Finding 634869 (2022-004)

Significant Deficiency
Requirement
P
Questioned Costs
-
Year
2022
Accepted
2023-03-30
Audit: 55905
Organization: Lutheran Seniorlife (PA)

AI Summary

  • Core Issue: St. John received a REAC inspection score below 31, indicating significant physical deficiencies that violate HUD requirements.
  • Impacted Requirements: Noncompliance with HUD standards due to unresolved deficiencies from the REAC inspection.
  • Recommended Follow-Up: St. John should prioritize addressing all REAC findings and ensure timely improvements, especially after recent flooding and delays caused by the pandemic.

Finding Text

2022-004 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing Number: 14.129 Award Period: Year Ended June 30, 2022 Type of Finding: ? Significant Deficiency in Internal Controls over Compliance ? Other Matters Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings.Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021.

Categories

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 58426 2022-003
    Significant Deficiency
  • 58427 2022-004
    Significant Deficiency
  • 58428 2022-001
    Significant Deficiency Repeat
  • 58429 2022-002
    Significant Deficiency
  • 634868 2022-003
    Significant Deficiency
  • 634870 2022-001
    Significant Deficiency Repeat
  • 634871 2022-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
14.129 Mortgage Insurance_nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities $9.29M
10.766 Community Facilities Loans and Grants $2.65M
93.498 Provider Relief Fund $1.20M