United States

Senior Living Health Care Connection: Staffing data collection alert

Prospective Payment System and Consolidated Billing series


This is the first in a series of three alerts highlighting the Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016 Final Rule.

Topics to be highlighted in the series include:

  1. Staffing data collection
  2. SNF Value Based Purchasing program
  3. SNF Quality Reporting program

Staffing data collection

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 Centers for Medicare & Medicaid Services (CMS) has developed an electronic system for facilities to submit staffing and census information electronically through the Payroll-Based Journal (PBJ) system. Facilities can begin to collect the staffing data on a voluntary basis, beginning on October 1, 2015, and on a mandatory basis, beginning on July 1, 2016.

Facilities (SNFs and NFs) are required to report total hours paid for services performed onsite for the residents of the facility, which does not include paid time off (e.g., vacation, sick leave, etc.). Additionally, hours for direct care staff who provide care and services to residents does not include individuals whose primary duty is maintaining the physical environment of the long-term care facility (e.g., housekeeping).

Facilities should report only the total hours of an employee, based on their primary role, and data reported should be auditable and able to be verified through either payroll, invoices or tied back to a contract. Facilities must use a reasonable methodology for calculating and reporting the number of hours spent on-site conducting primary responsibilities. The reported hours should not include hours for staff providing services to residents in noncertified beds. Contract staff hours are also to be reported, and each contract staff member must receive a unique ID that is affiliated with the unique facility ID.

Each facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:

  • 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)
  • Resident census data on the last day of each quarter
  • Information on direct care staff turnover and tenure
    • The hours of care provided by each category of staff per resident per day
    • Staff start date, end date (as applicable)
    • Hours worked for each individual

Staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours worked by each staff member each day within a quarter. Census data includes the facility’s census on the last day of each of the three months in a quarter.

Submission of staffing information through PBJ will be accessed through the Quality Improvement & Evaluation System (QIES). To connect to PBJ through QIES, you must have a CMSNet User ID. There are two primary submission methods:

  1. Manual data entry
  2. Uploaded data from an automated payroll or time and attendance system (XML format only)

Facilities can use both methods and combinations of these methods. Facilities must obtain a user ID for individual, corporate and third-party users. Most already use this ID for MDS submission. In addition facilities must obtain a PBJ QIES Provider ID for CASPER Reporting and for PBJ system access.

The whole process should be quick, but be sure to have the facility information (CCN state, etc.) readily available. For additional information, visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.

Facilities are highly encouraged to begin submitting staffing data on a voluntary basis within the next few months. This will ensure a smooth transition when the reporting is mandated on July 1, 2016.

Look for the next alert, which highlights Value-Based Purchasing and the SNF Readmission Measure.

For more information, contact Joan McCarthy at 312.634.3479.

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