ST. PAUL - A state office that exists to protect vulnerable Minnesotans, such as those in nursing homes, is dysfunctional and fails to safeguard people in its charge, a watchdog agency reports.

The Office of Legislative Auditor issued one of its most critical reports ever on Tuesday, March 6. Legislative Auditor James Nobles called it "a serious problem in state government."

Nobles and Deputy Legislative Auditor Judy Randall told of poor Health Department management, lost case files, lengthy delays and failure to communicate with vulnerable people.

"The problems ... are deep and pervasive and have been there a long time," Nobles said. "They are rooted in poor management."

Workers take pride in their work, Nobles said, but "for too long they have had to work in an environment that was ... sometimes toxic."

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Problems Nobles' office found included:

• Ineffective case management.

• Unwritten and frequently changing policies.

• Ineffective staff training.

• Staff turnover that sometimes is 25 percent a year.

• Lack of staff confidence in leadership.

The investigation into the Office of Health Facility Complaints within the Health Department showed those problems resulted in investigations of abuse being long delayed.

Just 17 percent of 2017 cases met a two-day deadline to be read, let alone investigated, the report showed.

The two-day deadline is for people in "immediate jeopardy," Randall said, incidents such as when someone has been threatened with serious harm.

The auditor's office reported that one of the cases its investigators checked out "appeared to have been lost for ... more than two years after (the office) received the allegation report."

In recent years, Randall said, the Health Department office took an average of 140 days to complete investigations, far more than the 60 days set in state law. It took an average of 38 days to interview vulnerable adults involved in an incident, Randall said, so long that people likely would not be able to remember details.

The report did not indicate if there were any deaths or health issues that resulted in investigation delays.

State Health Commissioner Jan Malcolm, who Gov. Mark Dayton appointed to fill an opening in recent weeks, said she agreed with the audit, adding changes already are being made.

The backlog of cases has been reduced. A stack of more than 2,300 cases that needed to go through triage has been eliminated, Malcolm said, and the 826 open investigations in December are down to 430.

"This progress, while extremely impressive, is a first step," the commissioner said. "Necessary, but not sufficient."

Part of the problem in the Health Department has been that reports filed electronically were printed out and investigators worked off the hard copies. Malcolm said that the 400 allegations submitted each week now are dealt with via computer, making case management more effective.

Malcolm promised to address morale after the audit report showed almost 60 percent of staff said they do not have confidence in senior leadership.

Staff members said there was "disorganization" and "mistrust" in the office.

Malcolm said her department is developing employee training and promised to do a better job of communication within the department and with those affected.

The commissioner refused to tell Rep. Ron Kresha, R-Little Falls, if she has fired anyone for the problems. Malcolm said she is not allowed to discuss the issue because it is a private personnel issue, but promised "we are addressing it quite directly."

Rep. Debra Kiel, R-Crookston, said the first thing the Legislature needs to do is collect information, so she has introduced legislation to establish a task force that would provide answers for the 2019 legislative session.

"We must make real and lasting changes" after getting more information, Kiel said.

"Seniors and their families need to have confidence in knowing how the system works ... and what they can do in the event of mistreatment," the representative said.

Fixing the state complaint office is the first step in reducing abuse and other maltreatment, Kiel said.

The audit report pointed out that the Health Department mostly regulates nursing homes, while other government agencies regulate assisted living and other facilities.

A group working on the issue, the Elder Abuse Workgroup, praised the overall audit report, but called for some changes in state law.

For instance, the group seeks to apply similar rules and laws to assisted living centers that nursing homes follow. It also seeks more rights for senior citizens to reduce the fear they feel ini reporting nursing home maltreatment.