Legislative auditor calls for stronger oversight of Minnesota's $1 billion home health program

The Minnesota Department of Human Services (DHS) and state lawmakers should take action to strengthen oversight of a $1 billion program that provides home caregiving services for thousands of vulnerable Minnesotans who depend on them to live independently, according to a state audit report released Monday.

The Office of the Legislative Auditor (OLA), an independent, nonpartisan arm of the Legislature, found several gaps in oversight and troubling inconsistencies within the state's personal care assistance (PCA) program, which helps people with disabilities, mental illnesses and chronic diseases with basic activities of daily living, such as bathing, eating and dressing.

The DHS uses two separate tools to determine eligibility for the PCA program, but the agency has not evaluated whether the two tools produce consistent results, and some county assessors have expressed concern about the differences, the auditor found. In addition, when enrolling personal care assistants, DHS does not verify that they meet all requirements in state law. In a small number of cases, this resulted in some children under age 16 working as PCAs in violation of state law. The agency also did not take timely action to fully investigate hundreds of suspected cases of fraud and abuse, according to the 122-page report.

At the same time, the auditor's report found that DHS has made progress over the past decade in preventing fraud in the program. The agency has implemented electronic controls that have been "generally effective" in preventing payments for claims that asserted personal care assistants worked more than 24 hours in a day or consecutive 24-hour days, which the legislative auditor's office identified as obvious signs of fraud when it last reviewed the program in 2009.

"Over the past eleven years, DHS and the Legislature have made changes to strengthen the oversight" of the program, wrote Legislative Auditor James Nobles. "However, opportunities for improvement remain."

Founded four decades ago, the personal care assistance program has long been considered an essential element of the state's social safety net. Approximately 44,000 Minnesotans received home care services in 2018 through the program, which is funded through Medicaid, the state-federal health insurance program that covers 1.1 million Minnesotans.

"Without this program, the lives of Minnesotans would be fundamentally impacted, and in some cases, lives would be at risk," Gertrude Matemba-Mutasa, assistant commissioner for Community Supports at the DHS, said in testimony Monday before a Senate committee.

Since early last summer, DHS officials have acknowledged that repeated breakdowns in internal controls caused the agency to make more than $100 million in overpayments for substance-use treatment services. At legislative hearings, Jodi Harpstead, the incoming commissioner of the $18.5 billion DHS, has pledged to shore up internal controls at the agency.

In a written statement issued Monday, Harpstead said, "We support continuous improvement efforts in all DHS programs and are proud of the strides we have made in overseeing PCA services across Minnesota since the last OLA audit in 2009."

However, she cautioned, "We are concerned that additional requirements could make it more difficult for people to find assistance and for providers to stay in business. We will work with the Legislature to find the right balance of regulatory oversight and program flexibility in the best interests of the people served."

Much of the legislative auditor's report focused on inconsistencies within the state's system for determining eligibility for PCA services, which can result in people receiving different levels of assistance. "It is important to have reasonably consistent assessments … to ensure equal access to services," Jodi Rodríguez, a project manager at the legislative auditor's office, said in Senate testimony.

For decades, county social workers used a paper-based system for screening who was eligible for PCA and other services through Medicaid. Then in 2013, the state launched an automated system, known as MnChoices, that was meant to standardize the evaluation process. However, DHS has not required all agencies to use this new system, which means that people across the state are still being evaluated with two separate tools with varying requirements. The result is a lack of uniformity: For instance, all county assessors who complete assessments through MnChoices must be certified and undergo training, while assessors who still use the legacy, paper-based system are not required to do so.

The auditor's findings echo those of a Star Tribune investigative report last fall, which found multiple problems with the state's high-stakes system for determining eligibility for Medicaid services. Across the state, the investigation found, access to this assistance was often arbitrary and unpredictable — dependent on where people lived rather than on individual need.

DHS is developing a revised version of MnChoices, and the department plans to require all county agencies to use it for evaluating people for services. However, DHS does not expect to roll out the new version until at least 2021.

The legislative auditor's office also found that not all personal care assistants underwent background studies and training before providing services, as required under state law. Some of the PCAs did not meet the state's minimum age requirements. The auditor found 48 children who were enrolled as personal care assistants before their 16th birthday, which is not allowed under state law. The auditor also found nearly 180 personal care assistants under 18 years of age who were affiliated with at least two PCA agencies, which also is not allowed.

The auditor's office made 20 recommendations for improving oversight and consistency in the program, including that the DHS establish a firm timeline for requiring assessors to use the MnChoices tool for all PCA assessments. The auditor also recommended that the Legislature require the DHS to regularly evaluate the consistency of assessments, among other measures.

"The concern about consistency and about fraud has been a perpetual problem for years," said Sen. Jim Abeler, R-Anoka, chairman of the Senate Human Services Reform Finance and Policy Committee. "It is disappointing that we have still have to be discussing this."