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If a root canal and a surprise IRS audit had a love baby, it would be the CMS PBJ audit.

You never quite know when it's coming, it's always more invasive than expected, and afterward, you're left questioning every timecard you've ever approved.

After experiencing half a dozen of these joyrides in the last year, I can confidently say: PBJ audits are not for the faint of heart. But the good news? They're not (usually) random. CMS isn't rolling the dice—they're looking for patterns, anomalies, and just enough weirdness in your data to send an email that ruins your Friday. 

If you haven't had your day in the spotlight, there's a one in three chance you will have your opportunity over the next year or two.

Elevate your Compliance

What Triggers a CMS PBJ Audit?

CMS is watching your staffing reports—and if your data doesn't add up, they're coming with questions. With the increased focus on Payroll-Based Journal (PBJ) reporting, especially under the new penalties rolled out in late 2024, knowing what gets you audited isn't just helpful—it's essential.

Here's what triggers a PBJ audit, based on the latest CMS guidance, expert analysis, and real-world examples:

1. Sudden Spikes or Drops in Reported Hours

CMS flags facilities that show significant quarter-over-quarter changes in reported nurse or direct care hours. A 15%+ increase or a sudden drop in hours compared to the previous quarter will get attention. Even if the change is legitimate, expect to justify it. One facility saw a 17% bump in RN hours and immediately received an audit request.

2. Outlier High Staffing Levels

Facilities reporting total nursing HPRD (hours per resident per day) well above the national average—especially over 6.0—are flagged as potential over-reporters. CMS views these as "too good to be true" and requests backup documentation. Past audit cycles have explicitly focused on providers showing HPRD in the top performance tier.

3. Unusually Low Staffing or RN Coverage Gaps

On the flip side, very low staffing (e.g., RN HPRD below 0.5 or total nurse HPRD below 2.0) or multiple days with no RN coverage (seven or more in a quarter) trigger automatic penalties and audit scrutiny. Even a few missed days may result in a one-star staffing rating or follow-up requests from surveyors.

4. Drastic Weekday vs. Weekend Discrepancies

If your weekday staffing looks solid but your weekend numbers fall off a cliff, CMS will notice. Audits have been prompted by facilities showing 4.5 HPRD on weekdays and only 2.0 on weekends. These patterns suggest care inconsistency—and may cue both audits and surprise inspections.

5. Improbable Work Hours for Individuals

Employees listed with excessive hours—more than 80 hours per week or 300+ per month—are an audit magnet. CMS knows what's realistic. Logging a single CNA for 16-hour days, seven days a week, will land your facility in the audit pile. The same goes for exempt staff shown working full-time hourly equivalents.

6. Extreme Turnover or Tenure Anomalies

Facilities reporting either implausibly high turnover (e.g., 80%+ staff change in one quarter) or zero turnover over a long period will attract attention. Both raise flags about data integrity. CMS expects realistic staff movement in an industry known for churn.

7. Data Irregularities and Obvious Errors

CMS isn't just looking at totals—they're digging into formatting, consistency, and logic. Failing to subtract required meal breaks, double-counting roles, misusing job codes, or reusing employee IDs will all raise suspicion. CMS compares reported PBJ data against payroll and time records if something looks wrong.

Real-World Examples:

• One facility reported over 8.0 nursing HPRD for three quarters straight. Audit triggered.

• Another forgot to include agency hours—CMS flagged an 80% turnover rate and dropped their rating.

• A PBJ file showed a CNA with 402 hours logged in one month. CMS requested timesheets.

• A facility changed timekeeping software and utilized new employee identifiers, falsely triggering high turnover rates.

Bottom Line:

PBJ audits aren't random. They're data-driven, and CMS has the algorithms to catch anomalies. Your job is to keep your reporting accurate, defensible, and consistent.

Before every submission, audit yourself:

• Do your hours make sense compared to last quarter?

• Do weekends look wildly different than weekdays?

• Are any individual employees clocking superhero hours?

CMS will assume the worst if your data looks suspicious until you prove otherwise.

Partners We Love

PBJ is just one of the compliance mazes operators must navigate in 2025.  New regulations are coming, and state and federal laws are changing by the month.  

The policies and practices that kept you out of trouble in years past are potentially out of compliance moving forward.

Download Viventium’s 2025 Skilled Nursing & Senior Living Compliance Guide to avoid some of the most common and concerning compliance pitfalls that community operators are facing in 2025.

Whenever you're ready, I can help you in a few ways.

1. Leverage our partnership with CEUSrEZ and purchase NAB-approved, online, self-paced, continuing education courses at a 20% discount here.
2. Use our free AI-powered Chatbot trained on all 900 pages of CMS Nursing Home Regulations, proprietary processes, and information from decades of skilled nursing leadership experience.  Click here.
3. Sign up for Assisto and keep track of the regulatory environment in your state.  Know what deficiencies surveyors cite in real-time and ensure you're not at risk for the same tag.  Sign up here.

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Thanks for reading.  Have a wonderful day.

Kevin Goedeke, Publisher and Founder