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CMS Staffing Compliance

PBJ Reporting Services for Skilled Nursing Facilities

Facilities rarely get a one-star staffing rating because they were understaffed. They get it because a file errored, an agency roster was missed, or the deadline passed on a Saturday.

A Quarterly Deadline With a One-Star Penalty

Payroll-Based Journal reporting comes from Section 6106 of the Affordable Care Act and has been mandatory since July 2016. Every Medicare- or Medicaid-certified nursing facility submits direct care staffing data to CMS each quarter, and the submission must be received by the end of the 45th calendar day after the quarter closes — 11:59 PM Eastern. In practice that means February 14, May 15, August 14, and November 14.

Miss it and CMS assigns a one-star staffing rating for that quarter regardless of how the facility was actually staffed. That rating publishes to Care Compare, where families and referral sources see it, and it stays visible for a full year. A single missed upload can cost you census.

The failures are almost never about staffing levels. They are job codes mapped to the wrong CMS category, agency and contract hours that never made it into the file, breaks included that should have been excluded, a census that does not reconcile because MDS discharge records were filed late, or a file that errored on submission and nobody opened the validation report to find out.

What Our PBJ Reporting Service Covers

We treat PBJ as a quarterly closing process with a hard date, not a task that gets remembered in week six.

  • Quarterly data extraction — hours pulled from your payroll and time-and-attendance systems
  • CMS job title code mapping — every role mapped to the correct CMS category and reviewed when roles change
  • Agency and contract staff capture — contract hours reconciled from vendor invoices and rosters, since CMS requires them reported alongside employees
  • Non-reportable time excluded — paid and unpaid breaks removed so reported hours match auditable records
  • Data element preparation — anonymized employee IDs, daily hours worked and paid, pay type, and hire and termination dates
  • XML preparation and submission — file built and uploaded, or entered manually where that is the better fit
  • CASPER report review — staffing reports pulled and reviewed before the deadline, not after
  • Final File Validation confirmation — we confirm the submission actually succeeded rather than assuming it did
  • Corrections and resubmission — errors found and fixed while the window is still open
  • Census cross-check — staffing reconciled against MDS-derived census, including timely discharge records
  • Deadline calendar management — all four quarterly dates tracked, with work starting early enough to fix problems

What the Submission Requires

PBJ is unforgiving about detail. These are the pieces we manage each quarter.

RequirementWhat We Cover
Quarterly deadlinesQuarter ending Dec 31 is due Feb 14; Mar 31 due May 15; Jun 30 due Aug 14; Sep 30 due Nov 14 — the 45th calendar day, 11:59 PM ET
Reportable staffDirect care nursing, therapy, and support roles — both your employees and agency or contract staff
Data elementsAnonymized employee ID (never an SSN), hours worked and paid per day, CMS job title code, pay type, hire and termination dates
Excluded timePaid and unpaid breaks are not reportable hours
CensusDerived from MDS submissions, which means late or missing discharge records distort your staffing ratios
ValidationCASPER staffing reports before the deadline and the Final File Validation Report to confirm success
Five-Star impactStaffing levels, staff turnover, weekend staffing, and administrator tenure

What Makes NHBS Different

We work the deadline backwardPreparation starts early enough that a rejected file is a Tuesday problem, not a midnight-on-the-14th problem.
Already in your back officeWe handle billing, A/R, and business office support. PBJ fits into work we are doing anyway, which is why it does not fall through.
We see the MDS side tooPBJ census comes from MDS submissions. When our MDS team and business office team are the same team, census reconciliation is not a mystery.
Agency hours are the usual gapContract staffing is where most facilities under-report. We reconcile from vendor documentation rather than hoping payroll caught it.
We confirm, not assumeEvery submission is verified against the Final File Validation Report. Uploading is not the same as submitting.
No long-term contractTry us for one quarter. It is a naturally self-contained engagement.

What Changes When This Is Handled Properly

The measurable outcome here is binary and entirely verifiable on your own CASPER reports:

The submission is on time

Every quarter, confirmed by the validation report, with no automatic one-star penalty for a missed or failed upload.

Hours reflect reality

Agency staff included, breaks excluded, job codes mapped correctly — so your rating reflects how you actually staff the building.

Nobody on your team loses a week

PBJ stops consuming your administrator or business office manager for the first two weeks after each quarter closes.

PBJ Reporting FAQs

When exactly is PBJ due?

Submissions must be received by the end of the 45th calendar day after the last day of the fiscal quarter, at 11:59 PM Eastern. That works out to February 14, May 15, August 14, and November 14 for the quarters ending December 31, March 31, June 30, and September 30 respectively.

What happens if we miss the deadline?

CMS assigns a one-star staffing rating for that quarter under the Five-Star Quality Rating System, regardless of your actual staffing levels. Only data successfully submitted by the deadline is used in the calculation.

That rating is public on Care Compare and affects referral decisions, so a missed upload is a census problem as much as a compliance one.

Do we have to report agency and contract staff?

Yes. CMS requires both employees and agency or contract staff, because the point is the actual staffing picture in the building. Under-reporting agency hours is one of the most common reasons a facility's rating does not match how it is really staffed.

Do breaks count toward reported hours?

No. Paid and unpaid breaks are both excluded. Reported hours need to match auditable payroll records, and CMS treats the data as auditable.

Do you need access to our payroll system?

Usually read access to payroll or time-and-attendance, plus your agency invoices or rosters. Some facilities prefer to send us an export each quarter instead. Both work — the export route just requires a little more coordination on timing.

Isn't PBJ a payroll function rather than a billing one?

It originates in payroll, but it is back-office compliance with a revenue consequence. The rating it produces is public, it influences referrals and census, and census is what drives everything we do on the billing side.

It also depends on MDS census data, which puts it squarely in the same workflow as our MDS and business office work. That is why we handle it.

Let Us Take the Next Quarter

PBJ is a naturally self-contained engagement. Hand us one quarter and see how it goes before deciding anything else.