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F851
(Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24)
§483.70(p) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.
§483.70(p)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).
§483.70(p)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).
§483.70(p)(3) Distinguishing employee from agency and contract staff.
When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.
§483.70(p)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.
§483.70(p)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.
INTENT §483.70(p)
To ensure that long-term care facilities are electronically submitting direct care staffing information (including agency and contract staff) per day, based on payroll and other verifiable and auditable data. The staffing hours, when combined with census information, can then be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure.
GUIDANCE §483.70(p)
The facility is responsible for ensuring all staffing data entered in the Payroll-Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and/or tied back to a contract.
The surveyors can obtain PBJ data from the Certification And Survey Provider Enhanced Reports (CASPER) report to determine if the facility submitted the required staffing information based on payroll data in a uniform format. The facility’s failure to submit PBJ data as required will be reflected on their CASPER report and result in a deficiency citation.
If concerns were identified based on the CASPER report, or from any other source, refer to the critical element pathway “Sufficient and Competent Staffing.”
Refer to the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual for submission guidelines. Please see the following link for more information: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html
For questions related to F851, surveyors, providers, or other stakeholders should email NHStaffing@cms.hhs.gov.
KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F851, the surveyor’s investigation will generally show that the facility failed to do any one of the following:
• Complete data for the entire reporting period, such as hours paid for all required staff, each day; or
• Provide accurate data; or
• Provide data by the required deadline; or,
• Submit the required staffing information based on payroll data in a uniform format.
Noncompliance at F851 focuses on the submission of staffing data. If the surveyor identifies concerns related to sufficient staffing, surveyors would investigate these concerns using the Sufficient and Competent Staff Critical Element Pathway, and guidance at §483.35 Nursing Services (F725 & F727).

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