States now required to conduct at least 50% of off-hour surveys on weekends for facilities with potential staffing issues

Jan 25, 2019
The Bottom Line

A list of facilities with potential staffing issues is being provided to CMS regional offices and state survey agencies to support survey activities for evaluating sufficient staffing, according to a memo released by CMS back in November, 2018. The memo states that “while CMS is encouraged by facilities’ efforts to improve staffing,” payroll based journal (PBJ) data has raised a few concerns, prompting them to inform state survey agencies of facilities with potential staffing issues.

These issues include facilities with significantly low nurse staffing levels on weekends and facilities with several days in a quarter without an RN onsite.

As a result, states will now be required to conduct at least 50% (formerly 10%) of the required off-hour surveys on weekends for facilities on CMS’ list. In addition, if surveyors confirm that compliance for 42 CFR 483.35(b)(1) (requirement for a facility to provide the services of an RN seven days a week, eight hours a day) isn’t being met, the facility will be cited under deficiency F-727.

Updates to the PBJ Policy Manual were also made, including additional guidance for deducting meal times for specific shifts, and an added Q&A to the PBJ Policy FAQs that explains the rationale for meal break policy.

Lastly, CMS has added language that instructs facilities to use a reasonable methodology to allocate the hours that universal care workers are providing CNA services and report these hours accordingly.

CMS has created two reports for providers to help ensure data is submitted accurately and in a timely manner:

  • MDS Census Summary Report: Allows users to retrieve the daily MDS-based patient census (i.e., count of patients) for each day in a quarter

  • MDS Census Detail Report: Allows users to retrieve a list of the patients that the MDS-based census is comprised of on a given date or dates

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 patient per day posted on NHC. More information on these reports can be found at

  • Select Section 12 - Payroll Based Journal (PBJ) Reports from the right side in the blue box

  • Find the specific report you would like to run and go to the page number cited

  • Follow the steps to pull the report

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