ALBANY – New York’s mental health facilities are not ensuring parents and guardians are properly notified of incidents of abuse and neglect, according to an audit by State Comptroller Thomas DiNapoli.
In May 2007, the state legislature enacted “Jonathan’s Law” to expand parents’, spouses’, guardians’, and other qualified persons’ access to records relating to incidents involving family members residing in facilities operated, licensed or certified by the Office of Mental Health (OMH) and other state agencies. The reportable incidents under Jonathan’s Law involve abuse (physical, sexual or psychological) or neglect, as well as incidents that may result in or have the potential to result in harm to the health, safety or welfare of a patient.
During a recent audit covering nearly four years and examining the records of eight facilities (four state-run and four privately operated), the comptrollers office found that OMH did not implement processes to effectively monitor whether the facilities are complying with Jonathan’s Law requirements. While auditors found that facilities have established practices for notifying qualified persons within 24 hours of initial reporting of incidents, 20 percent of the incidents reviewed (42 total, all involving children under the age of 18) lacked support showing that the required notification had been made.
Auditors also found facilities do not always provide all records to parents and guardians when requested or are not providing them within 21 days of a request or the conclusion of the investigation, as required. Only 33 percent of the records reviewed were provided within the required time frame.
OMH manages the operation of 24 state psychiatric centers and the oversight of more than 650 providers that operate private facilities.
Jonathan’s Law is named for the late Jonathan Carey. In February 2007, Carey, a 13-year-old non-verbal autistic and developmentally disabled boy, died while in the care of a state facility. His parents had attempted multiple times to obtain information concerning several unexplained injuries, unauthorized changes in treatment and suspected abuse and neglect with little success. As a result, an effort was made to improve state law so that family members would be better notified of injuries and abuses involving patients.
Additional findings in the audit include:
- OMH does not use the New York State Incident Management and Reporting System (NIMRS) to capture information related to Jonathan’s Law compliance and cannot readily determine whether facility officials are meeting the law’s requirements.
- Each facility provided different information – with some offering more detail than others – to qualified persons when fulfilling records requests. As a result, qualified persons may not be receiving all pertinent information on incidents affecting the well-being of their family members.
DiNapoli recommended OMH incorporate the reporting of actions taken to comply with Jonathan’s Law into NIMRS to allow the office to more readily track efforts to meet requirements. Also, OMH should provide updated guidance to facilities on their responsibilities related to Jonathan’s Law requirements including clear and consistent implementation procedures and require their prompt implementation.
“Vulnerable patients are at greater risk when their parents and family members are kept in the dark,” said DiNapoli in a recent media release. “Jonathan’s Law can only help prevent tragedies if abuse and mistreatment in mental health facilities is properly reported and actions are taken. State officials must do more to ensure facilities are meeting requirements.”
OMH officials disagreed with the audit findings. The office’s response is included in the final report, which can be found online at: https://www.osc.state.ny.us/audits/allaudits/093019/sga-2019-18s22.pdf.
During the course of their work, auditors also sought information from the Justice Center for the Protection of People with Special Needs (Center), but, due to legal restrictions, they were unable to examine unsubstantiated records. A bill was introduced in the last legislative session and passed the Senate that would allow OSC access to these records.