‘Families need to know if somebody died there’: Audit finds gaps in group home report cards, state licensing
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A new audit suggests the state needs to better regulate how assisted living facilities are licensed.
A Minnesota’s Office of the Legislative Auditor report published Wednesday found that a report card program designed for the public to compare group homes and other assisted living facilities does not include information about serious maltreatment findings. It also found that 40 percent of inspections of assisted living facilities were more than 90 days late.
“[The report card] is kind of the one way in which the state says anything about the quality of assisted living facilities compared to one another,” said David Kirchner, an audit project manager with the Office of the Legislative Auditor. “We found that some facilities that have been cited for fairly serious violations had average or even high ratings in these report card ratings.”
The report from the legislative auditor follows a series of investigations by MPR News and APM Reports into Minnesota’s booming group home industry. One investigation found that a government official in Liberia was running group homes in Minnesota while living and working overseas. Another investigation found that a group home was initially fined only $1,000 after a resident was found dead in the group home's backyard.
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“The star rating ideally would reflect those [maltreatment] findings,” said Temporary Department of Human Services Commissioner John Connolly. “We agree that this needs work.”
MPR News and APM Reports reviewed thousands of state maltreatment investigations and found that at least 50 residents have died since 2022. In 19 of those cases, state investigators concluded the homes had neglected those vulnerable people. But even when a resident dies, fines are often capped at $5,000 for neglect and it’s uncommon for a facility’s license to be revoked.
Historically in Minnesota, the Department of Human Services has overseen group homes. But since 2009, there’s been a moratorium in place prohibiting the department from licensing any new group homes. Still, providers were able to seek exemptions from the Department of Human Services, or receive a license from the Health Department to open a group home as a small assisted living facility.
But no matter which state agency licenses the group homes, the Department of Human Services pays the bills, because it administers the state’s Medicaid program, also called Medical Assistance. That means Health Department-licensed group homes are jointly overseen by both agencies. Auditors said that dual oversight has created potential problems when it comes to licensing.
The report card was designed to help people with mental or physical disabilities or their family members compare different group homes and other assisted living facilities. The report card tool is managed by the Department of Human Services, even though the facilities are licensed by the Department of Health. Auditors said the Legislature appropriated $6.7 million for the report card tool.
The Department of Human Services only uses information from routine, biennial inspections when creating the report card, and does not include any information from maltreatment investigations.
A Human Services administrator told an auditor that developers intended to incorporate both types of investigations into their report card ratings but said the different formats of investigation findings and inspection findings “created challenges.” The audit also found that the report cards do not indicate when the Health Department has suspended or revoked a facility’s license.
The audit also found that the Health Department has a significant backlog in inspections. Only 29 percent of the inspections due in the first half of 2025 were completed on time.
A review of the state’s Assisted Living Report Card website found that the state gave a five-star rating for safety to a Golden Touch Health Care facility, the group home company run by Liberian government official Sekou Dukuly, where a 46-year-old woman with a serious lung condition died after collapsing on the bathroom floor.
The state determined the facility neglected her because its staff members weren’t trained in CPR. The state revoked licenses for Golden Touch Health Care group homes, citing “credible allegations of Medicaid fraud,” following reporting by MPR News and APM Reports.
Questioned about Golden Touch Health Care’s report card, Health Department Deputy Commissioner Wendy Underwood said, “We are continually working with DHS on how to improve and collaborate and work together and I think those things happen in real time and we’re continuing to do that every day."
The state also gave a three-star rating for resident health and a four-star rating for safety to a group home in Brooklyn Center where a resident who had been missing for 20 days was found dead of a suspected overdose in her bedroom. Police said she had been dead “for a significant amount of time.” It also gave Fortunate Homes, where a man who went missing was found dead 29 hours later in the facility’s backyard, a four-star rating for resident health and a five-star rating for staffing.
“It’s just a failure of the system again,” said Julie Riggs, whose husband Ryan died in the backyard of the Fortunate Homes facility. “Families need to know if somebody died there.”
The Health Department hasn't shared clear, accurate data with the Human Services Department about licensure status and facility capacity, the audit said. In one case, an assisted living facility licensed for only six residents received Medical Assistance payments for 18 residents during a single month in 2024. The same year, over 100 facilities were paid for more than their licensed capacity, the audit found. Most of those providers ran multiple facilities, but the audit couldn't explain some of the discrepancies.
The state has traditionally relied on county case managers to check if all those services are being provided. But the audit said that approach might miss staffing shortages that affect the entire group home.
Among its recommendations, the legislative auditor’s office said the Human Services department should improve its assisted living report card methodology and request additional data-gathering authority from the Legislature if necessary.
The report also raised concerns that the fragmented oversight of the industry could lead to gaps in oversight and overpayment and pointed out that Health Department inspectors have not been verifying whether assisted living facilities are providing care consistent with what’s being billed to the Human Services Department. In May, the Minnesota Legislature set aside $150,000 for the Health Department to find a new way to license group homes currently classified as assisted living facilities.
APM Reports journalist Jennifer Lu contributed to this story.
