03/05/2026

Survey Tip of the Week: Payroll Reports

The Long-Term Care Survey Process requires surveyors to review the Payroll-Based Journal (PBJ) reports for areas of concern prior to the beginning of a facility’s recertification survey. The facility’s CASPER PBJ Staffing Data Report is accessed through the CMS survey system and must be reviewed for at least every recertification survey. The report provides information on overall direct care staffing levels as well as licensed nurse staffing and is used to identify potential areas of concern before surveyors enter the facility. 

While multiple factors are considered when determining whether staffing is sufficient, including the facility assessment, resident assessments, and plan of care needs, the PBJ Staffing Data Report can highlight clear indicators of potential noncompliance. In particular, the report identifies specific infraction dates when a facility reported no RN hours or failed to have a licensed nurse on duty for a 24-hour period. 

Survey teams are expected to review this information carefully during offsite preparation. For standard recertification surveys without a staffing complaint, the team coordinator reviews the most recent quarter of PBJ data. If a survey includes a staffing-related complaint or Ombudsman concern, surveyors may review additional quarters of staffing data tied to the relevant timeframe. Any discrepancies identified must be documented in the Long-Term Care Survey Process (LTCSP) offsite preparation screen, ensuring all survey team members are aware of potential staffing concerns before entering the facility. 

If the PBJ Staffing Data Report identifies RN coverage or licensed nurse coverage triggers, surveyors will notify the facility during the entrance conference, including the specific infraction dates identified in the report. Facilities are informed that a citation may be issued under the regulatory F-tags of F725 (Sufficient Nursing Staff) and/or F727 (RN 8 Hours per Day) unless acceptable supporting evidence is provided. 

LeadingAge Ohio encourages facilities to routinely review their PBJ submissions and internal staffing records to ensure accuracy and confirm that RN and licensed nurse coverage requirements are consistently met. Proactively monitoring PBJ reports can help identify discrepancies early and reduce the risk of citations during surveys.