ST. PAUL, Minn. - A scathing report says a state agency set up to investigate allegations of maltreatment by nursing homes and other care facilities "has not met its responsibilities to protect vulnerable adults in Minnesota."

THE FINDINGS

The report, issued Tuesday by the Minnesota Office of the Legislative Auditor, takes to task The Office of Health Facility Complaints (OHFC) for a laundry list of shortcomings. Among them:

  • Between fiscal years 2012 and 2017, the number of allegation reports OHFC received increased by more than 50 percent, reaching 24,100 in Fiscal Year 2017. Of those 2017 reports, the auditor says OHFC triaged for onsite investigation only 5 percent.
  • OHFC does not inform vulnerable adults or their family members whether providers have reported suspected maltreatment.
  • OHFC does not have an effective case management system, which has contributed to lost files and poor decisions regarding resource allocation.
  • The majority of OHFC staff do not have confidence in OHFC leadership’s ability to lead the office.
  • OHFC has frequently failed to meet required triage and investigation deadlines.
  • OHFC posts investigation reports on its website, but the website is incomplete and difficult to navigate.
  • OHFC does a poor job managing its data, and MDH does not use available allegation and investigation data to identify trends and inform prevention efforts.

As part of the evaluation the auditor's office reviewed files of 53 cases that OHFC investigated. Investigators found that OHFC investigators sometimes failed to interview key individuals—including the vulnerable adult. Many of the case files we reviewed did not contain documentation to support information in OHFC’s investigation reports.

READ the full report here

The report also asserts that OHFC frequently failed to meet state and federal requirements for meeting investigation deadlines. For example, federal regulations require OHFC to triage certain allegation reports within two business days. In 2017 OHFC met this two-day deadline only 56 percent of the time.

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There are also multiple deadlines for conducting and completing investigations. State law requires OHFC to conclude an investigation within 60 days of receiving an allegation report, a deadline OHFC met in just 12 percent of the 2017 cases it investigated.

THE FIX

The auditor's report recommends implementing an electronic case management system, amending state law so vulnerable adults, their family members or case workers can be informed when a provider files a report alleging maltreatment, and having the Minnesota Department of Health commissioner play a stronger role in overseeing OHFC.

Minnesota Health Commissioner Jan Malcom released a statement thanking the legislator's office for the report, and agreeing with recommendations for fixing the broken system.

"We have publicly acknowledged that in recent years, OHFC has not met Minnesotans’ expectations for investigating maltreatment complaints in a timely way," said Malcom. "Since December 2017, we have made significant progress on many of the concerns cited in the OLA’s evaluation. Just last week, we announced completing a triage review of all 2,321 reports in our backlog. Our investigation backlog has been reduced by about half – from over 800 cases down to around 400 as of last week. We have publicly acknowledged that in recent years, OHFC has not met Minnesotans’ expectations for investigating maltreatment complaints in a timely way. Since December 2017, we have made significant progress on many of the concerns cited in the OLA’s evaluation. Just last week, we announced completing a triage review of all 2,321 reports in our backlog. Our investigation backlog has been reduced by about half – from over 800 cases down to around 400 as of last week."