Payroll-Based Journal (PBJ) reporting is one of the most consequential compliance obligations facing skilled nursing facility administrators today. What began as a data collection initiative has evolved into a primary driver of public-facing quality ratings, enforcement actions, and reimbursement considerations.
Yet despite its importance, PBJ reporting remains a source of confusion, frustration, and costly errors for many facilities. The data requirements are detailed, the submission deadlines are firm, and the consequences of inaccurate reporting are increasingly severe.
This guide provides a comprehensive overview of PBJ reporting requirements, common pitfalls, and best practices for ensuring your facility's submissions are accurate, timely, and working in your favor rather than against you.
What Is PBJ and Why Does It Matter?
The Payroll-Based Journal system was established under the Affordable Care Act (Section 6106), which required CMS to develop a system for facilities to electronically report direct care staffing information based on payroll and other auditable data.
Before PBJ, staffing data on Nursing Home Compare (now Care Compare) was based on self-reported data from the CMS-671 form, submitted during the annual survey. This data was a snapshot of a two-week period and was widely regarded as unreliable -- facilities could (and did) inflate their staffing numbers for the reporting period.
PBJ changed the game by requiring facilities to submit staffing data derived from actual payroll records on a quarterly basis. This means CMS now has a continuous, auditable picture of your facility's staffing levels throughout the year, not just during a convenient two-week window.
Why PBJ Matters More Than Ever
1. Five-Star Staffing Ratings. PBJ data is the primary source for your facility's staffing component on the CMS Five-Star Quality Rating System. The staffing star rating accounts for one of the five domains that determine your overall star rating, and it directly influences the other domains as well. A low staffing rating drags down your entire Five-Star profile.
2. Public Transparency. PBJ data populates the staffing information displayed on Care Compare, which families, hospital discharge planners, and managed care organizations use to evaluate and compare facilities. Inaccurate data that understates your staffing can damage your competitive position.
3. Enforcement and Audit Risk. CMS uses PBJ data to identify facilities with staffing levels that fall below federal and state minimums. Facilities flagged for inadequate staffing may receive targeted surveys, and the PBJ data itself may be audited against your payroll records.
4. Federal Staffing Mandates. The 2024 federal staffing rule established minimum staffing requirements for SNFs. PBJ data is the mechanism CMS uses to monitor compliance with these requirements. As the implementation timeline progresses through 2026, PBJ accuracy becomes even more critical.
PBJ Data Categories
PBJ submissions include three categories of data. Understanding what is required for each category is essential for accurate reporting.
Staffing Data
This is the core of PBJ reporting. For every day of the quarter, you must report the hours worked by each direct care staff member. The data elements include:
- Employee identifier. A unique ID for each staff member (not SSN -- use an internal employee ID or a hashed identifier).
- Hours worked by day. The actual hours worked on each calendar day, derived from your timekeeping or payroll system.
- Job title category. CMS defines specific job title categories that map to roles in your facility. Accurate job title mapping is critical -- miscategorizing a staff member can distort your reported staffing ratios.
- Pay type. Whether the staff member is a facility employee, contract/agency staff, or other classification. Agency hours are reported differently and are weighted differently in staffing calculations.
The job title categories that CMS uses for PBJ reporting include:
- Administrator (non-nursing)
- Medical Director
- Other Physician
- Registered Nurse Director of Nursing (RN DON)
- Registered Nurse with Administrative Duties
- Registered Nurse (RN)
- Licensed Practical/Vocational Nurse with Administrative Duties
- Licensed Practical/Vocational Nurse (LPN/LVN)
- Certified Nurse Aide (CNA)
- Nurse Aide in Training
- Medication Aide/Technician
- Physical Therapist, Occupational Therapist, Speech-Language Pathologist (and their respective assistants)
- Mental Health Service Worker
- Activities Staff
- Pharmacist
- Dietitian
- Therapeutic Recreation Specialist
- Qualified Social Worker
- Other Social Worker
Getting the job title mapping right is one of the most common challenges facilities face. When a staff member performs multiple roles during a shift, hours should be allocated to each role proportionally.
Census Data
You must report your facility's daily resident census for every day of the quarter. This figure represents the number of residents in the facility at midnight (census count time) and is used by CMS to calculate staffing ratios on a per-resident-day basis.
Census accuracy is as important as staffing accuracy. If your census is understated, your calculated staffing ratios will appear artificially high. If overstated, your ratios will appear artificially low. Either scenario can create problems.
Include:
- All residents occupying a bed at midnight, including residents on therapeutic leave if your state counts them in census.
- Residents admitted during the day but who occupy a bed at midnight.
Exclude:
- Residents who were discharged or died before midnight.
- Beds that are available but unoccupied.
Employee Data
For each employee reported in the staffing data, you must also submit basic employee information:
- Employee ID (unique, non-SSN identifier)
- Hire date
- Termination date (if applicable during the quarter)
This data allows CMS to track staffing turnover and continuity metrics, which are increasingly factored into quality assessments.
Submission Deadlines and Process
Quarterly Deadlines
PBJ data is submitted quarterly, with specific deadlines for each reporting period:
| Quarter | Reporting Period | Submission Deadline | |---|---|---| | Q1 | January 1 - March 31 | May 15 | | Q2 | April 1 - June 30 | August 14 | | Q3 | July 1 - September 30 | November 14 | | Q4 | October 1 - December 31 | February 14 |
These deadlines are firm. Late submissions may result in your facility being flagged for non-compliance, and your staffing data may not be reflected on Care Compare or in Five-Star calculations for that period.
Submission Methods
PBJ data is submitted through the CMS CASPER (Certification and Survey Provider Enhanced Reports) system. There are two submission methods:
1. XML File Upload. Most facilities use their payroll or staffing software to generate an XML file in the CMS-specified format, which is then uploaded through the CASPER system. This is the most efficient method for facilities with electronic timekeeping.
2. Manual Entry. CMS provides a manual data entry option through the PBJ system interface. This is practical only for very small facilities with minimal staff. Manual entry is error-prone and not recommended for most facilities.
Corrections and Resubmissions
If you discover errors after submission, you can resubmit corrected data up until the submission deadline for that quarter. After the deadline, corrections may be accepted during a limited grace period, but this is not guaranteed. The best practice is to review and validate your data well before the deadline so you have time to make corrections.
Common PBJ Errors and How to Avoid Them
Errors in PBJ reporting are disturbingly common, and they often work against the facility by understating actual staffing levels. Here are the most frequent mistakes and how to prevent them.
1. Incorrect Job Title Mapping
The Problem: Staff members are mapped to the wrong CMS job title category. For example, a licensed nurse who spends part of their day in administrative duties may be coded entirely as an administrative nurse, removing their hours from the direct care calculation.
The Fix: Review your job title mapping annually and whenever you add new positions. Cross-reference CMS job title definitions with actual job descriptions. For staff who split time between roles, allocate hours proportionally to each applicable category.
2. Missing Agency or Contract Staff Hours
The Problem: Agency and contract staff hours are not included in PBJ submissions, or they are included but not properly categorized as contract staff.
The Fix: Establish a process for collecting and recording agency staff hours daily. Require agencies to provide timesheets that include the information needed for PBJ reporting. Assign someone to reconcile agency hours weekly, not just at the end of the quarter.
3. Census Discrepancies
The Problem: The daily census figures submitted in PBJ do not match your facility's actual census records, ADT (admission-discharge-transfer) logs, or MDS data.
The Fix: Reconcile PBJ census data against your ADT system before each submission. Audit a sample of days each month to catch discrepancies early. Ensure your census counting methodology is consistent and documented.
4. Payroll Hours vs. Worked Hours Confusion
The Problem: PBJ should report hours actually worked providing direct care, not total payroll hours. Paid time off, orientation hours not spent in direct care, and administrative time may be inadvertently included or excluded.
The Fix: Configure your payroll or timekeeping system to distinguish between direct care hours, administrative hours, PTO, and other non-direct-care time. Verify that your PBJ export logic correctly filters for the appropriate hour types.
5. Not Accounting for Non-Standard Pay Periods
The Problem: Your payroll periods do not align with calendar quarters. Hours that straddle the quarter boundary may be double-counted, omitted, or misattributed.
The Fix: Map each payroll period to the correct calendar days. If a pay period spans two quarters, split the hours to the appropriate calendar days based on actual timekeeping records, not a simple proration.
6. Failing to Report All Qualified Staff
The Problem: Some staff categories are overlooked in PBJ submissions. Mental health workers, activities staff, social workers, and therapy staff are sometimes excluded because facilities focus only on nursing categories.
The Fix: Review the complete list of CMS job title categories and ensure every applicable role in your facility is included. These non-nursing hours contribute to your total staffing calculations and can improve your reported ratios.
How PBJ Impacts Your Five-Star Rating
Understanding the connection between PBJ data and your Five-Star rating is essential for strategic staffing management.
The Staffing Rating Component
CMS calculates the staffing star rating using two primary measures derived from PBJ data:
- Total nursing hours per resident day (HPRD). This includes RN, LPN/LVN, and nurse aide hours divided by the average daily census.
- RN hours per resident day. RN hours receive separate consideration because CMS places particular emphasis on registered nurse staffing.
These measures are compared against national thresholds to determine your one- to five-star staffing rating.
Case-Mix Adjustment
CMS adjusts staffing measures for case mix using MDS-derived acuity data. This means a facility with a higher-acuity population is expected to have higher staffing levels. If your residents are sicker and more complex, your required HPRD to achieve a given star rating is higher.
This adjustment also means that accurate MDS coding matters for your staffing rating. Under-coded acuity can actually help your adjusted staffing ratio appear better, but it creates problems with reimbursement and does not reflect the true care needs of your population.
Weekend Staffing Penalty
CMS also evaluates weekend staffing levels separately. Facilities with significant drops in staffing on weekends compared to weekdays may receive a penalty that reduces their staffing star rating. This is intended to discourage facilities from concentrating staff on weekdays when surveyors are most likely to visit.
Turnover and Retention Adjustments
CMS has incorporated staff turnover metrics into the staffing rating methodology. Facilities with high turnover rates, as evidenced by PBJ employee data, may receive a downward adjustment to their staffing rating. This adds another dimension to the importance of retention strategies.
Best Practices for PBJ Compliance
Establish a PBJ Point Person
Designate one person in your facility as the PBJ coordinator. This person should understand payroll systems, CMS reporting requirements, and the connection between PBJ data and quality ratings. They should not be an afterthought addition to someone's already-full plate.
Reconcile Data Monthly
Do not wait until the end of the quarter to review your PBJ data. Monthly reconciliation between timekeeping records, payroll data, census logs, and PBJ extracts catches errors when they are easiest to correct.
Run Pre-Submission Audits
Before each quarterly submission, run a comprehensive audit that checks:
- Total hours by job title category against payroll records
- Daily census against ADT logs
- Employee records for accuracy (hire dates, termination dates)
- Agency hours against agency invoices
- Hours distribution for reasonableness (no single employee with impossible hour counts)
Leverage Technology
Modern staffing and payroll platforms can automate much of the PBJ reporting process, but automation is only as good as the data that feeds it. Ensure your systems are configured correctly and that staff responsible for timekeeping understand the importance of accurate clock-in and clock-out records.
Understand Your Data Before CMS Does
Pull your facility's staffing data from Care Compare regularly and compare it to your internal records. If there are discrepancies, investigate and correct them before your next submission. Do not be surprised by your own data.
Get Help with PBJ Compliance
PBJ reporting sits at the intersection of payroll, clinical operations, and regulatory compliance -- and getting it right requires expertise across all three areas. If your facility is struggling with PBJ accuracy, dealing with staffing rating issues, or simply wants to ensure its reporting process is optimized, we can help.
Our PBJ compliance services include data auditing, process optimization, job title mapping reviews, and ongoing support to ensure your PBJ submissions are accurate, timely, and strategically aligned with your quality rating goals.
Contact us to schedule a PBJ compliance assessment and learn how we can help your facility get the staffing credit it deserves.