Report 2019-119 All Recommendation Responses

Report 2019-119: Lanterman-Petris-Short Act: California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care (Release Date: July 2020)

Recommendation for Legislative Action

To ensure that counties are able to access important data about individuals whom they place on involuntary holds under the LPS Act, the Legislature should amend state law to do the following:
Require Justice to make the information that mental health facilities report to it about involuntary holds available to Health Care Services on an ongoing basis.

Require treatment facilities to report to Health Care Services all short-term holds that result from the grave disability criterion.

Direct Health Care Services to obtain daily the mental health facility information from Justice and make that information, as well as the information that facilities report directly to it, available to county mental health departments for county residents, and for a limited time for nonresidents on an involuntary hold within the county.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation for Legislative Action

To ensure that it is informed about the costs of providing adequate care to individuals treated through the LPS Act, the Legislature should require State Hospitals to report by no later than April 2021 about the cost of expanding its facilities' capacities to reduce and stabilize the LPS waitlist. The report should include a range of options including, but not limited to, reducing the LPS waitlist to limit wait times to within 60 days.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation for Legislative Action

To protect the privacy of individuals who are the subject of conservatorship proceedings, the Legislature should amend state law to explicitly prohibit these proceedings from being open to the public unless the subjects of the proceedings direct otherwise.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation #4 To: San Francisco Department of Public Health

To evaluate and address shortages in the capacity of its treatment facilities, San Francisco should, by August 2021, conduct an assessment that determines the number and type of treatment beds that it needs to provide adequate care for individuals who require involuntary treatment. Once the county completes the assessment, it should adopt plans to develop the needed capacity.

60-Day Agency Response

In early 2020 the DPH Mental Health Reform team engaged a simulation modeling vendor, Mosimtec, to answer the question: How many beds are needed in each behavioral health bed category to maintain consistent patient flow for adult clients in San Francisco with zero wait time? Through an in-depth analysis of patient placements in nearly 1,000 beds in the DPH behavioral health system of care in Fiscal Year 2018-2019, bed simulation modeling offered quantitative recommendations for improving patient flow. Recommendations include 1. Invest in additional bed capacity in Locked Subacute Treatment, Psychiatric Skilled Nursing Facilities, Residential Care Facilities (Board and Cares and facilities for the Elderly), and 12-month Mental Health Residential Treatment; 2. Complement all behavioral health bed investments one-to-one with long-term housing placements such as Permanent Supportive Housing to better serve people experiencing homelessness; 3. Create a robust wait time and patient placement data-tracking system to better understand the impact of operational barriers on patient wait time; and 4. Repeat bed simulation annually to understand trends and inform long-term planning, mitigate data limitations, and explore other interventions that would improve patient experience. The study, which included the bed needs of conserved individuals awaiting placement, resulted in a budget request for 117 additional beds at a cost of $10.6 million. This budget request was approved by the SF Board of Supervisors on 9/22/2020 and we anticipate its approval by Mayor London Breed on 10/1/2020. Next, DPH will identify a plan to achieve the additional capacity recommended by the study.

  • Estimated Completion Date: August 31, 2021
  • Response Date: September 2020

California State Auditor's Assessment of 60-Day Status: Partially Implemented


Recommendation #5 To: Shasta County Health and Human Services Agency

To evaluate and address shortages in the capacity of its treatment facilities, Shasta should, by August 2021, conduct an assessment that determines the number and type of treatment beds that it needs to provide adequate care for individuals who require involuntary treatment. Once the county completes the assessment, it should adopt plans to develop the needed capacity.

60-Day Agency Response

1. Shasta County HHSA analysts Joseph Carpenter and Josette McKrola, Adult Services Clinical Division Chiefs Monteca Zumalt and Genell Restivo, Deputy Director Robin Bowman, Public Guardian Program Manager Amparo Buck and Director Paige Greene will work collaboratively to conduct an assessment to determine the number and type of treatment beds needed to provide adequate care to individuals receiving involuntary treatment by the six-month review date.

2. After assessment is complete, Adult Services contract Analysts Stewart Buettell and Patricia Pratt, Clinical Program Coordinator Mey Chao-Lee, Clinical Division Chiefs Monteca Zumalt and Genell Restivo, Deputy Director Robin Bowman, and Director Paige Greene will adopt plans to develop needed capacity.

  • Estimated Completion Date: 07/31/2021
  • Response Date: September 2020

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #6 To: Los Angeles County Department of Mental Health

To ensure that it connects patients who have been placed on multiple short-term holds to appropriate ongoing treatment, Los Angeles should, by no later than August 2021, adopt a systematic approach to identifying such individuals, obtaining available mental health history information about these individuals, and connecting these individuals to services that support their ongoing mental health.

60-Day Agency Response

LACDMH agreed in principal with this recommendation but only on the condition that data regarding short-term holds (5150's) currently in possession of DOJ be made available to LACDMH. This will require legislative action. Transparent access to data on short-term holds can further improve LACDMH's ongoing efforts to identify those in need of additional engagement interventions. In the meantime, LACDMH continues to utilize available data to identify individuals who qualify for specialty mental health services and voluntarily accept these services. LACDMH utilizes hospital liaisons, to the extent these liaisons are available, to identify individuals who are placed on multiple short-term holds so they can be referred for outreach and engagement or linked to the clinically appropriate level of treatment.

  • Estimated Completion Date: Dependent on when DOJ data will be made available to LACDMH
  • Response Date: September 2020

California State Auditor's Assessment of 60-Day Status: Pending

It is important for Los Angeles to make progress in identifying individuals placed on multiple short-term holds. We did not condition our recommendation on changes to state law. In our report we describe how Los Angeles was expanding its hospital liaison efforts but that these efforts had only expanded to five of the 49 designated facilities in the county. Without additional information from Los Angeles, we cannot assess the progress it has made. We look forward to the six-month update on this recommendation.


Recommendation #7 To: San Francisco Department of Public Health

To ensure that it connects patients who have been placed on multiple short-term holds to appropriate ongoing treatment, San Francisco should, by no later than August 2021, adopt a systematic approach to identifying such individuals, obtaining available mental health history information about these individuals, and connecting these individuals to services that support their ongoing mental health.

60-Day Agency Response

Mental Health SF legislation creates an Office of Coordinated Care (OCC) to oversee mental health and substance use services. The OCC is responsible for 1) Maintaining an up-to-date inventory of available space in all City operated and funded mental health and substance use programs; 2) Providing and supervising case managers responsible for monitoring compliance with individual treatment plans and identifying appropriate housing placements; and 3) Coordinating the care of patients who are exiting the County Jail system or General Hospital's Psychiatric Emergency Services. Funding for the OCC has been budgeted pending mayoral approval, and includes a Bed and Patient Tracking System; Jail and PES Linkage Support; Crisis Linkage Support; and more positions for Case Management, Intensive Case Management, and Critical Care Management.

SF-DPH recently reached out to the Manager of Community Health of one of our largest private hospitals asking to discuss the feasibility of obtaining alerts when individuals are admitted for involuntary detention who have had multiple prior involuntary detentions. By working through the details of such a data sharing agreement, we hope to establish a workflow that could be replicated in our other Designated Receiving Facilities.

A Street Crisis Response Team is being developed which will provide a non-law enforcement response to behavioral health emergencies and divert individuals in crisis away from emergency rooms and criminal justice settings into behavioral health treatment facilities. Each team will include a paramedic from the Fire Department, and a behavioral health clinician and behavioral health peer from the Department of Public Health.

  • Estimated Completion Date: August 31, 2021
  • Response Date: September 2020

California State Auditor's Assessment of 60-Day Status: Pending


Recommendation #8 To: Los Angeles County Department of Mental Health

To ensure that conservatorships do not terminate because of the absence of testimony from doctors, Los Angeles should immediately implement a comprehensive solution to this problem, such as using its own staff as expert witnesses when individuals' treating physicians are unable to testify. In addition, by no later than August 2021, it should develop a revised approach to scheduling conservatorship hearings and trials so that it significantly reduces the rate at which doctors' failures to testify result in terminated conservatorships.

60-Day Agency Response

LACDMH disagreed with this recommendation but can report that due to COVID the court has adopted tele- testimony for LPS conservatorship hearings, eliminating the physical appearance of treating physicians or forensic evaluators at the mental health court. LACDMH has advocated strongly with the Los Angeles County Public Defender Office to allow tele-testimony prior to COVID. This development has been widely accepted and praised by physicians because they have increased opportunities to appear without negatively impacting their primary responsibility to treat their patient. A preliminary review of terminated LPS cases shows a decrease in the number of cases terminated since March 2020 due to lack of a doctor testifying. Permanent adoption of tele-testimony will likely continue this trend of more doctors testifying and less cases being terminated due to lack of a doctor. This will require legislative action. Unfortunately, due to COVID and the significant reductions in revenue for LACDMH and the County of LA, use of LACDMH doctors in the LPS conservatorship process will be limited to outpatient conservatorship cases and other cases in which LACDMH doctors already serve as the treating physician.

  • Response Date: September 2020

California State Auditor's Assessment of 60-Day Status: Pending

Los Angeles describes a temporary change in court practices as having a beneficial effect on the availability of testimony from doctors. However, the solution is not guaranteed to continue once pandemic conditions subside. We look forward to Los Angeles's future updates about its long term proposed solution to the problem of conservatorships that terminate due to the unavailability of doctors to testify.


Recommendation for Legislative Action

To allow counties to provide effective treatment to individuals in the least restrictive setting, the Legislature should amend the criteria for assisted outpatient treatment programs to do the following:
Allow individuals who are exiting or have recently exited conservatorships to be eligible for those programs.

Provide express authority to include medication requirements in court-ordered assisted outpatient treatment plans so long as the medication is self-administered.

Include progressive measures to encourage compliance with assisted outpatient treatment plans, such as additional visits with medical professionals and more frequent appearances before the court.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation for Legislative Action

The Legislature should amend state law to require counties to adopt assisted outpatient treatment programs. However, to ensure the counties' ability to effectively implement such programs, the amended law should allow counties to opt out of adopting assisted outpatient treatment programs by seeking a time-limited waiver from Health Care Services. The Legislature should require a county seeking a waiver to specify what barriers exist to adopting an assisted outpatient treatment program and how the county will attempt to remove those barriers. The Legislature should require Health Care Services to make a final determination as to whether a county will be permitted to opt out of adopting an assisted outpatient treatment program.

Description of Legislative Action

AB 1976 (Chapter 140, Statutes of 2020) commencing July 1, 2021, requires counties to offer assisted outpatient programs, unless they opt out by a resolution passed by the governing body stating the reasons for opting out and any facts or circumstances relied on in making that decision. Counties are also authorized to offer assisted outpatient programs in combination with one or more counties, and prohibited from reducing existing voluntary mental health programs serving adults, or children's mental health programs, as a result of implementing the assisted outpatient programs.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: Legislation Enacted


Recommendation for Legislative Action

To increase the accountability for and effectiveness of the counties' use of mental health funds, the Legislature should amend state law to do the following:
Assign primary responsibility to the Oversight Commission for comprehensive tracking of spending on mental health programs and services from major fund sources and of program-and service-level and statewide outcome data. The Legislature should require the Oversight Commission to consult with state and local mental health authorities to carry out this responsibility. The Legislature should also require the Oversight Commission to explore available data and information when developing this reporting framework, and it should grant the Oversight Commission authority to obtain relevant data and information from other state entities.

Require the Oversight Commission to develop categories of mental health programs and services, similar to those we present in Figure 11, that are tailored to inform assessments of spending patterns. The Legislature should subsequently require counties to report to the Oversight Commission their expenses in each of these categories as well as their unspent funding from all major funding sources.

Require counties to report to the Oversight Commission, in a format prescribed by the commission, program-and service-level outcomes that enable stakeholders to determine whether counties' use of funds benefits individuals living with mental illnesses.

Direct the Oversight Commission to develop statewide measurements of mental health—such as those we highlight in Figure 11—and report publicly about those measurements annually so that stakeholders and policymakers can assess the progress the State is making in addressing mental health needs.

Require the Oversight Commission to work with counties and other state and local agencies as necessary to use the information it collects to improve mental health in California.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation for Legislative Action

To better serve individuals who are among the most in need of critical, community-based treatment and services, the Legislature should amend state law to do the following:
Identify those who have left LPS Act holds and who experience serious mental illnesses as a population that MHSA funds must target.

Establish a goal in the MHSA of connecting all such individuals to the community-based programs and services that they would benefit from—such as assisted outpatient treatment—and require counties to fund efforts to link these individuals to those programs and services. The Legislature should also establish that a goal of providing those programs and services is to reduce the number of repeated involuntary holds or conservatorships that occur.

Specify that counties can use any portion of their MHSA funds for this purpose as long as they comply with other statutory and regulatory requirements.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


Recommendation for Legislative Action

If Health Care Services does not follow through with its plan to provide, on its website, information about each county's unspent MHSA funds, the Legislature should amend state law to explicitly require counties to include information about their balances of unspent MHSA funds in their MHSA annual revenue and expenditure reports.

Description of Legislative Action

As of September 28, 2020, the Legislature has not taken action to address this specific recommendation.

  • Legislative Action Current As-of: October 2020

California State Auditor's Assessment of 60-Day Status: No Action Taken


All Recommendations in 2019-119

Agency responses received are posted verbatim.