CMS Peels Back Curtain on Why Providers Receive PBJ Audits

As part of the federal government’s effort to verify staffing levels at skilled nursing facilities, skilled nursing facilities are rated on their nursing and caretaking personnel based on payroll records. How the government assesses those records has raised questions among providers, and the Centers for Medicare & Medicaid Services (CMS) recently gave Skilled Nursing News a glimpse into the audit process.

The goal is to have every facility submitting verifiable, auditable data, using the payroll-based journal (PBJ) staffing information. It’s the audit aspect that has led to some uncertainty. At the American Health Care Association (AHCA) conference and expo in San Diego in October, several speakers on a PBJ panel wanted to know more about what might trigger an audit by CMS.

“It’s the million-dollar question, right?” Don Feige, the founder and former owner of SNF-focused software firm ezPBJ, told Skilled Nursing News.


The hunt for red flags

Feige is trying to crowdsource the answer to that question based on the audit requests he receives from his ezPBJ customers. While Feige founded the company in 2016, it was acquired in August this year by the by Des Moines, Iowa-based Briggs Healthcare, which works with about 12,000 long-term care facilities.

After being flagged for an audit, facilities have five business days to upload the requested data to a website set up specifically for the purpose, according to a presentation by Lois McCaskey, vice president of labor management at Genesis Health Care. A pair of private companies,Granite Dolphin Actuarial Services and the accounting firm Myers and Stauffer, have partnered up to conduct the audits for CMS.


When the PBJ system was introduced in April, the audits seemed designed to draw SNFs’ attention to inaccuracies in their data, Feige told SNN.

“Early on, from how we were seeing [the audits], it felt like the deviations, the bad data, was showing up, and [SNFs] were getting audited for that to get fixed,” he said. “When we saw audits, it felt like CMS was saying, ‘This doesn’t look right to us. Go check your numbers and see what’s going on.’ Without really saying it that way.”

The PBJ data is analyzed every quarter for possible inaccurate reporting, and the criteria for audits changes each quarter, based on continued analysis of each quarter’s data, a spokesperson for CMS told SNN in response to e-mailed questions about the policy and the mechanics of the audit process.

The accuracy of the PBJ data is of paramount importance for SNFs, since facilities that report seven days or more without a registered nurse (RN) onsite will automatically receive a one-star staffing rating for three months.  But data accuracy is not the only thing that could trigger such a rating for a quarter; submitted data that fails an audit can also bring about a one-star rating for staffing.

“Past triggers [for an audit] include facilities with greater than eight nursing hours per resident per day, a high number of days with no RN hours, and individual employees reporting greater than 400 hours per month,” the CMS spokesperson said.

The process itself involves analyzing a sample of records to verify the accuracy of the data submitted, she added.

“If a systemic issue is found, such as not adhering to the reporting policies in the PBJ Manual (e.g., removing meal time), the results are extrapolated to the employees outside the sample to determine the total error rate,” the CMS spokesperson explained. “If isolated errors are found, such as erroneously submitting data for a single employee, the results are not extrapolated to the other employees.”

Defining ‘discrepancies’

At the PBJ presentation at the AHCA conference, attendees wanted to know what constituted a significant discrepancy  and with good reason, since according to the CMS spokesperson, facilities whose audit finds “significant discrepancies” between the hours reported and hours verified are presumed to have low staffing levels.

“Examples of significant discrepancies include, but are not limited to, instances in which the difference between the submitted hours and verified hours result in a change that is greater than 4%, is large enough that it would change a facility’s star rating, or is large enough that it would change how the facility compares to its state’s average,” the CMS spokesperson explained.

Meal breaks have also caused some confusion for SNFs, Feige told SNN, since a nursing home worker providing direct care could easily end up working through the time alloted to them for a break. But even if that happens, meal breaks still need to be removed from PBJ hours. It’s led to some anger among Feige’s customers, he told SNN.

The CMS spokesperson confirmed that meal break time has to be removed from each employee’s daily hours.

“For example, CMS expects each nursing facility to reduce total hours worked by .50 hours for each shift of 8 hours or more and 1.0 hour for shifts of 16 hours or more to account for meal time,” she explained. “Time allotted for meals should be removed whether or not the employee actually takes a meal break and whether or not the employee is paid for the time spent on a meal break.”

Studying the data

CMS continues to study the new staffing data to determine how to publicly report other staffing information, allowing for more information for consumers and stakeholders about the quality of care and staffing level of a given facility, the spokesperson said. Some of the factors the agency is evaluating include rates of turnover and tenure, and hours worked by non-nursing staff that affect resident care.

It also could end up playing a broader role in state oversight.

“We also intend to use the data to support the health inspection process, by informing state inspectors of potential staffing issues,” the CMS spokesperson told SNN. “This will help inspectors and nursing home operators learn if a facility’s staffing is an underlying cause for quality issues. If state surveyors identify harm or potential harm as a result of insufficient staffing, they should cite it as noncompliance. If the noncompliance meets CMS criteria for enforcement remedies, the facility will be subject to sanctions and could potentially be terminated from the Medicare program.”

And facilities need to remember not to put the cart before the horse. Accurate data is the goal of PBJ, and it’s something facilities need to make sure they’re achieving.

“We remind facilities that they should be focused on reporting accurate information, rather than focusing on what happens if they don’t,” the CMS spokesperson said.

Written by Maggie Flynn

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