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Nurse Staffing in Nursing Homes: CMS Transition to Payroll-Based Journal Staffing Data on Nursing Home Compare Will Provide Better Information for the Public

Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) will begin using Payroll-Based Journal (PBJ) staffing data to determine each facility’s staff rating on Nursing Home Compare. All facilities must submit staffing data each quarter on “the number of hours staff are paid to work each day of that quarter.”[1] The goal of the requirement is to provide better public reporting of each facility’s staffing practices in a manner that is auditable based on payroll “and other verifiable sources.”[2] Prior to the PBJ requirement, a facility’s staff rating on Nursing Home Compare was based on self-reported data and was susceptible to greater manipulation by some facilities.

The transition to PBJ data is also accompanied by staffing data audits. According to the CMS memorandum announcing the transition, “CMS and its contractors have begun conducting audits aimed at verifying that the staffing hours submitted by facilities are aligned with the hours staff were paid to work over the same timeframe.”[3] When these audits result in a finding that a facility’s PBJ data is significantly inaccurate or incomplete, CMS will presume that the facility has low staffing levels, resulting in a one-star staffing rating and a reduction of the facility’s overall star rating.[4]

Similarly, beginning July 2018, a finding that the facility failed to have a registered nurse on duty as required by law (eight hours a day, seven days a week), for at least seven days each quarter, will also result in a one-star staffing rating on Nursing Home Compare.[5] CMS’s memo adds that, based on PBJ data for the third quarter of 2017, about six percent of facilities had seven or more days without a reported RN and 80 percent of those days were on weekends.[6]

Elder Justice Alert: Republican Congressmen Question CMS’s Oversight of Nursing Homes

House Energy and Commerce Committee Chairman Greg Walden, Subcommittee Chairman Gregg Harper, Subcommittee Chairman Michael Burgess, and member Gus Bilirakis voiced their concerns over media reports of nursing home resident harm in an April 2, 2018, letter to CMS Administrator Seema Verma. The letter states that “[t]hese reports raise serious questions about the degree to which the Centers for Medicare & Medicaid Services (CMS) is fulfilling its responsibility to ensure federal quality of care standards are being met…”[7]  The Congressmen add that the adequacy of CMS’s oversight of skilled nursing facilities has also been “called into question” in reports by the HHS Inspector General and the Government Accountability Office (GAO).[8] 

The Congressmen specifically point to the tragedy that occurred in Florida, where 14 residents of the Rehabilitation Center at Hollywood Hills died after the facility’s air conditioner lost power during Hurricane Irma. Raising the link between ownership and poorly performing facilities, the Congressmen note that this is not the first time that the facility’s owner has been “scrutinized by the federal government.”[9] Previously, the owner entered into a settlement agreement with the Department of Justice in a civil case regarding kickbacks and medically unnecessary treatments that were performed on “elderly beneficiaries to generate Medicare and Medicaid payments.”[10] Even more recently, another one of the owner’s facilities was found to have 30 violations, including “sexual assault of patients, low staffing, and ignoring patients.”[11]

The Congressmen have asked CMS to provide the Committee with information about CMS’s role overseeing nursing homes, including the Rehabilitation Center at Hollywood Hills and any other facility linked to that facility’s owner.


[1] Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on and the Five Star Quality Rating System, CMS (April 6, 2018),
[2] Id.

[3] Id.
[4] Id.
[5] Id.
[6] See id. (noting that “[a]s the number of RN hours increases, so does performance on . . . quality measures”).
[7] Letter from Greg Walden et al. to Seema Verma (April 2, 2018),
[8] Id.

[9] Id.
[10] Id.
[11] Id.


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