The state agency charged with preventing abuse in senior care homes is plagued by severe dysfunction, chronic delays and a chaotic work environment that has hindered timely and effective investigations, according to a forthcoming report by Minnesota’s legislative auditor.

The problems are so acute that officials with the auditor’s office requested a meeting late last year with top administrators at the Minnesota Department of Health, where they laid out a series of measures to improve oversight of senior care facilities. Traditionally, the legislative auditor’s office waits until its reports are complete before it meets with agency staff or issues recommendations.

“What we found was troubling,” said Judy Randall, deputy legislative auditor, who declined to disclose details until the report is released early next month. “Usually, we don’t see things that are so concerning. But we felt like the issues were serious enough that immediate actions were necessary.”

The highly anticipated report is expected to amplify mounting concerns among lawmakers that the Office of Health Facility Complaints (OHFC), a division within the Health Department, lacks the tools and expertise to investigate the more than 20,000 allegations of abuse and neglect at senior homes that it receives each year. The audit originated a year ago with a grass-roots campaign by families of elder abuse victims, who brought their concerns to the state.

Since those problems came to light, the administration of Gov. Mark Dayton convened a work group to review the problem and took immediate steps to eliminate a huge backlog of maltreatment complaints that had not been reviewed. That backlog has since been dramatically reduced to just a few hundred cases, after Dayton gave the much-larger Department of Human Services (DHS) sweeping new powers over the OHFC.

In interviews, however, several prominent lawmakers said those changes are insufficient, and they anticipate the auditor’s report will outline more structural reforms.

A few legislators have even broached the idea of shutting down the OHFC, which has a staff of 55 and investigates maltreatment complaints for 2,600 facilities, and shifting its functions to DHS, which already investigates maltreatment at 8,900 state-licensed programs. DHS has a more modern computer system and has a much stronger track record of completing abuse investigations within the 60-day time frame mandated under state law, state officials acknowledge.

“Frankly, it’s time we reorganize the oversight function and seriously examine whether it still makes sense to have two separate agencies investigating abuse,” said Sen. Jim Abeler, R-Anoka, chairman of the Senate Human Services Finance and Policy Committee. “Because the system as it’s structured now is not working.”

A five-part Star Tribune series published in November found that the OHFC had failed to keep pace with a dramatic surge in abuse allegations at senior facilities across the state. The investigation documented that hundreds of serious incidents of criminal abuse, including beatings, sexual assaults and thefts, go uninvestigated each year. In the rare instances when the state did investigate, the cases would drag on for months, angering families and undermining criminal prosecutions.

Sen. Scott Dibble, DFL-Minneapolis, the first lawmaker to call on the legislative auditor to evaluate the OHFC, is among those who supports structural reforms, though like others he is waiting for the report to make specific proposals. “There is something seriously wrong with our state’s entire system,” he said. “Even if you gave [the OHFC] all the money in the world, you would not fix the fundamental flaws in the process.”

Hidden camera

The idea for a legislative audit came out of a simple meeting early last year at the State Capitol.

At a meeting with Dibble, a group of relatives of abuse victims known as Elder Voice Family Advocates expressed frustration with the OHFC’s mishandling of their complaints. They told Dibble their complaints often went ignored and that, even when the state did investigate, the details of investigations were kept secret from the victims and their relatives.

Kay Bromelkamp, one of the advocates present, recounted how it took nearly four months for the state to verify that her mother was verbally and emotionally abused even though much of the abuse was captured by a hidden camera placed in her mother’s room. By the time the state released its report, Bromelkamp’s mother had already died at the assisted-living facility where she had been abused.

“I still wonder if that report had come out sooner … whether my mom would have gotten better and would still be alive today,” said Bromelkamp, who lives in Minneapolis. “These delays have a real human impact.”

Dibble recalled being so outraged by their accounts that he began crafting a proposal that afternoon for a review by the legislative auditor’s office. “It was disturbing to hear, time and again, about the utter lack of response” by the OHFC, Dibble said.

When the Legislative Audit Commission announced last spring that the OHFC would be a topic for evaluation, out of more than 120 requests, Bromelkamp nearly burst into tears. “We finally felt that someone was listening,” she said.

A ‘bomb’

Known for dogged and thorough research, the legislative auditor’s office has a history of shaking up public entities. Last year, for instance, legislators voted overwhelmingly to overhaul the U.S. Bank Stadium’s public watchdog panel after an auditor’s report revealed that members of the panel had violated ethical standards by providing luxury-suite tickets to family and friends. The office is also reviewing how the University of Minnesota handles allegations of sexual harassment.

The legislative auditor’s evaluation of the OHFC has taken nearly a year. Auditors analyzed about 100 allegations filed with the agency and shadowed OHFC staff during 10 onsite investigations in nursing homes and assisted-living facilities. The office also examined how the OHFC chooses which complaints to investigate and looked into concerns about the agency’s workplace culture, including allegations of bullying by senior administrators, according to staff who were interviewed.

Because of the legislative auditor’s rare access to nonpublic data, the office was also able to review individual case files and the agency’s internal complaint database.

“This report will be another bomb dropping” on the OHFC, said Josh Berg, a former program manager at the health department and member of an industry task force on elder abuse. “It will point to how badly they were drowning.”

Bromelkamp said she expects the forthcoming report to validate concerns that elder abuse victims and their families have been raising for years. “At first, you feel like you’re all alone in this struggle,” she said. “Now, we know there might be change and that there is hope for our elders.”