Other·February 28, 2023

§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 1/17/2023, 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 to release the report to the public. During a concurrent interview and record review of the Payroll-Based Journal (PBJ) Staffing Report for quarter 2 (1/1/2022 to 3/31/2022), quarter 3 (4/1/2022 to 6/30/2022), and quarter 4 (7/1/2022 to 9/30/2022), on 1/20/2023 at 4:08 p.m., with the Administrator (ADM), the ADM verified the reports indicated all three quarters were triggered because the facility failed to submit the direct care staffing information data for the quarters. The ADM stated she was in the process of getting the next quarter 10/1/2022 to 12/31/2022 completed. The ADM stated it is due by 2/14/2023. The ADM stated the employee who oversaw the submission of data to CMS left. During an interview on 1/20/2023 at 6:06 p.m., with the Director of Nursing (DON), the DON verified with the ADM the facility did not have a policy about submission of PBJ staffing data. A review of CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual, Version 2.6., dated 6/2022, indicated: "(5) Submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Direct care staffing and census data will be collected quarterly, and it was required to be timely and accurate. Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely .... The facility failed to electronically submit to CMS staffing information based on payroll data on a quarterly schedule for 2022. As a result, CMS was unable to timely collect the facility’s direct care staffing information for 2022 and to 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.