Who this applies to: Owners, administrators, CEOs, COOs, CFOs, finance directors, directors of nursing, HR, and IT at nursing facilities.
The Centers for Medicare and Medicaid Services (CMS) has strict regulations for reporting direct care staffing and census information through the Payroll-Based Journal (PBJ) system, requiring nursing facilities to report this information quarterly. CMS publishes the data and uses it to determine star ratings on the staffing component of the Nursing Home Compare website. While star ratings are obviously important for your facility’s reputation and ability to attract new patients and residents, there are other reasons that you should ensure that the data you submit on your PBJ is accurate and complete. This article offers nine actionable steps you can take to prepare your nursing facility for the CMS Payroll-based Journal audit.
Why accurate PBJ data is important
The data you provide can be accessed by other regulatory agencies, including state licensing agencies, and may be used for licensing and complaint investigation surveys, with any identified non-compliance resulting in citations, fines, or penalties. In 2026, the Office of Inspector General (OIG) started PBJ data audits as they relate to medical director hours reporting. Some state Medicaid agencies utilize PBJ data in a variety of ways, such as to validate paid nursing hours reported on Medicaid cost reports. Facilities need to be aware of a wide range of potential data uses and have comprehensive internal data review procedures to help ensure the public use file reflects accurate reporting and that the facility is prepared for an audit.
PBJ Data Specifications revisions
A revised version of the PBJ Data Specifications (Version 4.10.0) is required as of April 2026. Another recently announced change is that, effective August 17, 2026, the PBJ system will transition to the Internet Quality Improvement and Evaluation System (iQIES). This change impacts an organization’s access to the reporting platform because it requires an HCQIS Access Roles and Profile (HARP) login to access iQIES. Please note, similar to the Provider Statistical and Reimbursement (PS&R) report, providers have an option to request different levels of access to PBJ:
| Access level |
Available actions |
Recommended for |
| Provider Security Official (PSO) - required |
- Approve other user access requests
- View, upload, edit, and submit PBJ data
- Run PBJ reports
|
Senior leadership of the organization |
| PBJ Submitter (Provider or Vendor) |
- View, upload, edit, and submit PBJ data
- Run PBJ reports
|
Primary PBJ submitter and back-up |
| Provider Administrator |
|
Facility administrator, director of nursing |
| PBJ Viewer |
View-only access with the ability to run PBJ reports |
HR, Finance, IT, Compliance, or consultants |
According to CMS provider file data published June 1, 2026, about 4% of Skilled Nursing Facilities (SNFs) nationwide missed PBJ submission, submitted incorrect/unverifiable data, or failed a PBJ audit.
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Best practices for timely, accurate PBJ reporting
1. Maintain and test access to the reporting portal(s)
With turnover and planned and unplanned absences, we recommend that at least two staff members maintain logins and practice submitting reports. With the PBJ reporting transition to iQIES in August 2026 and April – June 2026 reports due by November 14, 2026, it is critical that facilities establish all required access (including back-up personnel) ahead of the reporting deadline. The iQIES Service Center is projecting an increase in the volume of calls and emails between July 2, 2026, and August 14, 2026, in preparation for this transition.
2. Understand that less might be more
PBJ reporting includes required and optional elements. The optional data may include worked hours for other service workers. Evaluate whether your organization should report optional data elements. If you opt to report this type of data, be sure that it is accurate and complete.
3. Plan ahead and consider more frequent submissions
Allow your team enough time for review after the quarter ends, but prior to the cut-off date. It is a requirement to file quarterly, but you may also submit data more frequently, such as after processing each pay period. This approach allows for more timely identification of employee classification issues or technical challenges. It also gets responsible staff into the habit of maintaining records on an ongoing basis, rather than as a quarterly event.
4. Don't forget to verify your submission
Do not skip the confirmations and available reports for review prior to the deadline. A frequent mistake we see in the industry is related to not reading acceptance/rejection reports carefully and assuming that the submission was accepted as submitted. Once the final data file is uploaded, SNF/NFs need to check their Final File Validation Report to verify that the data was submitted successfully. Please be aware that it may require up to 24 hours for the validation report to be available and allow for time to correct any errors and resubmissions, if needed.
5. Make finding a needle in a haystack easier
Carefully review and summarize data as described in the PBJ Report User Guide (CASPER Section 12 – Reports). We recommend obtaining all related reports (in CASPER, “D” at the end of the report number indicates detailed reports and “S” refers to summary reports). We recommend utilizing Excel data summarization tools to carefully review data. To help facilities with transition from CASPER to iQIES reporting, below is a list of available reports in both systems.
Please note that users will only be allowed to run reports for the providers to which they have access with their iQIES role. The iQIES reports are expected to contain the same information as the CASPER reports, updated to have the iQIES formatting. CMS planned to migrate previous submissions for up to 10 years, which will allow users to run all reports except the Submitter Final Validation report for data submitted in QIES and iQIES (see notes in table below).
| CASPER Report Number and Title |
iQIES Report |
Description |
Available download formats |
Use for |
| 1700D - Employee Report |
PBJ Employee Report |
Lists the active and/or terminated employees associated with a facility during a specified period |
PDF or CSV |
Verify all employees have a unique ID |
|
Notes:
- All PBJ reports in iQIES can be located in Report Category/Report Type: Payroll-Based Journal/Staffing.
- The use of the term Contractor was replaced with Contract throughout the report to match PBJ Specifications.
|
| 1702D - Individual Daily Staffing Report |
PBJ Individual Daily Staffing Report |
Details facility staffing information during a specified period by Employee ID |
PDF or CSV |
Use pivot table to summarize and review hours by employee or position / category and period (recommend daily, weekly, and monthly reports). |
| Note differences from CASPER report: The ‘Only Include Data Accepted Prior to the Deadline’ filter on the report criteria page is no longer applicable and will not be available in the iQIES report. |
| 1702S - Staffing Summary Report |
PBJ Staffing Summary Report |
Summarizes staffing information by job title for a facility during a specified period. |
PDF or CSV |
Review summary of hours reported for the quarter to help ensure staff or contractor reports are submitted. Consider comparing this report to the prior quarter. |
| 1703D - Job Title Report |
PBJ Job Title Report |
Details by work date the staffing hours submitted for select job title(s) during a specified period. |
CSV/Excel |
Review hours by job title and classification. |
| Note differences from CASPER report: The ‘Only Include Data Accepted Prior to the Deadline’ filter on the report criteria page is no longer applicable and will not be available in the iQIES report. The use of the term Contractor was replaced with Contract throughout the report to match PBJ Specifications. |
| 1704S,1704D - Daily MDS Census Summary Report |
PBJ Daily MDS Census Summary Report |
Provides daily facility census counts for a specified period. Lists the IDs of the residents included in daily facility census counts for a specified period. |
PDF or CSV |
Use to reconcile to your internal total daily census. |
| 1705D - PBJ Staffing Data Report |
PBJ Staffing Data Report |
Identifies areas of concern that may trigger follow-up during the survey, including:
- Failed to submit data for the quarter
- Excessively low weekend staffing
- One-star staffing rating
- No RN hours
- Failed to have licensed nursing coverage 24 hours/day
|
PDF |
Review compliance and error triggers summary (triggered or not triggered, metric suppressed due to invalid data, new facility, special focus facility). |
|
|
|
|
|
| FFVR - PBJ On Demand Final File Validation Report |
PBJ On Demand Final File Validation Report |
Indicates whether the submitted file was accepted or rejected and details the warning and fatal errors applicable to the data or the data file structure submitted. |
PDF |
Use to confirm submission and acceptance. |
| Note differences from CASPER report: The 60-day waiting period for requesting the on-demand PBJ Final Validation Reports has been removed to account for new access in iQIES and the QIES system-generated Final Validation Reports being unavailable in the iQIES PBJ Final Validation folders. |
| PBJ System-generated Final Validation Report |
PBJ System Generated Final File Validation Report |
Indicates whether the submitted file was accepted or rejected and details the warning and fatal errors applicable to the data or the data file structure submitted. |
PDF |
Use to confirm submission and acceptance. |
|
Notes:
- Differences from CASPER report: The system-generated Final Validation Reports in QIES (system used prior to August 2026) will not be migrated into iQIES. Users will be allowed to access CASPER to obtain these until they are automatically deleted based on the report's retention time period, if desired. Alternatively, users can generate the iQIES user-requested final validation reports for submissions performed in QIES if it is more convenient.
- The iQIES report now includes a CMS Certification Number (CCN), and error sections such as General, Staffing, Employee, or Employee Link have been delineated to make the report more intuitive for users.
|
iQIES users can schedule reports to run at their preferred frequency. Review these reports to help ensure the quarterly PBJ data reflects your records. Most of the detail reports (D) are available as a .csv file download, which is instrumental with the assistance of Excel templates to simplify and expedite your review. We recommend using pivot tables, data filtering, and conditional formatting rules to bring attention to potential errors, omissions, or high-risk audit areas, including:
- Any days without at minimum eight RN hours
- Exempt staff with >40 reported worked hours per week
- Non-exempt (hourly) staff with more than 80 hours per week or >300 hours per month
- High or low average total nurse (aides, LPNs, and RNs) staffing (less than two and more than five hours per patient day. Visit BerryDunn’s senior living self-service benchmarking portal for comparison to your peers
- Changes in total average nurse staff hours per patient day by over 10% compared to the previous quarter(s)
6. Share the knowledge with PBJ reporting and management teams
Educate your PBJ reporting and management oversight team, discuss, and gain clarity on your internal record-keeping policies and procedures. Obtain the most recent manuals. We recommend electronic bookmarks to the CMS site rather than printed paper copies, as the guidance may change.
7. Trust but verify to help ensure compliance
While you may have complete trust in your team, nobody is immune to an occasional mistake or omission. Responsibility for PBJ compliance is with facility leadership. Review the reports carefully and make timely corrections.
8. Keep a close eye on the Nursing Home Compare website
Check the CMS nursing home compare information for your facility regularly to help ensure information is correct.
9. Don't panic: It is fixable!
If you have an unfavorable PBJ audit, there are actions you can take to remedy the situation and avoid it in the future. We suggest that your team:
- Includes the PBJ program compliance review in your QAPI initiatives, which makes it a multi-departmental challenge to get back on track and prevent any future non-compliance
- Engages your communications team in crafting a meaningful response to any potential community inquiries if you receive a one-star rating in staffing. Be prepared to describe the issue objectively and without blame, while outlining the steps the facility is taking to improve.
- Takes an objective look at your systems. Consider an external consultant to help with identification of the process gap and ideas for sustainable remediation.
If you have any questions, please reach out to Olga Gross-Balzano or a member of BerryDunn’s Senior Living team of experts.