deadline November 14. The facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the CMS in 2022. As a result, CMS was unable to timely collect the facility’s direct care staffing information for 2022 and release the report to the public. The above violation had a direct relationship to the health, safety, or security of the residents at the facility.