Don’t let inaccurate staffing information steal your stars

Don’t let inaccurate staffing information steal your stars

AUGUST 21, 2019

Adequate and qualified staffing is vital to the successful operation of a long-term care facility. The Centers for Medicare & Medicaid Services (CMS) also identifies staffing as a key component of a facility’s ability to provide their residents with quality care. In recent years, CMS has used staffing data in several ways aimed at measuring its impact on the quality of care. Staffing information is posted on the CMS Nursing Home Compare website and it is used in the Five Star Quality Rating System to help consumers understand how staffing translates into level of quality. Since July 2016, facilities have been submitting staffing data electronically through the Payroll Based Journal (PBJ) system as required under section 1128I(g) of the Social Security Act (the Act) and 42 CFR §483.70(q). The data entered are the number of hours that direct care staff are paid to work each day. This includes agency and contract staff. CMS periodically analyzes the data for possible inaccurate reporting and some facilities could be flagged for auditing.

In April, PBJ data gained even more importance as CMS changes to the Five-Star rating system took effect. Previously, if a facility reported seven or more days per quarter without a registered nurse (RN) onsite, the facility was given an automatic one-star rating for the Staffing Levels category. Now, a facility will get an automatic one-star rating if they don’t have a RN on-site for four days or more per quarter. Failing to submit PBJ data by required deadlines can also result in a one-star rating.

Additionally, facilities can receive a one-star for significant inaccuracies of verified staffing hours found during auditing. According to a 2018 CMS memo,“Examples of significant inaccuracies are instances where the difference between the submitted hours and verified hours is large enough that it would change a facility’s star rating, or change how the facility compares to its state’s average.” Inaccuracies can lead to potential non-compliance action so it’s important that facilities do everything they can to ensure they are gathering and submitting accurate information. Facilities can be proactive and perform an internal audit of PBJ information prior to submitting it to identify potential trouble spots.

The Compliance Store has several resources for addressing staffing and submitting PBJ information. We also have tools to help facilities check the accuracy of their data, including one for internal audits. To learn more about how you can connect with the right information to guide you through gathering and submitting PBJ data, contact The Compliance Store at

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