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NEWS from the Office of the New York State Comptroller
Contact: Press Office 518-474-4015

DiNapoli Audit Finds Lapses in Treatment Under Kendra's Law

Delayed Services in Court-Ordered Treatment Program, Failure to Act on Significant Incidents Can Have Dangerous and Fatal Consequences for People With Mental Illness and the Public

February 8, 2024

The state’s Office of Mental Health (OMH) needs to do a better job of overseeing court-ordered treatment for individuals under Kendra’s Law to ensure that needed services are delivered in a timely manner, according to an audit released today by New York State Comptroller Thomas P. DiNapoli.

“Kendra’s Law was enacted to ensure that those with severe mental illness get treatment to prevent them harming themselves or others,” DiNapoli said. “In many instances, the program is working, but when there are lapses, the consequences can be fatal as our audit shows. OMH should implement our recommendations to improve the administration of Kendra’s Law at a time when we’re facing a serious mental health crisis.”

Kendra’s Law was enacted in 1999 to allow court-ordered Assisted Outpatient Treatment (AOT) for individuals with serious mental illness that pose risks to themselves or others and whose treatment history meets a set of criteria. The law is named for Kendra Webdale, who was killed when she was pushed in front of a subway train by a man with a history of mental illness and hospitalizations. OMH, its five regional field offices, and local mental health authorities around the state jointly administer the involuntary treatment under the law.

Under Kendra’s Law, through August 2023 local authorities have done nearly 47,000 investigations. Of 33,847 AOT petitions filed, 96% were granted, with New York City accounting for some 20,000 (62%).

Local mental health authorities are supposed to investigate AOT referrals in a timely manner and determine if AOT criteria are met and a petition for AOT is warranted, but a timeframe for this review is undefined. Using a benchmark of six months, auditors found that nearly half of the investigations (19 of 41 sampled) took longer, including five that took over two years.

Auditors looked at 46 AOT cases and found most (44) individuals received court-ordered treatment timely, but found that in at least one case, a delay in initial treatment coincided with catastrophic consequences. In this case, the patient’s first meeting with a provider was nearly a month after treatment was ordered. A second meeting, which should have been scheduled for the following week, was not. On the day it should have taken place, the individual was arrested for homicide. OMH only found out afterwards when local mental health authorities reported it to the field office and, following an investigation, determined that care providers failed to promptly connect with the individual.

Under Kendra’s Law, it is essential that information be communicated timely between caregivers for the program and treatment to succeed; however, DiNapoli’s auditors found that when significant events occurred, information was often incomplete and not well communicated among stakeholders. Significant events can include becoming homeless, being arrested or incarcerated, and refusing court-ordered medications or other services.

Providers are supposed to report such events to local authorities within 24 hours to forestall any negative impact on treatment. Certain significant events, including attempted suicides, weapons possession, sex offenses or domestic violence, are required to be reported by local authorities to OMH’s field offices and entered in OMH’s AOT tracking system.

When auditors looked at a sample of 46 individuals’ cases, there were 550 significant events that were reported in OMH’s AOT tracking system for 43 cases. They found issues with data entries for 123 (22%) of the events. They also found 47 unreported events that were recorded in case records but not reported to the local mental health authority.

In one example, a treatment recipient reported having suicidal thoughts on 33 separate occasions over 19 months. Each instance should have been reported as a significant event to the local mental health authority, but none were. The individual took their own life the day they were discharged from a hospital.

AOT orders are generally for one year, but can be renewed. The audit found lapses in treatment when local authorities failed to complete the case reviews that are required for renewing treatment. Auditors reviewed 37 cases and found 23 examples (62%) in which the required case review either was not done, or there was no evidence that it was done, before their court-ordered treatment expired.

In 17 cases, the individual was not examined by a physician. In six instances, local authorities did not document any attempt to examine the individuals before their treatment expired. The lack of review resulted in the treatment order expiring for 11 individuals and temporary lapses (ranging from 34-198 days) in treatment orders for 12 others.

In one case, a renewal examination was scheduled for one week before the treatment order was set to expire, but there was no evidence that the local authority made an attempt to complete the examination. After the court-ordered treatment expired, the individual was removed from their homeless shelter for testing positive for narcotics, an outcome which might have been avoided if they had been examined.

In another case that lacked evidence of local authorities attempting to renew the AOT, the individual before the treatment order expired exhibited signs of delusion, was hospitalized and was reportedly aggressive toward hospital staff. In both cases, the court orders for AOT were eventually renewed, but the lapses in treatment, and subsequent potential of harm to the individual or someone else, could have been avoided.

The audit recommended that OMH:

  • Set timeframe guidelines so local authorities and field offices have a benchmark for completing investigations.
  • Look into collecting data on the time it takes to connect individuals with their court-ordered services.
  • Improve reporting on significant events to better capture and share information.
  • Improve assurance that local authorities are taking appropriate action to renew services when needed before they expire to avoid lapses in treatment and monitoring.

In its response to the audit, OMH generally agreed with its recommendations. Officials said the agency would develop guidelines to define the “timely” completion of AOT investigations; that it was currently reviewing and modifying its significant event reporting to expand the level of detail required and the appropriate sharing of information; and that it expected to complete training materials on AOT renewals in 2024. OMH’s full response is included in the audit.

Office of Mental Health: Oversight of Kendra’s Law