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

Develop a dedicated budget to address Privacy Office training needs and initiatives

Update all privacy guidance to reflect current Federal requirements and processes.

Implement a formal process for the Privacy Office to issue and communicate privacy guidance, requirements, and deadlines.

Update and continue to maintain a central collaboration area to include all current privacy program policies, procedures, and guidance