Objective

To determine the extent of implementation, as of September 2025, of the six recommendations included in our initial audit report, Oversight of Kendra’s Law (Report 2022-S-43).

About the Program

In August 1999, Kendra’s Law (Law) was enacted, creating a statutory framework for court-ordered Assisted Outpatient Treatment (AOT) to ensure that individuals with severe mental illness and a history of hospitalizations or violence participate in community-based services appropriate to their needs. The Law was named in memory of Kendra Webdale, a young woman who died in January 1999 after being pushed in front of a New York City subway train by a man with a history of mental illness and hospitalization. The Law took effect in November 1999 and is reviewed periodically by the Legislature.

In January 2022 an incident occurred in which a woman, Michelle Go, was similarly pushed to her death in front of a New York City subway train by a mentally ill person. The Law was later extended through 2027, as part of the periodic legislative review process, and was also amended to allow AOT recipients to be considered for a new AOT order up to 6 months after their order expires in some circumstances. Ensuring that people with mental illness get care to prevent or mitigate harm to themselves or others in the community continues to be a pressing issue. The Enacted Budget for the State Fiscal Year ending March 31, 2026 includes more than $18 million to enhance both county and state-level AOT implementation and support.

Implementation of AOT is a joint responsibility and collaboration among the Office of Mental Health (OMH), its five regional Field Offices (Field Offices), and local mental health authorities in 57 counties and New York City (we refer to local authorities collectively as local government units or LGUs. Under the Law, LGUs must timely investigate a referred person’s circumstances to determine if the person meets AOT criteria. If so, they file a petition for AOT with the appropriate court and a hearing is held to review the case and proposed treatment plan. Th Law doesn’t define “timely,” and at the time of our initial audit, OMH hadn’t developed guidance to use as a benchmark in determining whether investigations are timely. OMH requires that AOT recipients be connected with their treatment services through a face-to-face visit within one week of the court order. In addition, providers are required to report significant events—those that may negatively impact a person’s AOT, such as being accused of or arrested for committing a crime—to their respective LGU within 24 hours of being made aware of them. 

AOT orders generally cover up to 1 year. Prior to an order’s expiration, LGUs must review whether current AOT recipients continue to meet AOT criteria, determine whether the order should be renewed, and, if so, notify their Field Office. 

The objective of our initial audit, issued February 8, 2024, was to determine whether OMH was effectively monitoring AOT to provide reasonable assurance that existing and potential AOT recipients received their court-ordered treatment. The audit covered the period April 2019 through September 2023. The audit resulted in areas we identified for improvement, including length of AOT investigations and related information-sharing, initiation of AOT services, the quality and completeness of information about significant events and how that information is shared, lapsing AOT orders, and LGUs’ reported reasons for AOT non-renewals. Our audit resulted in six recommendations to address these areas.

Key Finding

OMH officials made progress in addressing the problems we identified in the initial audit report. Of the report’s six recommendations, three have been implemented, two have been partially implemented, and one has not been implemented. 

Key Recommendation

OMH officials are requested, but not required, to provide information about any actions planned to address the unresolved issues discussed in this follow-up within 30 days of the report’s issuance.