PBJ Staffing Data Reconciliation Audit
A quarterly PBJ Staffing Data Reconciliation Audit template for checking payroll, schedules, and agency invoices before CMS submission. Use it to catch mismatches, role-mapping errors, and unsupported hours before they become reporting defects.
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Built for: Skilled Nursing Facilities · Long Term Care · Post Acute Care · Senior Living Compliance
Overview
The PBJ Staffing Data Reconciliation Audit template is a quarterly inspection and audit worksheet for confirming that Payroll-Based Journal staffing data matches the source records used to build it. It walks the reviewer through submission readiness, payroll time record reconciliation, contract labor and agency invoice validation, role mapping, and final approval controls.
Use this template when you are preparing a CMS PBJ submission and need to verify that reported hours are supported by payroll records, approved schedules, and vendor invoices. It is especially useful when multiple departments, agencies, or payroll systems feed the final file. The structure helps you catch unsupported hours, duplicate agency entries, misclassified staff, and unresolved exceptions before the submission is finalized.
Do not use this template as a generic staffing dashboard or a retrospective performance report. It is not meant for headcount planning, budget forecasting, or daily staffing operations. If you are not preparing a PBJ filing, or if you do not have source records for the full quarter, the audit will be incomplete and the results will be misleading. The template is most valuable when the reviewer can trace every reported hour back to a time record, invoice, or documented exception.
Standards & compliance context
- This template supports CMS PBJ reporting by creating a documented reconciliation trail between reported staffing hours and underlying source records.
- It aligns with general healthcare compliance expectations for data accuracy, traceability, and approval control, which are common themes in CMS audits and internal QA programs.
- If your organization uses agency labor, the template helps demonstrate that contract staffing was validated against vendor documentation and the correct reporting period.
- Facilities that maintain broader quality systems can treat this as a controlled audit record under an ISO 9001-style document and corrective-action workflow.
- The template is focused on reporting integrity, not clinical care, so it should be used alongside your facility’s payroll, HR, and billing controls rather than as a standalone policy.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Audit Scope and Submission Readiness
This section confirms the reporting period, entity details, file version, and source-document availability before any reconciliation begins.
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Quarterly reporting period matches the intended CMS submission window
Record the start and end dates for the quarter under review and confirm they match the submission period.
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Facility CCN and legal entity information match source records
Verify the CMS Certification Number and facility legal name are consistent across PBJ, payroll, and contract documentation.
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PBJ submission file version and export date documented
Capture the file version, export date, and preparer name for traceability.
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Supporting source documents available for the full quarter
Confirm availability of payroll registers, timecards, approved schedules, agency invoices, and prior correction logs.
Payroll Time Record Reconciliation
This section ties reported staffing hours back to payroll records so unsupported or misclassified time is caught early.
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Total reported hours reconcile to payroll time records
Enter the variance between PBJ reported hours and payroll/timekeeping hours for the quarter.
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Direct care staff hours are supported by time records
Verify nursing, therapy, and other direct care hours are traceable to approved time records.
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Overtime, shift differentials, and missed punches reviewed for accuracy
Confirm payroll adjustments were reviewed and reflected correctly in the PBJ export.
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Unworked paid time excluded from PBJ submission
Verify PTO, holiday pay, bereavement, and other non-worked paid time were excluded where required.
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Time record exceptions documented and resolved
List unresolved exceptions such as missing punches, duplicate shifts, or manual edits and note the resolution status.
Contract Labor and Agency Invoice Validation
This section verifies that agency hours are backed by approved invoices and valid vendor documentation for the correct quarter.
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Agency hours reconcile to approved invoices
Enter the variance between PBJ contract labor hours and invoiced hours for the quarter.
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Contract labor staff have valid vendor and assignment documentation
Verify each agency worker included in PBJ has supporting vendor records, assignment dates, and role documentation.
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Invoice dates and service periods align to the reporting quarter
Confirm invoices and service periods fall within the quarter being submitted or are properly allocated.
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Duplicate agency entries identified and removed
Check for duplicate hours, duplicate invoices, or repeated staff identifiers in the PBJ file.
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Contract labor exceptions documented with corrective action
Document any invoice mismatches, missing vendor support, or disputed hours and the corrective action taken.
Role Mapping and Staffing Category Accuracy
This section checks that each staff member is reported in the right PBJ category based on title, credential, and actual function.
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Staff job titles map correctly to PBJ reporting categories
Confirm each employee and contractor is assigned to the correct PBJ category for the hours reported.
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Licensed staff credentials verified for reported role
Confirm licenses, certifications, and expiration dates support the role reported in PBJ.
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Administrative and support hours excluded from clinical categories
Verify non-clinical hours were not misclassified as nursing or therapy hours.
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Staffing category exceptions reviewed with department leadership
Document any disputed role mappings, reclassifications, or approval decisions.
Submission Controls, Corrections, and Approval
This section captures variances, corrective actions, and final sign-off so the submission is controlled and defensible.
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All identified variances corrected or formally explained
Verify all material discrepancies have been corrected in the source data or documented with justification.
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Correction log includes issue, owner, due date, and resolution status
Confirm a complete log exists for all findings and corrective actions.
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Final PBJ submission reviewed and approved by authorized leader
Authorized approver signs off on the reconciled PBJ submission prior to CMS filing.
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Submission readiness status
Select the final readiness status for CMS submission.
How to use this template
- Start by entering the quarter, facility CCN, legal entity name, PBJ file version, and export date, then confirm that all supporting source documents are available for the full reporting period.
- Assign the audit to a reviewer who can access payroll, scheduling, HR, and agency billing records, and make sure department leaders know who will resolve exceptions.
- Reconcile reported hours to payroll time records, then check overtime, shift differentials, missed punches, and unworked paid time so only reportable hours remain in the PBJ file.
- Validate contract labor by matching agency hours to approved invoices, vendor assignments, and service periods, and remove any duplicate entries or unsupported labor records.
- Review role mapping and staffing categories with department leadership, document every variance in the correction log, and obtain final approval from an authorized leader before submission.
Best practices
- Reconcile the PBJ file against source records line by line, not just by total hours, so category errors do not hide inside a balanced summary.
- Flag unworked paid time separately from worked hours, because paid leave, training, and other non-working time are common sources of PBJ misstatement.
- Verify licensed staff credentials before accepting their reported role, especially when a nurse, therapist, or supervisor can appear in more than one staffing category.
- Match agency invoices to the exact reporting quarter and service period, and investigate any invoice that spans dates outside the submission window.
- Document every exception with an owner, due date, and resolution status so the correction trail is complete when the file is approved.
- Keep a copy of the final PBJ export and the source documents used for reconciliation, since audit support is strongest when the evidence set is preserved together.
- Review department-level mappings with nursing and HR leadership before submission, because local job titles often do not align cleanly with PBJ reporting categories.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What does this PBJ Staffing Data Reconciliation Audit template cover?
It covers the quarter-end review of PBJ staffing data against payroll time records, approved schedules, and contract labor invoices. The template is organized to verify submission readiness, reconcile reported hours, validate agency labor, confirm role mapping, and document corrections before filing. It is designed for facilities that submit PBJ data to CMS and need a repeatable audit trail.
How often should this audit be run?
This template is built for quarterly use, aligned to the PBJ reporting period and the CMS submission window. Many facilities also use it as a monthly internal checkpoint so variances are easier to resolve before quarter close. If your payroll or agency labor volume is high, a mid-quarter review can reduce last-minute corrections.
Who should own the audit?
The audit is usually owned by a compliance, finance, HR, or reimbursement lead, with input from nursing leadership and payroll. A designated reviewer should have access to source records and authority to resolve discrepancies. Final approval should come from an authorized leader who can sign off on the submission.
What records do I need to complete it?
You need payroll time records, approved staffing schedules, agency invoices, vendor assignment documentation, and the final PBJ export or draft file. It also helps to have employee role data, credential records for licensed staff, and a correction log. The template assumes those source documents are available for the full quarter.
What are the most common mistakes this audit catches?
Common issues include hours that do not reconcile to payroll, unworked paid time incorrectly included, duplicate agency entries, and staff mapped to the wrong PBJ category. It also surfaces missing vendor documentation, invoice dates outside the reporting quarter, and licensed staff reported under an unsupported role. Those are the kinds of defects that can distort staffing data and create follow-up work after submission.
How does this help with CMS or regulatory review?
The template creates a documented reconciliation trail that supports the accuracy of the PBJ submission. That matters because PBJ reporting is tied to CMS expectations for staffing transparency and auditability. It also helps show that variances were reviewed, corrected, or formally explained before submission.
Can this template be customized for my facility type or staffing model?
Yes. You can add facility-specific job titles, local agency vendors, department-level approvers, or extra checks for float staff and per-diem labor. If your organization uses a different payroll system or timekeeping workflow, you can also adapt the source-document fields without changing the audit logic. The core sections should still follow the same reconciliation sequence.
How is this better than a manual spreadsheet check?
A manual spreadsheet check often misses the control points that matter most: source-document availability, role mapping, exception ownership, and approval status. This template turns the review into a repeatable audit with clear sections and documented outcomes. That makes it easier to standardize across quarters and easier to defend if questions come up later.
What should I do if I find a variance during the audit?
Record the issue in the correction log, assign an owner, and set a due date before the final submission is approved. If the variance cannot be corrected in time, document the reason and the impact on the reported hours. The goal is to either fix the data or leave a clear explanation that shows the discrepancy was reviewed.
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