The Centers for Medicare and Medicaid Services (CMS) is moving forward with implementation of the Payroll-Based Journal (PBJ), an electronic system through which nursing facilities will soon be required to submit staffing and census information. In announcing this initiative, CMS stated that it “has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care.”1 This understanding and the increased collection and auditing of staffing and census data likely foreshadows the agency’s intent to more closely compare data gathered on existing quality measures with trends in staffing levels. As CMS reviews the data collected through the PBJ, staffing levels will likely receive even more attention during surveys. Ultimately, collected staffing data will likely inform CMS’ development of objective staffing competency standards as proposed within a CMS July 16, 2015 Proposed Rule that would comprehensively revise Medicare and Medicaid participation requirements of nursing facilities.2
Section 6106 of the Affordable Care Act (ACA) mandates that the Department of Health and Human Services require nursing facilities to electronically submit direct care staffing information (including agency and contract staff) from payroll and other auditable data systems in a uniform format. The information collected must:
To implement these requirements, CMS has developed the Payroll-Based Journal (PBJ) and issued a Draft PBJ Policy Manual.
Draft Policy Manual
System Registration & Technical Requirements
The PBJ system will require a CMSNet user ID and will be accessible through the Quality Improvement & Evaluation System (QIES). Most facilities will already have access to the CMSNet and QIES systems for MDS submissions, but facility staff and vendors—such as payroll vendors—will still need to register for access to the PBJ system in order to enter data. Registration will begin this August for those facilities interested in submitting staffing and census data to the PBJ system on a voluntary basis. Voluntary data submissions will begin on October 1, 2015. CMS intends to implement mandatory quarterly reporting of staffing and census data by all facilities on July 1, 2016.
The PBJ system is designed to accept both manual data entries and information uploaded from payroll or timekeeping systems. Facilities planning to register in August for voluntary PBJ submissions should consult with their automated payroll or time and attendance system vendors prior to registration to determine system compatibility. The supported formats and detailed technical specifications are available for download from the CMS website.3 CMS is instructing facilities, vendors, and software developers to direct all questions regarding PJB data specifications to NursingHomePBJTechIssues@cms.hhs.gov.
Data Submission & Content
The draft policy states that CMS will require facilities to submit staffing and census data for each fiscal quarter. Submissions must reflect the number of hours worked by each staff member for each day of the quarter and the resident census for the last day of each month within the quarter. The required resident census information consists of the number of residents whose primary payor is Medicare, Medicaid, or Other as of the last day of the month. Facilities will need to transmit this data within forty-five days following the last day of the quarter for the submission to be considered timely. Although facilities must transmit data quarterly, the PBJ system will allow facilities to enter data at any time; therefore, facilities having to enter data manually will not have to wait and input all of the information for the quarter at one time.
Facilities will need to enter all employees and contract staff into the system with a unique Employee ID. Employee IDs must not contain any personally-identifiable information, and records indicating to whom an Employee ID corresponds will not be stored in the PBJ system. Employee IDs cannot be reused upon termination of an employee unless that same employee later returns. For each employee, facilities will also have to input:
The breakdown of staffing hours and classifications should look familiar to those staff accustomed to completing the CMS-671 form as part of their facility’s survey process. The PBJ covers the same Labor Categories (e.g., Nursing Services, Administrative Services, Therapeutic Services) and similar4 Job Descriptions (e.g., within Nursing Services: RN, LPN, CNA, etc.) as those reported on the CMS-671. Staff members entering data into the PBJ system manually will select the Labor Category and corresponding Job Description from a dropdown menu. For facilities planning to upload data into the system, the PBJ submission specifications download provides files containing all of the required coding information and values.
The reporting requirements proposed for the PBJ system are likely to result in far more accurate data on staffing and census. Requiring these data in large amounts and in a uniform format offers considerable opportunities for analyzing and auditing these data sets along customizable parameters. Averaging daily staffing numbers on a quarterly basis will yield more precise figures than attempting to generalize typical staffing levels based on a two-week period out of each year. There may also be concern on the part of CMS that current staffing numbers are artificially inflated by gathering data for the pay period immediately preceding a facility’s annual survey, as facilities may have generally higher staffing levels while they are in their survey window. However, improved data collection techniques may be beneficial to facilities as well. For example, quarterly reporting will better account for phenomena such as seasonal trends and fluctuations in skilled census.
It is foreseeable, based on CMS’s characterization of staffing as a vital component of quality, that the agency may compare staffing and census data with data collected on existing quality measures (e.g., falls with injury, antipsychotic use, pressure ulcers) to extrapolate a correlation. However, knowing a facility’s average staffing ratio and knowing how many falls with injury occurred that quarter provides no insight into what relationship, if any, exists between the two. Simply comparing staffing data to one or more other quality measures fails to control for the influence of countless other variables.
How CMS will analyze, interpret, and ultimately utilize information collected through the PBJ system remains to be seen, but nursing facility staff may want to brush off their old statistics textbook and be prepared to educate consumers on what exactly these numbers do and do not tell them. Similarly, facilities might benefit from familiarity with some of their own figures that CMS will not be reporting on, such as average years of experience of direct care staff.
If you have questions regarding implementation of the Payroll-Based Journal System and reporting requirements, or if you require legal assistance coordinating with vendors and contract staff, please contact Peter Mellette (Peter@mellettepc.com), Harrison Gibbs (Harrison@mellettepc.com), Nathan Mortier (Nathan@mellettepc.com), or Elizabeth Dahl (Elizabeth@mellettepc.com) or call Mellette PC at (757) 259-9200.
This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up to date and fact specific advice.
1 CMS, Staffing Data Submission PBJ (updated Apr. 29, 2015), available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.
2 Reform of Requirements for Long-Term Care Facilities, 80 Fed. Reg. 42167 (proposed July 16, 2015) (to be codified at 42 C.F.R. pt. 483).
3 The “Submission Specs” for the October 2015 release are available in the Downloads section at the link provided above or may be accessed directly at the following link: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/PBJ-1-0-Submission-Specs.zip. Facilities are encouraged, however, to check the CMS website for updates; particularly once facilities begin uploading data during the voluntary submission period, some of the technical requirements and specification may undergo adjustments.
4 The PBJ does include some more specific job descriptions than the 671. For example, the PBJ system includes job descriptions for RNs with administrative duties and LPNs with administrative duties, versus the 671’s more general “Nurses with Administrative Duties.”