​Staffing-related survey findings rarely result from a lack of effort or intent. More often, they reflect small operational gaps that develop gradually as staffing practices, documentation, and reporting evolve at different speeds. Over time, those misalignments can leave facilities exposed during survey, even when leaders believe they are compliant.

Because staffing compliance spans multiple functions, including scheduling, payroll, credentialing, agency oversight, and reporting, it benefits from periodic, intentional review. The following CMS staffing compliance areas frequently surface during surveys and represent practical opportunities for facilities to reduce risk through manageable operational checks.

1. Registered nurse coverage is one area that consistently draws scrutiny. CMS requires facilities to maintain and document RN coverage in accordance with federal and state requirements, including weekends and holidays. In practice, schedules often reflect planned coverage, but last-minute call-offs, substitutions, or coverage adjustments are not always reconciled in supporting documentation. Facilities can reduce exposure by confirming that RN coverage logs align with payroll and timekeeping records, particularly when coverage changes occur. In many organizations, this review is most effective when responsibility for reconciliation is clearly defined rather than assumed.
2. Payroll-Based Journal reporting is another common source of findings. CMS expects PBJ submissions to accurately reflect staffing hours worked, categorized correctly by role. While many facilities generate PBJ files directly from payroll systems, discrepancies can occur when job codes change, classifications are updated, or agency staff hours are not mapped consistently. Facilities that perform routine internal reviews comparing PBJ submissions to payroll records before filing tend to identify inconsistencies earlier, especially during periods of staffing transition.
3. Credential and licensure tracking presents similar challenges. Most facilities verify credentials at hire, but renewal monitoring can become fragmented over time, particularly when staff change roles or when agency clinicians rotate frequently. CMS expects facilities to demonstrate that licensed staff maintain current credentials and that documentation is readily accessible. A centralized review process that periodically verifies license status across both employee and contract staff, rather than relying on individual reminders, helps prevent last-minute gaps during survey.
4. Agency and contract staffing documentation also warrants regular attention. CMS expects facilities to maintain records demonstrating qualifications, hours worked, and compliance for non-employee staff. In practice, agencies may provide credentials at onboarding, but updates are not always captured consistently. Additionally, agency hours may be tracked separately from employee records, creating reconciliation challenges. Facilities that clearly define documentation responsibilities in agency agreements and periodically reconcile agency hours with payroll and PBJ data are better positioned to demonstrate consistency during review.
5. Finally, staffing-related policies should be reviewed with operational reality in mind. Policies may technically exist but no longer reflect current staffing models or workflows. Surveyors often identify disconnects between written policy and day-to-day practice, even when care delivery itself is appropriate. Facilities that review staffing policies on a regular cadence, particularly following workforce or scheduling changes, are better able to explain how policies are operationalized.

Taken together, these areas highlight a broader pattern: staffing compliance risk tends to build quietly when documentation, data, and operational practice drift out of sync. Facilities that conduct focused, periodic reviews across these domains are better positioned to demonstrate preparedness and consistency during survey.

Approaching CMS staffing compliance as an ongoing operational discipline, rather than a survey-driven response, allows leaders to address issues early and with less disruption, supporting both regulatory readiness and workforce stability.

Kelly Brooks is an SPHR-certified HR leader and founder of AblePBJ.com with decades of experience in skilled nursing and assisted living. 

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