1. Payroll Based Journal Reporting for CMS – Challenges and Success
September 13, 2016

2. Learning Objectives At the end of this session, you will be able to:
Discuss the CMS Payroll Based Journal Reporting system and what is needed to comply with the new regulation
Analyze the payroll data requirements and discuss direct vs. indirect, contract vs. employee, and differences between PBJ and the current system
Review the classification of employees (i.e. Nurse Supervisor, R.N. and dual role employees) and how they are to be properly categorized for PBJ reporting based on recent CMS information
Prepare for challenges that are commonly encountered in meeting the regulation

3. Regulatory Overview
Final Rule published August 4, 2015 in the Federal Register
Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data
This data, when combined with census information, is to be reported on the level of staff in each nursing home (slightly different from the current process using CMS-671 and CMS-672 forms)
This data is to report employee turnover and tenure – a new item
Intent is to link payroll records to the CMS five star rating system

4. Initial Registration
All Future Submissions

5. Payroll Based Journal - Overview
CMS has long identified staffing as one of the vital components of a nursing home’s ability to provide care. Over time, CMS has utilized staffing data for many purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes. Staffing is used in the Nursing Home Five Star Rating System to help consumers understand the level of difference of staffing in nursing homes.
MANDATORY Reporting Period: Began July 1, 2016
First Deadline: November 14, 2016 (for data through September, 2016)
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. The first quarter is July 1 – September 30, with reporting due within the 45th calendar day after September 30th.

6. Daily Staffing Hours Record Census Data Methods of Submission
Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
Submission of direct care staffing on a daily basis – required to be submitted within 45 days after the end of each quarter (7/1/16-9/30/16 is first mandatory quarter)
Employee Record
Employee ID (No PII such as Name or SS#), Hire Date, Term Date, Pay type
Daily Staffing Hours Record
Date, Hours Paid, Job Title Code, Labor Category Code, Pay type
Census Data
Methods of Submission
Manual data entry (virtually impossible)
Uploaded data from an automated payroll or time and attendance system (XML format only)

7. Current System: Staffing Domain as it Affects Your 5 Star Rating
There is considerable evidence of a relationship between nursing home staffing levels and resident outcomes. The CMS Staffing Study found a clear association between nurse staffing ratios and nursing home quality of care, identifying specific ratios of staff to residents below which residents are at substantially higher risk of quality problems.
The rating for staffing is based on two case-mix adjusted measures:
Total nursing hours per resident date (RN + LPN + nurse aide hours)
RN hours per resident day
The source data for the staffing measures is CMS form CMS-671 (Long Term Care Facility Application for Medicare and Medicaid) from CASPER. The resident census is based on the count of total residents from CMS form CMS-672 (Resident Census and Conditions of Residents). The specific fields that are currently used in the RN, LPN, and nurse aide hours calculations are:
RN hours: Includes registered nurses (tag number F41 on the CMS-671 form), RN director of nursing (F39), and nurses with administrative duties (F40) (now split between LPN and RNs).
Rick to start presenting here.

8. Current System: Staffing Domain as it Affects Your 5 Star Rating

9. Current System: Staffing Domain as it Affects Your 5 Star Rating

10. But an examination of the rating system by The New York Times has found that Rosewood and many other top-ranked nursing homes have been given a seal of approval that is based on incomplete information and that can seriously mislead consumers, investors, and others about conditions at the homes.

11. NEW Reporting Requirement - Staffing Data
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.
Direct Care Staff – provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being (expanded.)
Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

12. NEW Reporting Requirement - Staffing Data
HOW IMPORTANT WILL IT BE TO YOU TO KNOW WHAT YOU ARE SUBMITTING EVERY DAY?
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

13. NEW Reporting Requirement - Staffing Data (Cont’d)
Submission requirements. The facility must electronically submit to CMS complete and accurate direct care staffing information
Direct care staff - included but not limited to: R.N., L.P.N., L.V.N., C.N.A., therapist, or other type of medical personnel;
Resident census data;
Information on direct care staff turnover and tenure,
hours of care provided by each category of staff per resident per day
start date, end date (as applicable)
hours worked for each individual.
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

14. NEW Reporting Requirement - Staffing Data (Cont’d)

15. NEW Reporting Requirement - Staffing Data (Cont’d)
Need to distinguish employee from agency and contract staff.
Data format. The facility must submit direct care staffing information in the uniform format specified by CMS.
Submission schedule: Quarterly.
For more information, please see
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

16. NEW - Labor and Job Codes
Reporting should be based on the employee’s primary role and their official categorical title.
Example:
For direct care consultants, data reported should be auditable and able to be verified through either payroll, invoices, and/or tied back to a contract.
** All agency and direct care contract staff hours MUST be reported per CMS.
Data elements to be entered include an unique employee ID, hire date, termination data, and pay type code.
For each individual employee, the day and date associated with the number of hours worked.
Reporting should be based on the employee’s primary role and their official categorical title. A code identifying the CMS defined job titles that matches the role of the staff member identified in Table 1 of the PBJ manual.
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

17. PAYROLL SCREEN

18. NEW - Submission Timeliness and Accuracy
Deadline: Submissions must be ENTERED by the end of the 45th calendar day after the last day in each fiscal quarter in order to be considered timely.
Facilities may enter and submit data throughout a quarter.
Facilities may view their data submitted through Certification and Survey Provider Enhanced Reports (CASPER) and via the PBJ Online System in summary.
Staffing information is required to be an accurate and complete submission of a facility’s staffing records. CMS will conduct audits to assess a facility’s compliance related to this requirement.
** Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Under-reporting is not likely to be considered by CMS.
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

19. WHAT ARE PROVIDERS FACED WITH?
Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
WHAT ARE PROVIDERS FACED WITH?
Properly capturing direct care hours of staff who do not punch a timeclock
Payroll and timekeeping systems that do not capture time as required by PBJ with the midnight split between days
Tracking direct care given by an employee or therapist to residents outside of the “nursing facility”
Adjusting time for paid hours that are not direct care – in service training, administrative duties, vacation, PTO, jury duty, etc.
Providing data that can be audited back to payroll or a vendor invoice/contract
Working with contractors who provide direct care to efficiently gather staff names, time worked and residents served in an efficient manner when the contractors have no incentive
Duplicitous interpretations and guidance from CMS

20. Working with Clients – Issues Identified
Even large payroll software vendors are not prepared yet for PBJ
Many providers are focusing on November 14th deadline rather than July 1st
A small number of specialty software products (ezPBJ, Onshift, etc.) have been developed for PBJ but delivered with little to no support on accuracy of information
Providers’ biggest issue is determining how to capture data that is currently not in electronic form and may not even be captured yet
Internally, providers do not know who should be responsible for PBJ
Providers need to use project management skills to create a repeatable process that can be audited in a timely manner

21. Working with Clients – Issues Identified
Payroll does not report “daily” hours, only a lump sum
Time and Attendance software….. Produce .xml file?
Allocation of hours worked for “nursing facility” and across payroll companies
Data capture of hours outside of the Time and Attendance System – creating a repeatable process
CMS Juniper Software WILL prevent access to any other program (i.e. Internet explorer, Chrome, Payroll System, Outlook, Excel, etc.) on the individual computer used WHILE LOGGED INTO THE PBJ SYSTEM!
Have all the necessary data/information available at the time you log in.
Lou start with the presentation – based on experience with clients.

22. Hours Excluded from Nursing Home PBJ Reporting
Hours NOT worked but paid (i.e. PTO, Sick Time, FMLA, Etc.)
In-service/training Hours (internal and/or external)
Hours for services performed that are billable (i.e. to Medicare FFS, Medicaid, Other payers etc.)
Convenience fees for outside medical providers such as Dentists, Audiologists, etc.
Staff hours providing services to non-nursing home residents (e.g. shared staff with ALF, ILF, ADHC, etc.)
The facility must submit the number of hours each staff member is paid to deliver services for each day worked. The hours do not include any type of leave, or non-work related absence from the facility. It also excludes training hours or others times the individual is not available for direct care with the residents.
What are some of the issues with reporting individuals on Third shift? How should a facility handle individuals that work in various areas such as IL/AL and the SNF?
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

23. Non Direct Care Examples Specifically Mentioned by CMS As Excluded From This Reporting Requirement
Food Service Supervisor and Workers
Housekeeping Services Supervisor
Facility Engineer
Volunteers
Private Duty and Hospice staff
Questions have arisen as to other categories, positions, and departments
Optional reporting of Housekeeping/Maintenance hours
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

24. Categories, Positions, and Departments Included in PBJ Reporting (except hours billed to payers i.e. Medicare FFS or other payer(s))
Administrative Staff: Administrator, Asst. Administrator (or replacement)
Medical Director, Salaried Physician, PA (no hours for rounds)
Nursing Services: DON, RN w/ Admin Duties, RN, LPN or LVN w/ Admin Duties, LPN or LVN, C.N.A., Nurse Aide in Training, Medication Aide/Technician, NP (no hours for rounds), Clinical Nurse Specialist
A Licensed Pharmacist used for consultation
Dietary Services: RD or Dietician, Paid Feeding Assistant(s)
Therapeutic Services: OT, OTR, COTA, OT Aide, RPT, PT, PTA, PT Aide, RT, RT Tech, SLP, Therapeutic Recreation Specialist (Licensed or certified), Qualified Activities Professional, Other Activities Staff
Qualified Social Worker – Licensed, Other Social Worker
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

25. Categories, Positions, and Departments Included in PBJ Reporting (cont’d) (except hours billed to payers i.e. Medicare FFS or other payer(s) – in most cases, no hours to be reported for these positions)
Dentist/Podiatrist
Mental Health Services Staff
Vocational Services Worker
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

26. Categories, Positions and Departments Not Required/Optional in PBJ Reporting
Blood Storage/Lab Service
Clinical Laboratory service workers
Diagnostic X-Ray service workers
Housekeeping/Maintenance
Other Service Workers
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

27. New Census Data Reporting Requirement
Month End Date:
Facilities must enter the resident census for the categories below, for the last date of each month.
Due Date:
45th calendar day, after the last day, in each fiscal quarter.
Number of residents whose primary payer is:
Medicaid
Medicare (traditional)
Other
CMS’s PBJ Version 1.0 Policy Manual Published August, including technical specifications changes /FAQ through 12/14/15

28. Facilities must enter the resident census for the categories below for the last date of each month. For facilities entering census data manually, the PBJ system will list the last date of each month for facilities to enter the associated census. Facilities uploading data from another system will need to adhere to the requirements in the technical specifications.
The census is to be reported by the number of residents who primary payer is Medicaid, Medicare or other.
Census Screen

29. Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
DECISIONS TO BE MADE:
Most data coming from external files or Time and Attendance systems (not payroll files) so tracing to contracts, invoices and payroll is important to document
Some Time and Attendance systems have reporting available, but they are still cumbersome and it is difficult to tell if these are accurately reported (i.e. midnight hours splits, staff allocated less than 100%, method to report staff in more than one role, etc.)
Internal time capture process changes may be needed
Allocations of hours worked to CMS Certified Beds is challenging – many questions very specific to each community

30. Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
DECISIONS TO BE MADE:
Temporary agency staff, staff whose time is not reported on community payroll, and other unusual issues have not typically been investigated fully
Client staff assigned have not been exposed to CMS 671 and 672 which currently calculates staffing ratios for star ratings in Nursing Home Compare
Clients requesting to “test their decisions” and “provide answers” to interpretations of CMS PBJ Manual v.2.1 which is vague and lacks definition as to how the data will be used in the future
Submissions to CMS PBJ have not been fully tested and validated
EFFICIENCY has not been achieved yet and may take some

31. CLIENT DISCUSSIONS AND RESPONSES:
Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
CLIENT DISCUSSIONS AND RESPONSES:
“We have PBJ covered”
“Help us make some final decisions” (or what they think are final)
“We are using a variety of reporting tools” (i.e. Onshift, Kronos, etc)
“Our therapy company (or other outsource company) will report the data for us so we do not have to worry about that component”
“We do not know how we are going to accomplish this because”:
Staff do not have expertise or we have had turnover
We do not understand how to get data from our various systems or which systems are best
We do not know how to tell if we are doing it correctly

32. Questions to ask yourself at this date:
Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
Questions to ask yourself at this date:
Have you successfully submitted data from contractors, payroll and manual time capture through the CMS PBJ website?
Have you been able to verify that the data submitted is complete and accurate?
Will your submitted data provide the same or a better staffing ratio as your current staffing rating in Nursing Home Compare?
Is your process efficient and automated so that this process will not take a considerable amount of time every week?

33. Key Interpretations of the CMS PBJ Manual
Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
Key Interpretations of the CMS PBJ Manual
Primary Role
Role changes during a workday
Administrators, DONs and ADONs
Medical Directors, Dentists, Podiatrists, etc.
Activities and Social Workers
Optional Categories
Housekeeping and Maintenance
Other Categories
Differences from CMS 671

34. Centers for Medicare and Medicaid Services (“CMS”) Electronic Staffing Data Submission Payroll Based Journal
ADVICE TO PROVIDERS:
Review PBJ Long-Term Care Facility Manual, Version 2.1, April 2016
Call us with your questions
WILL IMPACT CMS NURSING HOME COMPARE AND NURSING HOME FIVE STAR RATING SYSTEM – review more often internally
Time is of the essence – make decisions and document now
CLA can help in a variety of ways:
Review client infrastructure and readiness
Develop and streamline alternative methods of data capture by sharing knowledge from other clients
Work with clients to improve auditability of PBJ submissions
Fully outsource the submission process for clients

35. CMS PBJ References:
PBJ Manual v.2.1: Questions on PBJ Manual: Join the Leading Age PBJ Listserv Questions regarding the PBJ Data Specifications should be directed to Software developers or vendors that provide services such as automated payroll or time and attendance systems that will support electronic submissions should use this address.

36. Questions?

37. Presenter:
Carl W. Moellenkamp, Director