Review and revise the policies and procedures for making partial payments of claims to check that each decision to make a partial payment of claim ensures that the payment restores the subject nursing home to financial viability to avoid a repeat of the situation that led to the loss on Hebrew Home.

Require Jamaica Hospital Nursing Home to provide support for $8,974,000 paid to its related company. Any amount that the owner cannot support as reasonable in price and necessary to the nursing home should be repaid to the nursing home.

Require Jamaica Hospital Nursing Home to provide support for $44,483,000 in accounts payable. Any amount that the owner cannot support as reasonable in price and necessary to the nursing home should be removed from the accounts payable

Require the owners of Bishop Wicke Health and Rehabilitation Center, Plaza Village Senior Living, Golden Hill Health Care Center, Immanuel Campus of Care, and their related companies to reimburse the nursing homes for the ineligible expenses of $7,027,289.

Require Shawnee Christian Nursing Center to return 27 beds to operation or pay down the mortgage by $815,973

Define the troubled and potentially troubled classifications for nursing homes and develop specific measures to identify when and how nursing homes are classified.

Develop and implement policies and procedures to revisit the classifications at least annually.

Develop and implement computerized controls to flag blank data fields and illogical financial data.

Develop and implement procedures to require owners, operators, and lenders to submit accurate and complete financial data.

Develop and implement internal controls to routinely compare financial data on mortgage payments to Multifamily Delinquency and Default Reporting System data on mortgage payments and follow up on any conflicting data.

Develop and implement procedures for referring operators who fail to provide required financial statements to the Departmental Enforcement Center.

Develop and implement metrics to evaluate each nursing home’s financial data for changes in utilization, payments, profitability, and solvency (debt service credit ratios).

Ensure the privacy program is staffed with experienced personnel (such as a Chief Privacy Officer) to manage the operational aspects of the program.

Issue a notice at the Secretary level delegating and clarifying the authority and responsibilities of the SAOP and Privacy Office

A. Document the roles and specific responsibilities of all positions assigned privacy responsibilities. B. Communicate these responsibilities on a recurring basis, at least annually, to individuals holding these positions.

Implement thorough human capital processes to ensure execution of the HUD privacy program and all its requirements

Finalize and approve the draft privacy program strategic plan

Ensure the privacy program is integrated with the enterprise risk program and that privacy risks are incorporated into the agency risk management process

Establish an executive leadership dashboard to communicate continuous monitoring of key program risks and issues

A. Develop an internal privacy program communication plan to describe how privacy issues will be disseminated and best practices will be shared. B. Implement the communication plan