With the quarterly Payroll Based Journal (PBJ) submission always on the horizon, facilities have a critical checklist to complete. While submitting staffing hours is the main goal, there's an essential validation step you can't overlook: reviewing your Minimum Data Set (MDS) census.

What is the MDS Census Report?

The "MDS census review" is the internal process of verifying the list of residents CMS believes are currently in your facility. It is not a report you simply run; it's a cross-check of your records against the officialCMS count, which is derived directly from your facility's submitted MDS assessments (or lack thereof).

The most critical thing to understand is how CMS calculates this number, as their method is what creates the risk. According to the CMS PBJ FAQ(Q23), their method is to:

1. Extract all MDS assessment data for your facility going back one year.
2. Identify discharged residents based on submitted discharge assessments OR an interval of 150 days or  more with no new assessment.
3. Assume any resident who does not meet these discharge criteria still resides in the facility

That 150-day rule is the key. A resident discharged 100 days ago without a proper assessment is still counted as active. As CMS notes, this means a"Failure to submit discharge assessments will likely result in an over-estimate of actual resident census... An over-estimate of resident census will result in the calculation of lower facility staffing levels..."

The primary objective of your review is to find and correct these"phantom resident" records before you submit your PBJ data.This ensures your census is accurate, your staffing ratios are calculated correctly, and your data stands up to auditor scrutiny.

The Link Between MDS Census and a Failed PBJ Audit

This verification process is crucial for compliance and accurate reporting. PBJ auditors are paying extremely close attention to mismatches between your facility's daily census (typically from your EHR) and the officialMDS census held by CMS. Why? An MDS census count that's higher than your actual resident count is a major red flag that something is wrong with your data.

This discrepancy often points to a correctable, but dangerous error:residents have been discharged, but the corresponding MDS discharge assessments were not completed or submitted in a timely manner.

This is where the audit risk begins. When your MDS census is artificially inflated (due to these "phantom residents" who are no longer in your facility), your PBJ-reported staffing hours are divided by a larger-than-actual number of residents. This results in an inaccurate calculation of your nursing hours per resident day (HRD), which is a serious data integrity problem.

This "significant variance" is exactly what auditors are trained to look for. CMS explicitly states in its FAQ (Q26) that a failed audit can be triggered if:

...a facility did not complete all MDS discharge assessments timely, resulting in an inaccurate census calculation.

A finding like this isn't just a simple correction. This can result in a failed PBJ audit and could lead to further investigation by CMS for potential noncompliance or billing inaccuracies. In order to ensure your MDS census is correct it's important to be completing discharge assessments on every resident not included in your census.

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Step-by-Step Guide to Running the MDS Census Report

PBJ reports are submitted quarterly, and facilities are expected to run their census report before submitting their PBJ information. 

1. To begin, visit the iQIES website.

2. Once you have entered your login information, click on the Reports menu, and click "Find a Report".

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3. Under Report Type, choose “Census.”

4. The search results will bring up “Daily MDS Census Report.” Under Actions, click “Run Report.”

5. Select your state, and enter your facility ID.

6. Once your facility appears on the screen, click “Add” under “Actions.”

7. When choosing which dates to include, use the prior fiscal quarter.

8. This will generate your report. At the top right corner, click “Download”, and you will see two options: to save your report as a PDF or CSV file. Save both files for your records. 

When comparing your internal census count (per day) compared to what CMS has recorded, we've found the CSV to be a much better starting place...

The challenge is to review this list for every day in the quarter. Once the list gets to the next calendar day, you'll need to start the audit over for that day.

Report Challenges and Troubleshooting

Unfortunately, running this report each quarter can be confusing and time-consuming. If you notice any discrepancies between your CMS census report and your facility’s daily census log, you are responsible for determining the issue and remedying it. Start by reviewing discharge assessments to find out if any are missing. 

Aim to plan time each quarter to run and review your CMS census report, so that you are prepared to submit your PBJ data on time. Though the process is cumbersome, it’s an essential step in staying compliant and being eligible for the resources your facility needs.

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A recent analysis by USA Today has found that nearly all nursing homes in the US fail to meet the minimum staffing requirements set forth by the Centers for Medicare & Medicaid Services (CMS). The analysis, which used payroll-based journal data from last August, showed that only 160 out of 14,500 skilled nursing facilities met the new requirements during the summer quarter of 2023. Furthermore, most nursing homes met the requirements on only three days out of a total of 92.

The CMS rule requires nursing homes to have a minimum of 3.48 hours per resident per day (HPRD) of total staffing, with specific allocations for registered nurses (RN) and nurse aides. However, according to the analysis, about 50% of federally funded facilities were able to provide at least 0.55 hours of care from an RN daily, while facilities were only able to provide each resident with 2.45 hours of care from a CNA on one day per week.

The gap in meeting staffing requirements was found to be significantly wider in many Southern states, with Louisiana, Oklahoma, and Texas performing the worst. In contrast, states such as Alaska, Hawaii, Utah, Maine, and Delaware fared better in meeting the total minimum staffing standard. The article notes that rural counties have five years to implement the minimum staffing standards, while urban areas are allowed up to three years.

The findings of this analysis highlight a significant challenge facing nursing homes across the US, particularly those in Southern states. The CMS rule is intended to ensure that residents receive adequate care and attention from qualified staff, but it appears that many facilities have a long way to go in terms of meeting these requirements.

This text appears to be a report from the Kaiser Family Foundation (KFF) analyzing the impact of new federal requirements for nursing facility staffing. Here are the main points:

Background: The Centers for Medicare and Medicaid Services (CMS) has finalized a rule requiring nursing facilities to have a minimum number of staff on duty at all times.

Key findings:

• In 45 states, fewer than half of nursing facilities have enough staff to meet the new requirements.
• About 1 in 5 nursing facilities would meet fully-implemented minimum staffing standards in the final rule with current staffing levels.
• Rural facilities are more likely to not meet the requirements compared to urban facilities.

Methodology: The analysis uses data from Nursing Home Compare, a publicly available dataset that provides information on quality of care and key characteristics for approximately 14,900 Medicare and/or Medicaid-certified nursing facilities. The analysis drops about 3% of nursing facilities due to missing data.

Limitations: The analysis does not look at facilities that meet the requirement to have an RN on staff 24 hours a day, seven days a week (24/7) due to limitations in publicly available data.

Implications: The report highlights concerns about the potential unintended consequences of the new requirements, including increased costs for nursing facilities and the potential impact on state budgets and federal spending. The need for nursing facility care is expected to increase as the population ages, which may intensify these challenges.

Overall, the report suggests that many nursing facilities face significant challenges in meeting the new staffing requirements, particularly rural facilities.

The Centers for Medicare & Medicaid Services (CMS) has proposed a 4.1% pay increase for nursing homes in fiscal year 2025, but declined to issue an update on its staffing minimum proposal as part of its annual payment rule proposal. The proposed increase includes a 2.8% market basket update and a 1.7% market basket forecast error adjustment, which is considered modest by industry leaders.

American Health Care Association President and CEO Mark Parkinson expressed disappointment with the proposed increase, stating that it will not be enough to offset the costs of meeting CMS's proposed staffing minimum requirement. Parkinson urged the Administration and CMS to reconsider the staffing mandate, warning that it could lead to nursing home closures and reduced access to long-term care for seniors.

The proposed rule also includes changes to the Patient-Driven Payment Model ICD-10 Code Mappings and Value-Based Purchasing updates. Additionally, CMS has proposed an expanded Civil Monetary Penalty process that would allow for more penalties to be imposed on nursing homes for health and safety violations. The agency is seeking comments on potential future updates to the non-therapy ancillary component of PDPM.

Industry leaders are cautiously optimistic about the proposed pay increase, which they believe will help offset increased labor costs associated with staffing shortages. ADVION Executive Vice President Cynthia Morton stated that the payment update reflects the increased costs experienced by providers over the past couple of years and will greatly help with recruiting and retaining staff.

The 211-page proposed rule is set to be officially published in the Federal Register, followed by a 60-day comment period. A final rule is expected to be announced by the end of July.

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