Not enough people are covered by an oversight system meant to safeguard residents of a New York housing program for people with mental illness, a federal judge found this week, after reviewing a report commissioned in response to a ProPublica and Frontline investigation.

Since January 2014, more than 750 people with severe mental illness have moved out of troubled New York City adult group homes and into subsidized apartments under a federal court order. The idea was to give them a chance to live outside institutions, with services coming to them as needed through a program called supported housing.

But last December, ProPublica and Frontline revealed that more than two dozen people who had moved out struggled to live safely on their own. Many had been repeatedly hospitalized. One went missing; another was in jail. At least six had died under suspicious circumstances, and the state had only recently developed a system to track such incidents.

The story prompted U.S. District Judge Nicholas Garaufis to order a report from Clarence Sundram, the independent court monitor assigned to oversee the transition. Garaufis asked Sundram to gauge the effectiveness of the incident reporting system implemented in the summer of 2018.

The report, filed this week and discussed in a hearing on Wednesday, uncovered a number of shortcomings — delays of weeks or months in filing incident reports, confusion over which of the myriad service providers are required to report what, and an overall failure by the state to sufficiently investigate problems and share results.

Perhaps the biggest flaw is that the new reporting system only covers about a quarter of the people who have moved out of adult homes — those enrolled in what’s called Adult Home Plus, a special program where residents are assigned a “care coordinator” with a caseload of no more than 12 to meet with them four times a month and help them organize their services.

According to the latest figures in Sundram’s report, only 179 residents are enrolled in Adult Home Plus out of the 774 who have moved out.

Except for the neediest supported housing residents, that program is only supposed to last for the first six months after they move out. Sundram found that serious incidents often occur well after someone’s first six months in supported housing.

“We recommend strongly, as we have previously, that the requirements for Incident Reporting be extended to include all class members living in supported housing,” Sundram said in his report. “It seems incongruous that two class members could be sharing the same apartment and have different levels of protection based on factors that are not related to the potential risks they face.”

Garaufis, the judge, questioned the state about this very issue at a hearing in February.

“If (the incident reporting system) doesn’t give us a complete picture of what is going on… then it would be inadequate for the court,” he said.

In response, Robert Begleiter, an attorney representing the state, said it was his understanding that “one quarter was meant to be a statistically significant sample,” but promised to “revisit” the matter if Garaufis thought it “too small a number.”

On Wednesday, government officials gathered in a courtroom with the mental health advocates who filed the lawsuit 16 years ago that led to the transition to independent living. Garaufis asked the plaintiffs why they had agreed to allow the state to monitor such a small portion of the population. The plaintiffs shifted blame to the state, saying they were disappointed it took so long for officials to acknowledge that the incident reporting system was lacking. Garaufis told all sides to work together to expand the number of people covered, and come back with a plan in September to improve oversight.

Garaufis said that having such a system in place was important for people interested in moving out of the adult homes as well as those who have already left.

But his attention was mostly focused on the fact that more people with severe mental illness are moving into the adult homes, defying state regulations at the heart of the court order that are supposed to prevent the homes from accepting people with such a diagnosis. Between February and April of this year, adult homes have gained 113 such residents.

At one point, as a state official told Garaufis how excited she was to describe the services being offered to people who had moved out of the adult homes, he banged on his podium, annoyed.

“I’m not a cheerleader, I’m a judge,” he said. “I get the feeling you are trying to convince me you’ve got it all under control. I’m sorry, you don’t have it under control.”

Lisa Ullman, who leads the effort to implement the settlement for the Department of Health and Office of Mental Health, told Garaufis she had referred the new admissions to the enforcement branch for further investigation.

Garaufis said he wanted a monthly update on the matter.

In his report, Sundram also found that many of the housing contractors involved in the transition outright failed to report incidents even when their clients were in Adult Home Plus. Then, when the reports were filed, Sundram said the state often failed to gather all the records that would help explain how the incidents occurred or interview the caretakers responsible for letting their clients slip through the cracks.

Sundram examined all 27 incidents reported to the state between July and December 2018. Many involved “repeated crisis episodes,” wherein people living in supported housing experienced symptoms of their mental illness severe enough to necessitate psychiatric attention. There were three deaths, but the details of them are not available in the report. He also found that four people had “insufficient life necessities,” meaning that they lacked food or medication. Four more lived in unsafe or unsanitary conditions.

Sundram’s findings echo those of the ProPublica and Frontline stories, particularly that of Nestor Bunch, a man with schizophrenia who moved into an apartment of his own for the first time at the age of 54.

Bunch had difficulty keeping up with his medication regimen, struggled with suicidal thoughts, found one roommate dead, then landed in the hospital for weeks with injuries from what appeared to be a beating. He lived in a series of supported housing apartments and was repeatedly hospitalized for psychiatric breaks. In a previous report, Sundram said Bunch’s experience showed the need for a “robust quality assurance program.”

At the end of this week’s report, Sundram issued several recommendations: that the state expand the incident reporting system to cover all supported housing residents in the class; that it complete all investigations within 30 days except under exceptional circumstances, when it would be given 90; that the state consider sharing guidance based on its investigations with an array of providers involved in the transition; and that the state gather more documents and interview more people involved in each incident.

In response to questions for this story, Department of Health spokesman Jonah Bruno referred ProPublica to statements made in court, but added this comment:

"We review all incident reports, and when we find the incident has broad applicability and demonstrates how similar incidents can be avoided in the future, we do share our findings with other settlement providers. We will continue to expand the ways we share what we learn with providers.