Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information, including agency and contract staff, based on payroll and other auditable data. The data, when combined with census information, can then be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure, which can impact the quality of care delivered.
The Centers for Medicare and Medicaid Services has developed a system known as Payroll-Based Journal (PBJ) that will help facilities to submit staffing and census information. This system will allow staffing and census information to be collected on a regular and more frequent basis than currently collected. It will also be auditable to ensure accuracy. All long-term care facilities will have access to this system at no cost to facilities.
CMS publicizes that it has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care. Over time, CMS has utilized staffing data for a myriad of purposes in what it says is an effort to more accurately and effectively gauge its impact on quality of care in nursing homes. Staffing information is also posted on the CMS Nursing Home Compare website, and it is used in the Nursing Home Five Star Quality Rating System to help consumers understand the level and differences of staffing in nursing homes.
In case you weren’t aware of the background, here it is: For the past five years, the Centers for Medicare & Medicaid Services has provided a one-to-five-star rating for nursing homes that participate in the government programs. The system gives nursing homes a rating in three important categories: nurse staffing, annual inspection results, and quality measures. The facilities then receive a composite rating combining those categories.
Critics of the system have noted that nursing homes had been allowed to self report much of their data, and some facilities may have “enhanced” their ratings.
So, in 2015, in an effort to improve transparency and reduce fraudulent reporting, Congress passed “The Improving Medicare Post-Acute Care Transformation Act,” or IMPACT. Among other things, this act requires nursing facilities to use staffing data based on payroll and other verifiable, auditable data, and send the data electronically to the Department of Health and Human Services.
There are items that will need further clarification. It has been pointed out, for example, that nursing homes may have difficulty determining just what constitutes payroll and staffing data. For example, many facilities utilize temporary staff, for one of many reasons: some facilities may be located in areas where it is difficult to find full-time, trained personnel, and some nurses don't want full-time jobs.
These nurses, known as “pool” labor, therefore do not appear on nursing homes' payroll systems as employees. Instead, the facilities pay the pool provider with a single check. It is thus unclear how nursing homes will account for these employees in their payroll data reports (the IMPACT law specifies that nursing homes should include agency and contract staff in their reporting).
With the new PBJ requirements, the CMS did make a rating system change that should be helpful both to consumers and nursing homes: it now filters out administrative resources at nursing homes, as that information may distract from identifying the actual level of hands-on care at the bedside of each facility. But therein lies another question about the use of salaried administrative personnel in direct care nursing roles. For example: a director of nursing’s job doesn't count toward the rankings. But if a nurse calls in sick one day, and the director of nursing substitutes on that shift, there is no way to show this through the normal payroll reporting procedure. Any facility that doesn’t properly account for these staffing situations could experience a reduction in the overall five star ranking, and a drop in stars can have a significant impact on the perceptions of residents, family and managed care payers.
CMS began collecting staffing and census data through the PBJ system on a voluntary basis beginning on October 1, 2015; it will be mandatory beginning on July 1, 2016. Registration for voluntary submission began August 2015; training is provided on registration for both voluntary and mandatory submissions.
This file provides general background and information about the submission requirements, such as sample submission screens, submission deadlines, and definitions of job categories. Questions regarding the PBJ Policy Manual should be directed to firstname.lastname@example.org.
Information about future implementation of the PBJ steps will be communicated over the next several months.