Nurse staffing levels, particularly registered nurse (RN) time, are an essential prerequisite for high quality care and life for nursing home residents. When the Centers for Medicare & Medicaid Services (CMS) first created the Care Compare website in 2008, it allowed facilities to self-report nurse staffing levels. The result was overstatement of staffing. Although the Payroll-Based Journal (PBJ) system, implemented in April 2018, was intended to provide more accurate staffing data, the HHS Office of Inspector General now reports that in March 2024, nearly half of all nursing homes in a 100-facility sample misreported RN hours on PBJ. CMS’s Processes Were Not Effective in Ensuring the Accuracy of Staffing Information Reported in the Payroll-Based Journal, A-09-24-02005 (Jun. 2026).
Self-reporting staffing levels
When the Centers for Medicare & Medicaid Services (CMS) first created the rating system for nursing homes on the Care Compare website in December 2008 (CMS, “CMS Issues Historic Star Quality Rating System for Nursing Homes” (Press Release, Dec 18, 2008)), it allowed facilities to self-report nurse staffing levels. The result was overstatement of staffing levels. Katie Thomas, “Medicare Star Ratings Allow Nursing Homes to Game the System,” The New York Times (Aug. 24, 2014); “The Worst-Performing Nursing Facilities Are Seldom Sanctioned; Self-Reporting is Not an Accurate Quality Measurement” (CMA Alert, Jan. 24, 2013).
As part of the Affordable Care Act, Congress required nursing homes to submit “staffing information based on payroll data in a uniform format,” 42 U.S.C. §1320a-7j(g). Congress provided specific funding for the payroll-based system in the Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014, Public Law 113–185.
Payroll-Based Journal
On October 6, 2014, CMS announced that beginning in 2015, it would report nurse staffing levels using a payroll-based staffing reporting system, now known as the Payroll Based Journal (PBJ). CMS, “CMS Announces Two Medicare Quality Improvement Initiatives” (Press Release, Oct. 6, 2014).
Describing the importance of staffing on quality of care and outcomes for nursing home residents and the “substantial amount of technical assistance [it provided] to help nursing homes submit data,” CMS finally announced the transition from self-reported staffing to PBJ in April 6, 2018. CMS, “Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on Medicare.gov and the Five Star Quality Rating System,” QSO-18-17-NH (Apr. 6, 2018). The PBJ data showed what residents’ advocates had claimed for years; that facilities did not have as many nurses providing care to residents as they claimed to have. Jordan Rau of Kaiser Health News reported that the PBJ data showed that “Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years.” Jordan Rau, “‘It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years,” The New York Times (Jul. 7, 2018). He added, “The payroll records provide the strongest evidence that over the last decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels.”
Inspector General’s June 2026 report
The HHS Office of Inspector General now reports that in March 2024, nearly half of all nursing homes in a 100-facility sample misreported RN hours on PBJ. OIG, CMS’s Processes Were Not Effective in Ensuring the Accuracy of Staffing Information Reported in the Payroll-Based Journal, A-09-24-02005 (Jun. 2026). Using a stratified random sample of 100 registered nurses (RNs) with “approximately 17,700 RN hours reported in the PBJ [Payroll Based Journal] by 99 nursing homes for March 2024,” an audit by the HHS Office of Inspector General (OIG) finds that hours for 45 RNs “were not supported in accordance with Federal requirements, ranging from 60 hours that were underreported for 1 sample to 192.5 hours that were overreported for another sample item.” Report 4, 5. From the sample, OIG estimated that in March 2024, “nursing homes reported approximately 938,000 hours (5 percent) for approximately 53,000 RNs (42 percent) in the PBJ that were not supported in accordance with Federal requirements,” id. 6, 13.
Specifically, “nursing homes did not accurately report the number of hours that RNs were paid to deliver services for each day worked (42 sample items):”
- “Reported hours that RNs did not work (19 sample items), id. 5, 7-8.
- “Did not deduct meal breaks from hours reported (18 sample items), id. 5, 8.
- “Did not report hours that RNs worked and were paid for (13 sample items), id. 5, 8.
- “Reported hours that RNs were not paid for (13 sample items), id. 5, 8.
- “Reported hours for RNs who attended training and were not available to perform their primary role (2 sample items), id. 5, 9.
- “Did not report RN hours by calendar day (2 sample items),” id. 6, 9.
Nursing homes also “reported hours for individuals who did not have active licenses to practice as RNs (two sample items),” id. 6, 10. A nursing home “reported hours for an RN who did not work onsite (one sample item),” id. 6, 10. OIG also found that, in two sample items, “nursing homes reported 336 hours that could not be verified because the nursing homes did not provide supporting documentation,” id. 6, 10.
OIG found that “CMS’s processes were not effective in ensuring the accuracy of staffing information reported in the PBJ,” id. 10, because
CMS did not (1) ensure that nursing homes took corrective actions to address findings identified in prior PBJ audits; (2) ensure that nursing homes fully understood the Federal requirements for reporting complete and accurate staffing information; and (3) regularly communicate trends in CMS PBJ audit findings to nursing homes, which may encourage nursing homes to improve the accuracy of staffing information they report in the PBJ.
Id. 11, discussed at id. 11-13. For example, of the 18 facilities identified as not properly accounting for meal breaks, four had had prior audit findings of this same error, four claimed to have made changes (which were not effective), and 10 did not make any changes because they “believed that they did not need to deduct time for meal breaks if the staff were paid to work during that time,” id. 11. In addition, from 2022 through 2024, “between 39 percent and 55 percent of the nursing homes audited during that timeframe had findings,” id. 13. OIG observes, “More frequent communication by CMS on the most updated trends may encourage nursing homes to improve the accuracy of staffing information they report in the PBJ,” id.
CMS’s rejection of OIG’s fourth recommendation – to regularly communicate with nursing homes about trends in PBJ audit findings – suggests that CMS does not intend to take action to improve nursing homes’ reporting of nurse staffing information.
June 25, 2026 – T. Edelman