Payroll Based Journal Reporting and PBJ Audits

January 26, 2024


The Five Star Quality Rating System has undergone a significant change to the Staffing Star portion of the Quality Rating. The weekend staffing and the staff turnover began affecting the calculation of the Staffing Star portion of the Quality Rating in July of 2022. Staffing turnover has been added. The nursing turnover will be reported publicly and will impact the SNF VBP measure, which impacts Medicare payment. This presentation will clearly demonstrate how PBJ reporting should be correctly completed. There is confusion about how to correctly report each individual’s job code and how important it is to clearly communicate when nurses change shifts, work extra on weekends and are absent for PTO, illness, meal breaks and education time. When a licensed nurse changes their primary role during the shift the actual roles performed should be clearly reported in PBJ.

The webinar will describe how CMS determines nurse turnover rates which include agency nurses who have worked at least 120 hours during the quarter and are then absent for 60 days. The nurse leaders should look at how they use staffing agencies and how to advocate for dedicated nurses who will work for the SNF so that agency nursing does not impact the facility’s turnover rate.

The nurse leaders do not know which data reports would be the most accurate to provide to CMS auditors when a PBJ audit occurs. This webinar will discuss reports from time clocks, staffing documentation for staff who do not punch in and reports from staffing agencies. In addition, the CMS PBJ system has very strict timelines for submitting staffing information which must be met. There are validation reports available in the QIES CASPER reporting system that nurse leaders and administrators should review after the data has been submitted to ensure the information has been correctly reported and submitted prior to the deadline. These reports will also be discussed. This pre-recorded webinar includes questions asked during the live presentation by the audience and answered by the presenter.



Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter, providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

  • 1.5 hours for Licensed Nurses
  • 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on August 10, 2025.


Hansen Hunter & Co. P.C. clients are invited to access any of our webinars for free by contacting Allison Johnson at our office at 503.244.2134 to receive your free registration code.


  • This nursing continuing professional development activity was approved by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Enduring material: To meet the requirements for these contact hours, you must watch the entire recorded presentation as well as answer and submit the post-test evaluation that is provided as a link along with the link to your webinar which you will receive via email after completing your purchase.