PBJ QSO Memorandums Archives

📢 Review CMS’ policy memos communicating updated PBJ policies and State guidance

What Are CMS' QSO Memorandums & Letters for PBJ?

CMS communicates major policy changes, survey focus requests and nursing home staffing goals through memorandum and letters. Those changes also get documented in the PBJ Policy Manual and FAQs and/or the Five Star QRS Technical Users Guide.

These QSO memoranda, guidance, clarifications and instructions are sent to State Survey Agencies and CMS Regional Offices and are sent typically by the Director of CMS’ Quality, Safety & Oversight Group. or prior to 2019, the Director of CMS’ Survey and Certification Group.

CMS oversees compliance with the Medicare health and safety standards for nursing homes and makes available to Medicare beneficiaries, providers and suppliers, researchers and State surveyors information about these oversight activities.

State Survey Agencies are responsible for the survey (inspection) to determine if nursing homes are complying with the prescribed health and safety standards under the agreements in Section 1864 of the Social Security Act (the Act) and collectively known as the certification process.

Skilled Nursing Facilities can glean compliance details and specifics by reviewing how CMS instructs states to conduct PBJ-related staffing compliance activities.

CMS QSO Memorandums Archive

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Revisions to Special Focus Facility (SFF) Program - Oct 2022

QSO memorandum 23-01-NH – issued October 21, 2022  – beefed up the Special Focus Facility (SFF) program conducted by CMS.  The SFF program by statute requires CMS to identify the poorest quality of care facilities by state.

CMS shared new SFF methodology to seek to improve “graduation” of non-compliant facilities, as well as reduce the “yo-yo’ing” of facilities in and out of the SFF program.

Before, CMS maintained a list of candidates for the SFF program based on quality of care as reported through the Minimum Data Set (MDS).

With this memo, CMS indicates that staffing has an important relationship to quality, and therefore CMS recommends choosing SFF program candidates based on a lower staffing Five Star or staffing ratio.

Revised Long-Term Care Surveyor Guidance - Jun 2022

Memorandum 22-19-NH – issued June 29, 2022 – substantially increased the role of payroll-based journal data in survey and increased the potential survey penalties for providers not fulfilling staffing requirements specified in the PBJ policies.

CMS is released guidance and associated training for nursing home surveyors in June 2022 for Phase 2 and Phase 3 Requirements.  Included in this memo are clarifications and technical corrections of Phase 2 guidance issued in 2017, and new guidance for Phase 3 requirements which went into effect in November 28, 2019.

The effective date for surveyors to begin using this guidance to identify noncompliance is October 24, 2022.

In prior Phase 2 guidance, CMS . incorporated the use of Payroll Based Journal (PBJ) staffing data submitted by providers to help inform surveyors of potential staffing concerns.

In this new guidance, CMS begins the use of Payroll Based Journal (PBJ) staffing data to direct surveyors to investigate potential noncompliance with CMS’ nurse staffing requirements, such as

  • insufficient staffing
  • lack of a registered nurse for eight hours each day, or
  • lack of licensed nursing for 24 hours a day.

Further, CMS clarified that the intent of the requirements for F-tags at §483.35, Nursing Services, by adding examples for deficiency categorization and added guidance at §483.70(q), F-tag 851 to provide guidance to surveyors to cite noncompliance with the Payroll Based Journal reporting requirements.

The QSO memorandum summarizes the changes, while the full details are found in the State Operations Manual – Appendix PP

Nursing Home Staff Turnover and Weekend Staffing Levels - Jan 2022

In QSO memorandum 22-08-NH – issued January 7, 2022 – CMS announced they will begin posting the following information for each nursing home on the Medicare.gov Care Compare website:

  • Weekend Staffing: The level of total nurse and registered nurse (RN) staffing
    on weekends provided by each nursing home over a quarter.
  • Staff Turnover: The percent of nursing staff and number of administrators that
    stopped working at the nursing home over a 12-month period.

This information will be added to the Care Compare website in January 2022 and used in the Nursing Home Five Star Quality Rating System in July 2022.

To enable researchers to analyze turnover, CMS will begin posting the submitted employee-level staffing data for all nursing homes.  This will allow researchers to identify each employee by their CMS created unique ID.

Finally, CMS is reminding Nursing Homes to Link Employee Identifiers when they are changed due to the changes in the facility’s staffing data systems.

Issued in 2020 and 2021 (during pandemic)

Updates to the Nursing Home Compare website and Five Star Quality Rating System - Dec 2020

The December 4, 2020 memorandum 21-06-NH from CMS included a substantial update and upgrade to the Five Star rating system as posted on Nursing Home Compare.  Particularly, the changes reflected a post-pandemic restart of normal activities.

CMS will resume calculating nursing homes Health Inspection and Quality Measure ratings on January 27, 2021. This follows previous changes to the Staffing ratings:

CMS waived the requirement for nursing homes to submit staffing data per 42 CFR 48370(q), and did not update the Staffing Rating domain of the Five Star Quality Rating System that was scheduled for April 2020.  However, due to the importance of staffing and its relationship to quality, CMS ended the waiver to submit staffing data on June 25, 2020. Furthermore, CMS resumed updating the Staffing Rating domain of the Five Star Quality Rating System in October 2020 (see QSO-20-34-NH). Staffing data will continue to be collected as required, and staffing ratings will continue to be updated quarterly, as scheduled.

On September 3, 2020, CMS announced the launch of Care Compare, a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov, including Nursing Home Compare. On December 1, 2020, the legacy Nursing Home Compare website, and the data.medicare.gov website (which houses the underlying data for the Nursing Home Compare website) are no longer available, and users will be redirected to the new websites.

Changes to Staffing Info and Quality Measures on Nursing Home Compare due to COVID-19 - Jun 2020

In QSO memo 20-34-NH from June 25, 2020 – CMS effectively froze staffing Five Star ratings on Nursing Home Compare and relieved failities of the burden of payroll-based journal data reporting.

On July 29, 2020, Staffing measures and star ratings will be held constant, and based on data submitted for Calendar Quarter 4 2019.

Also, CMS is ending an earlier waiver of the requirement for nursing homes to submit staffing data through the Payroll-Based Journal System. Nursing homes must submit data for Calendar Quarter 2 by August 14, 2020.

Quality Measures: On July 29, 2020, quality measures based on a data collection period ending December 31, 2019 will be held constant.

Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts, FAQs - Apr 2020

The April 2020 QSO memorandum 20-28-NH from CMS focused on critical takensteps to ensure America’s nursing homes are prepared to respond to the threat of the COVID-19.

As it relates to staffing, the action taken was for CMS to publish a list of the average number of nursing and total staff that work onsite in each nursing home, each day. This information can be used to help direct adequate personal protective equipment (PPE) and testing to nursing homes.

Issued in 2018 and 2019

April 2019 Improvements to Nursing Home Compare and the Five Star Rating System - Mar 2019

The March 5, 2019 memorandum 19-08-NH from CMS was solely focused on improvements to Nursing Home Compare’s Five Star ratings. A large portion was dedicated to the survey freeze for that portion of the Five Star ratings and updates to the Quality Measure domain.

Staffing Five Star rating changes

New Rating Tiers: To incentivize improved nursing home staffing levels, CMS established new thresholds for staffing ratings and adjusted the staffing rating’s grid to increase the weight (value of) registered nurse staffing hours on the staffing rating.

One Star penalty for missing RN hours: Previously facilities that reported seven or more days in a quarter with no RN onsite are automatically assigned one-star for their staffing rating domain. This memorandum lowered that threshold to four days from seven.

Payroll Based Journal (PBJ) Policy Manual Updates, Notification to States and New Minimum Data Set (MDS) Census Reports - Nov 2018

In QSO memo 19-02-NH from November 30, 2018 – CMS introduced the use of PBJ data in state surveys, as well as made some updates to the PBJ Policy Manual.

PBJ Reports to States

CMS will begin informing state survey agencies of facilities with potential staffing issues.  Specifically, issues are considered facilities with:

  • significantly low nurse staffing levels on weekends
  • facilities with several days in a quarter without an RN onsite

In addition, CMS required that states conduct at least fifty percent of the required off hours surveys on weekends using the list of facilities provided by CMS.

Policy Manual Updates

CMS updated the PBJ policy manual to further refine the data its collecting, with additional clarification regarding:

  • deducting time for meal breaks
  • allocating time for universal care workers

MDS Census Calculations

CMS has created two reports for providers to help ensure data is submitted accurately and in a timely manner. These reports use the same methodology CMS uses to calculate each facility’s census, which is then used to calculate the number of staff hours per resident per day posted on the Nursing Home Compare website

Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare Five Star - Apr 2018

The April 218 QSO memorandum 18-17-NH from CMS introduced three significant evolutions of the PBJ program and moved the program from a focus on data collection to a focus on outcomes – particularly the staffing Five Star rating.

Staffing Five Star rating on the Nursing Home Compare Quality Rating System (QRS)

Starting in April, 2018, CMS will use PBJ data to determine each facility’s staffing measure on the Nursing Home Compare tool on Medicare.gov website, and calculate the staffing rating used in the Nursing Home Five Star Quality Rating System.

In a parallel step, beginning on June 1, 2018, facilities will no longer be required to complete the staffing portion of the CMS-671 form found on page 2. The 671 form was the staffing data collection tool before the implementation of payroll-based journal.

Staffing Data

CMS began conducting audits aimed to verify that the staffing hours submitted by facilities are aligned with the hours staff were paid to work over the same timeframe.  Some common errors identified through audits include:

  • Exclude time for meal breaks
  • Each employee must have their own unique identifier (ID)
  • Exclude hours for staff that provide care to individuals in non-certified areas of a larger institution or institutional complex that houses the certified facility

Facilities whose audit identifies significant inaccuracies between the hours reported and the hours verified will be presumed to have low levels of staff – which then will result in the facility receiving a one-star staffing rating.  A one star forStaffing will also reduce the facility’s overall (composite) rating by one star for a quarter.

Requirement for RN Staffing

CMS is placing imporance on facilities fulfilling the requirement to have an RN onsite at least 8 consecutive hours a day, 7 days a week under sections 1819(b)(4)(C) and1919(b)(4)(C) of the Act, and 42 CFR §483.35(b)).

From PBJ data, CMS observed recurring instances or aberrant patterns of days with no RN onsite. For example, based on the data submitted for Calendar Quarter 3, 2017, approximately 6% of facilities that submitted complete data had 7 or more days where no hours for RNs were reported. Also, approximately 80% of all days with no RN hours were weekend days.

Therefore CMS added a penalty for facilities reporting 7 or more days in a quarter with no RN hours – they will receive a one-star staffing rating, which will drop their overall (composite) rating by one star for that quarter.

Issued in 2016 and 2017

Electronic Staffing Submission - Payroll-Based Journal (PBJ) Public Use File - Sep 2017

In this September 2017 memorandum 17-45-NH CMS provide new information in three specific areas.

Public Use Files

To ensure transparency of the data submitted, CMS will begin posting data for viewing by LTC facilities, stakeholders, or the general public. The PBJ public use file will be available at at https://data.cms.gov/ beginning November 1, 2017.

Posted data will include the total number of hours submitted for nursing services job categories (e.g., registered nurse, licensed practical nurse, and nurse aides) for each day in the quarter, in addition to each facility’s census for each day in the quarter as calculated using minimum data set (MDS) submissions.

Nursing Home Compare Icons

The Nursing Home Compare website indicates whether providers have submitted data by the required deadline, and if providers have submitted, complete, incomplete, or inaccurate data.  A new icon system is introduced – CMS uses icons to indicate the status of each facility’s latest submission:

  • A green icon is used to indicate that a facility has submitted complete data by the deadline
  • Conversely, a grey icon is used to indicate that a facility has submitted incomplete or inaccurate data

Employee IDs

CMS intends to calculate rates of tenure and turnover using each employee’s unique identifier (ID).  However they are seeing occasions where a facility needs to change the unique employee ID of its staff.  Therefore CMS is providing a method for facilities to link an old employee ID with a new one.

Electronic Staffing Submission – Payroll-Based Journal Update - Apr 2017

In April 2017 memorandum 17-25-NH CMS updates providers on their learnings from the prior submissions.  Approximately 91% of LTC facilities submitted staffing data by the last deadline of February 14, 2017.  CMS reminds the rest that PBJ submissions are not optional.

Providers are being given feedback from CMS in the monthly Nursing Home Compare Provider Preview, which is available in their  certification and Survey Provider Enhanced Reports (CASPER) folder.  Feedback includes likely submission errors such as:

  • If a facility did not report hours for nursing staff for each day
  • If a facility reported over 80 hours worked for any one staff member over a one week period, or over 300 hours worked in a month
  • A comparison of the facility’s reported census information to a census calculated using Minimum Data Set (MDS) data. CMS is considering the MDS method instead of reported census.

In addition, CMS is adding information to the Nursing Home Compare website to encourage provider compliance:

  • Added icons next to each facility to reflect whether that facility has submitted data by the last deadline System
  • Removed the Overall and Staffing Five Star ratings for providers that have not submitted any data for two consecutive deadlines (May 15 and February 14). Ratings will be suppressed (i.e., removed) until data is received

Finally CMS notified everyone that they’ve updated the PBJ Policy Manual to make these items optional (instead of required)

  • hire date for each staff member
  • termination date for each staff member
  • hours for staff in the Dental Services (Job Title Code 32)
  • hours for staff in the Podiatry Services (Job Title Code 33)
  • hours for staff in the Vocational Services (Job Title Code 35)

 

PBJ Implementation of Required Electronic Submission of Staffing Data for Long Term Care (LTC) Facilities - Mar 2016

In memorandum 16-13-NH – from March 2016 – CMS alerts providers to the impending start date for the new requirements to electronically submit staffing data through the PBJ. The memorandum largely restates and summarizes on one place the various PBJ requirements and resources available to date including:

  • Mandatory submission period begins July 1, 2016
  • Facilities should 1) Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users
  • 2) Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access and
  • 3) Complete training on PBJ Training Modules for an introduction to the PBJ system and step by step
    registration instruction on QTSO e-University

And CMS reminds facilities that the PBJ program is required, not optional and that CMS maintains
authority to issue enforcement remedies, such as the imposition of civil money penalties (CMPs),
for noncompliance with the PBJ requirements.

Issued in 2015

Final Rule - Staffing Data Collection Requirements - Aug 2015

In thus August, 2015 informational memorandum 15-49-NH – CMS provides notice of the Final Rule establishing the Payroll-Based Journal electronic payroll data submission program.

The final rule published on August 4, 2015 implements the new requirements regarding the submission of staffing data to the Centers for Medicare & Medicaid Services (CMS) based on payroll and other verifiable and auditable data. The full text document can be found at https://www.federalregister.gov/articles/2015/08/04/2015-18950/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities.

  • Voluntary: Electronic Submission of Staffing Data: Registration begins August 4, 2015 for facilities to register for the voluntarily submission period which begins October 1, 2015.
  • Mandatory: Electronic Submission of Staffing Data: Effective July 1, 2016 long-term care facilities that participate in Medicare and Medicaid must electronically submit direct care staffing information (including information for agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format to CMS.

 

SNF Medicare FY 2016 Staffing Requirements - May 2015

In the May 2015 informational memorandum 15-37-NH, CMS provides notice of the proposed rule-making regarding the collection of staffing data in long-term care facilities that was published on April 20, 2015.

The proposed rule would implement the new requirements regarding the submission of staffing data to the Centers for Medicare & Medicaid Services (CMS) based on payroll and other verifiable and auditable data.

The proposed rule “FY 2016 SNF PPS for Staffing Data Collection in Long-Term Care Facilities” was published on April 20, 2015. The document can be found at http://www.gpo.gov/fdsys/pkg/FR-2015-04-20/pdf/2015-08944.pdf.

Public comments are due no later than 5 p.m. on June 19, 2015.

Implementation of Section 6106 of the Affordable Care Act - Apr 2015

In the inaugural PBJ memorandum 15-35-NH from April 2015, CMS notifies States of the posting of technical specifications and related information for the electronic submission of staffing information based on payroll data. This information is posted here.

This memorandum provides information such as:

  • timing of submissions
  • sample entry screens for CMS’ PBJ system
  • how CMS expects facilities to electronically submit their staffing data – either through a payroll vendor or through manual entry

The memorandum also outlines the expected timeline of PBJ data collection including:

  • Registration for voluntary submission beginning August 2015
  • Initial data collection on a voluntary basis beginning October 1, 2015
  • PBJ data collection on a mandatory basis beginning July 1, 2016

 

More Resources in the PBJ Library

Payroll-Based Journal (PBJ) Policy Manuals

Policy Archive

Five Star QRS Technical Users’ Guides

Guide Archive

CMS QSO Memorandums and Guidance

Memos Archive

PBJ Resources for Providers from CMS

Provider Hub

Studies and Research Using PBJ Data

PBJ Studies