PBJ Data Leads to New Off-Hour Survey Requirement 

On November 30th, 2018, the Centers for Medicare & Medicaid Services (CMS), Quality, Safety and Oversight Group(QSO), released QSO Memorandum, 19-02-NH, outlining updates to the Payroll Based Journal (PBJ) Policy Manual, notification to states on new survey requirements, and new Minimum Data Set (MDS) Census reports.  

The Memo announces that CMS will inform state survey agencies of facilities with potential staffing issues and require that states utilize that list to determine providers for off-hour surveys.  Using the new PBJ data, CMS will identify the following: 

  • Facilities with low staffing on the weekends
  • Facilities with several days in a quarter without an RN onsite 

CMS will then provide the state survey agencies with this list of facilities with the potential issues to support survey activities for evaluating staffing sufficiency and improving resident health and safety.  States will now be required to conduct at least fifty percent of the required off-hours survey using the list provided by CMS. 

In addition, CMS will identify the facilities with a high risk of noncompliance in the RN staffing requirements.  Survey teams, conducting an annual survey or complaint survey, will investigate the requirement of a RN seven days a week, eight hours a day.  If a surveyor confirms there is noncompliance, and the requirement is not met, the facility will be cited under deficiency F-tag 727.