PERFORMANCE AUDIT REPORT
Larned State Hospital: Reviewing the
Operations of the Sexual Predator
Treatment Program, Part 2

A Report to the Legislative Post Audit Committee
By the Legislative Division of Post Audit
State of Kansas
April 2015
R-15-006

Legislative Division of Post Audit
The Legislative Division of Post Audit is the audit
arm of the Kansas Legislature. Created in 1971,
the division’s mission is to conduct audits that
provide the Legislature with accurate, unbiased
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have been endorsed by the American
Institute of Certified Public Accountants
(AICPA) and adopted by the Legislative Post
Audit Committee.
LEGISLATIVE POST AUDIT COMMITTEE
Representative John Barker, Chair
Representative Tom Burroughs
Representative Peggy Mast
Representative Virgil Peck, Jr.
Representative Ed Trimmer
Senator Michael O’Donnell, Vice-Chair
Senator Anthony Hensley
Senator Laura Kelly
Senator Jeff Longbine
Senator Julia Lynn
LEGISLATIVE DIVISION OF POST AUDIT
800 SW Jackson
Suite 1200
Topeka, Kansas 66612-2212
Telephone: (785) 296-3792
Fax: (785) 296-4482
Website: http://www.kslpa.org
Scott Frank, Legislative Post Auditor

HOW DO I REQUEST AN AUDIT?
By law, individual legislators, legislative committees, or the Governor may request an audit, but
any audit work conducted by the division must be directed by the Legislative Post Audit
Committee. Any legislator who would like to request an audit should contact the division directly
at (785) 296-3792.

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This audit was conducted by Lynn Retz, Matt Etzel, Ashly LoBurgio Basgall and Daniel
McCarville, Chris Clarke was the audit manager. If you need any additional information
about the audit’s findings, please contact Lynn Retz at the Division’s offices.
Legislative Division of Post Audit
800 SW Jackson Street, Suite 1200
Topeka, Kansas 66612
(785) 296-3792
Website: www.kslpa.org

Table of Contents
Introduction .................................................................................................................................................. 1
Overview of the Sexual Predator Treatment Program
In 1994, the Legislature Created a Civil Commitment Program for Sexual Predators Through the Sexually
Violent Predator Act ................................................................................................................................. 5
As of December 2014, the Sexual Predator Treatment Program Had 243 Residents and the Population
Was Continuing to Grow .......................................................................................................................... 6
The Program’s Staffing and Expenditures Have Also Grown Since 2010 .................................................... 8
The Constitutionality of Involuntary Civil Commitment Has Been Challenged in Kansas and Other States
................................................................................................................................................................ 10
Question 1: How does Kansas’ Sexual Predator Treatment Program Compare to Similar Programs
in Other States and Best Practices?
The Recommended Practices for Sexual Predator Programs Emphasize Individualized Treatment ......... 11
Kansas’ Program Generally Did Not Adhere to These Recommended Practices, While Other States’
Programs We Reviewed Generally Did.................................................................................................. 12
Kansas’ Sexual Predator Treatment Program Met Many Legal Requirements, Although There Were
Several Exceptions................................................................................................................................. 16
Residents Did Not Necessarily Arrive at the Reintegration Facilities with the Skills to be Successful ....... 18
Program Officials Had Not Maintained Appropriate Records and Documentation to Effectively Manage the
Program .................................................................................................................................................. 18
Policies and Program Guidance Were Outdated and Not Adhered To ...................................................... 20
Until Recently, KDADS Had Not Filed Annual Reports with the Legislature as Required by Statute ......... 20

Question 2: What Actions Could be Taken to Reduce the Resident Population of the Sexual
Predator Treatment Program?
Unless Changes Are Made, the Sexual Predator Treatment Program Will Exceed Capacity in the Next
Few Years and Will Continue to Grow for the Foreseeable Future ....................................................... 21
We Evaluated the Impact of Six Different Options to Reduce the Program’s Resident Population ........... 24
Option 1: Treating Low-Risk Residents in a Community Setting Would Reduce the Resident Population
and Reduce Program Costs ................................................................................................................... 26
Option 2: Treating Medically Infirm Residents in a Secured Nursing Facility Would Reduce the Resident
Population, But Would Not Significantly Affect Program Costs ............................................................. 28

Option 3: Treating Residents on the “Parallel Track” in a Separate Secured Facility Would Reduce the
Resident Population, But Potentially Increase Costs ............................................................................. 29
Option 4: Expanding the Number of Reintegration Slots from 16 to 32 Would Not Reduce the Resident
Population .............................................................................................................................................. 31
Option 5: Limiting the Time a Resident Can Occupy a Slot in a Reintegration Facility Would Not
Significantly Reduce the Resident Population at Larned State Hospital ............................................... 33
Option 6: Beginning Sexual Predator Treatment Before the Offender is Released From Prison Would Not
Significantly Impact Resident Population and Could Increase Costs .................................................... 34
Statutory Housing Restrictions Make it Difficult for Residents to Leave the Program ................................ 36
Conclusion ................................................................................................................................... 37
Recommendations ...................................................................................................................... 37

List of Figures
Figure OV-1: Select Demographic Information for Sexual Predator Treatment Program Residents (As of
December, 2014)...................................................................................................................................... 7
Figure OV-2: Summary of Sexual Predator Treatment Program Operations .............................................. 9
Figure 1-1: Conditional Release and Unconditional Discharge of Residents from Inception of Program to
2014 ....................................................................................................................................................... 16
Figure 2-1: Baseline Projection of Resident Population ............................................................................. 23
Figure 2-2: Summary of the Baseline and the Six Options to Reduce the Number of Residents
Committed to the Sexual Predator Treatment Program......................................................................... 25
Figure 2-3: Option 1: Comparison of Projected Resident Populations without Low-Risk Sexually Violent
Predators ................................................................................................................................................ 27
Figure 2-4: Option 2: Comparison of Projected Resident Populations without Medically Infirm Residents
................................................................................................................................................................ 28
Figure 2-5: Option 3: Comparison of Projected Resident Populations without Parallel Track Residents.. 30
Figure 2-6: Option 4: Comparison of Projected Resident Populations with 32 Reintegration Beds .......... 32
Figure 2-7: Option 6: Comparison of Projected Resident Population with Prison Based Sexual Predator
Treatment ............................................................................................................................................... 35

List of Appendices
Appendix A: Scope Statement................................................................................................................... 41
Appendix B: Population Model Methodology............................................................................................. 43
Appendix C: Long-term Projection Comparison Between the Baseline Population and the Population for
Each of the Six Options (2016 – 2090) .................................................................................................. 47
Appendix D: Research-based Guidelines .................................................................................................. 49
Appendix E: Agency Response ................................................................................................................. 51

Larned State Hospital: Reviewing the Operations of the
Sexual Predator Treatment Program
Goes Here
The Sexual Predator Treatment Program was established in 1994
and has been provided primarily through the Larned State Hospital.
The program provides control, care and treatment for convicted sex
offenders who have completed their prison sentences but have
been determined by a judge or jury to be sexually violent predators
and involuntarily committed to the custody of the Secretary of
Kansas Department for Aging and Disability Services.
In 2005, Legislative Post Audit issued a report on the Sexual
Predator Treatment Program. In that report, we estimated the size
of the offender population could increase to about 235 offenders by
2015. The reasons for this included the continuing commitment of
new offenders to the program and Kansas’ stringent requirement
that the risk of a reoffense be reduced to “practically nil” before an
offender would be released from the program. The statutory
standard focuses on community safety by requiring that in order
for release the sexually violent predator’s mental abnormality or
personality disorder has so changed the person is safe to be at
large.
As of December 2014, the program had 243 residents, with 227
residents at Larned State Hospital, eight residents at Osawatomie
State Hospital and eight at Parsons State Hospital. Agency officials
estimate that in the coming years the program will grow by 18
offenders per year.
Legislators have expressed concern about the growing size of the
offender population, employee workload, and working conditions
at the Larned facility. They would like to know how Kansas’
program compares to other state programs in terms of cost and
treatment, what actions could be taken to limit program growth,
and whether the Larned facility is being adequately managed.
This performance audit answers the following questions:
1. How does Kansas’ Sexual Predator Treatment Program
compare to similar programs in other states and best
practices?
2. What actions could be taken to reduce the resident
population of the Sexual Predator Treatment Program?

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A copy of the scope statement for this audit approved by the
Legislative Post Audit Committee is included in Appendix A. The
scope statement includes three questions. In May 2013, the
Legislative Post Audit Committee decided to split the audit into
two parts and delay work on questions one and two. Part 1 covered
question three and was released in September 2013. This audit
answers questions one and two. For reporting purposes we made
minor changes to the wording for question two.
Our audit work included a variety of steps designed to help us
answer question one. We reviewed the Kansas Constitution, state
statutes, as well as federal and state case law to identify the
program’s legal requirements, and compared those requirements to
the program elements at Larned State Hospital. We interviewed
Kansas Department of Aging and Disability officials and Larned
State Hospital staff to understand the services offered through the
program. We visited the facility and reviewed documents
concerning the population, services, and treatment plans for a
sample of residents. Some of our findings are based on this sample
of resident records. These findings are not projectable to the
program as a whole. We also collected staffing and expenditure
data and surveyed staff. In identifying research-based guidance, we
reviewed literature and spoke with individuals who work in this
field. Additionally, we contacted other state officials concerning
their program requirements, and expenditures.
For question two, we collected and analyzed population data for
the Sexual Predator Treatment Program since its inception. We
interviewed program staff, agency officials, and other potential
stakeholders to identify various options, consequences, barriers or
limitations to address population issues. In addition, we considered
actions taken by other states to address program population issues.
We developed an in-house model to project population growth for
the program if no changes are made to the program. We then
compared that projection to six potential options. Our methodology
is described in more detail in Appendix B.
Due to the audit’s scope, our work on internal controls was limited
to management oversight of the program. We reviewed steps
officials take to ensure services are provided, and reviewed how
they collect and utilize data to manage the program.
We conducted this performance audit in accordance with generally
accepted government auditing standards. Those standards require
that we plan and perform the audit to obtain sufficient, appropriate
evidence to provide a reasonable basis for our findings and
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conclusions based on our audit objectives. We believe the evidence
obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
We took steps to check the accuracy, completeness and validity of
data provided by agency officials including population
demographics, expenditure and staffing data. We made
adjustments as necessary to ensure accuracy and reasonableness of
the data. Expenditure data for Larned State Hospital was used for
calculating cost per resident and is likely understated making our
projections conservative. After adjustments, the data were reliable
enough for our purposes. For the projections in question two, we
believe the assumptions and data provides a reasonable basis for
our estimates and conclusions. However, the information should be
viewed as an indicator of what the future population and costs may
look like and not as absolute fact.
Our findings begin on page 11, following a brief overview of the
Sexual Predator Treatment Program.

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Overview of the Sexual Predator Treatment Program
In 1994, the Legislature
Created a Civil
Commitment Program
for Sexual Predators
Through the Sexually
Violent Predator Act

The desire to protect Kansas communities by providing for the
control, care and treatment of sexually violent predators until they
are no longer a danger prompted the Legislature to act. Through
the 1994 Sexually Violent Predator Act, the Legislature created a
separate civil commitment for the long-term control, care, and
treatment of sexual predators.
The goal of the Sexual Predator Treatment Program is to
prevent sexual predators from reoffending after their release.
Statutes require sexual predators remain committed until their
abnormality or disorder has changed and they are deemed “safe” to
be allowed to return to society. Functionally, Kansas has set a very
high standard for release from the program, with the goal being
“no new victims.”
A district court determines whether a sexual predator is likely
to reoffend and should be civilly committed. The commitment
process is multi-staged and rigorous. When an individual appears
to meet the criteria of a sexually violent predator, notice is
provided to the Attorney General and Department of Corrections
multi-disciplinary team. If it is determined the individual meets the
definition of a sexually violent predator, the Attorney General may
file a petition for commitment. Once that happens, Larned State
Hospital professionals complete an evaluation of the individual.
There is a civil trial to determine whether the individual charged or
convicted of a sexually violent offense suffers from a mental
abnormality or personality disorder that will make that person
likely to engage in repeat acts of sexual violence if not treated. If
the judge or jury finds beyond a reasonable doubt this is the case,
the individual is committed to the program. For the last three years,
the Attorney General’s office has reviewed about 270 offenders
per year. On average, only 13 each year were committed to the
Sexual Predator Treatment Program.
The seven-phase treatment program is primarily administered
at Larned State Hospital. Although the program is civil rather
than criminal, the facilities have many characteristics that are
similar to prisons, including locked doors, perimeter fencing, and
security staff. The rights of committed individuals are generally
restricted and include confinement to their assigned residential
units, controlled movement within the facility, and no access to the
Internet. These measures are intended to facilitate control by
providing for the safety and security of the public and persons
committed to the program.

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The treatment program has seven phases. The first five phases are
provided at Larned State Hospital. The last two phases—known as
reintegration—are provided at Osawatomie and Parsons State
Hospitals. Residents on phase seven are considered to be on
transitional release status. Residents who complete all seven
phases are conditionally released from the program. District courts
monitor residents who are conditionally released into the
community for at least five years. After that period, a resident is
eligible for final discharge from the program by the court.
Although admission to the program is involuntary, participation in
treatment is voluntary. This is because residents have a statutory
right to refuse treatment. However, residents who decline treatment
remain confined to the facility and are not eligible to advance to
reintegration facilities. According to program staff, about 40% of
residents at Larned State Hospital were not participating in
treatment as of December 2014.

As of December 2014,
the Sexual Predator
Treatment Program
Had 243 Residents and
the Population Was
Continuing to Grow

The first sex offender was committed to the program in October
1994. In 1997, after the U.S. Supreme Court ruled Kansas’
sexually violent predator law was constitutional, the program
began to grow rapidly and has continued to do so.
As of December 2014, the program housed a population of 243
residents—227 at Larned and eight each at the reintegration
facilities in Osawatomie and Parsons. Although the program is
not legally restricted to males, all residents admitted to date have
been male. Figure OV-1 on the next page summarizes residents’
age, number of years they have spent in the program and treatment
phase as of December 2014. As the figure shows, most residents
are between 40 and 59 years old, most are in phase two or three of
treatment, and the majority have been in the program more than
five years.
Because the program continues to add residents while very few
have been released, the population will continue to grow well
into the future. Since the program began, only three residents
have completed the program. In addition, 13 residents have been
released by court order for technical reasons, while another 28
residents have died before completing the program. Based on
assumptions about death rates and program completion rates, we
estimate the program will exceed its current capacity between 2017
and 2020. Further, we estimate the number of residents will

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continue to grow and reach 300 to 330 residents within the next 10
years. We discuss this in more detail in Question 2 on page 21 of
this audit report.
Figure OV-1
Select Demographic Information for Sexual Predator
Treatment Program Residents (As of December, 2014)
Age of Residents
78

Number of Residents

80
60

60

51

40

35

20

16
3

0
20 - 29

30 - 39

40 - 49
50 - 59
Age of Residents

60 - 69

70 +

Number of Residents

Number of Years at
Sexual Predator Treatment Program
100

88

80

70

63

60
40

22

20
0
Less than 5 Years

5 to 9 Years

10 to 14 Years

15 + Years

Years in Program

Number of Residents by Program Phase
Number of Residents

120
100

100
85
80
60
40

28

23

16

20

14
2

3
0
Phase
One

Phase
Two

Phase
Three

Phase
Four

Phase
Five

Phase
Six(a)

Phase
Seven(a)

Deaths

(a) Located at Osawatomie and Parsons State Hospitals.
Source: Larned State Hospital (audited).

The Department for Aging and Disability Services (KDADS)
has considered a number of options to address population
growth, but so far has taken limited action. Officials told us
they have considered four primary actions to address the
population concerns, including:


Increase the number of individuals from 8 to 16 at Osawatomie
and Parsons State Hospital reintegration facilities. Phases six
and seven are the reintegration phases, with phase seven referred to

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as “transitional release.” As of February 2015, statute limits the
number of individuals on transitional release to no more than eight
per county. Increasing the number of beds would allow more
residents to continue to progress through the program. At the time of
this report, KDADS officials supported legislation which would double
the number of available beds in the reintegration facilities from 8 to
16 each. This option is discussed in further detail in Question 2 on
page 31.

The Program’s Staffing
and Expenditures Have
Also Grown Since 2010



Establish alternative environments for medically infirm and
elderly residents, as well as residents with disabilities. Officials
told us alternative facilities would allow them to tailor the program to
meet the needs of the individuals in these particular areas. Further, it
would create additional capacity at Larned for future residents.
However, to date officials have not identified how to implement these
changes. This option is discussed in further detail in Question 2 on
pages 28 and 29.



Improve residents’ participation to facilitate increased program
completion rates. Officials acknowledge the motivation of residents
is an issue that limits participation and ultimately limits the number of
individuals eligible to complete the program. As of December 2014
about 40% did not participate in treatment. Officials have not
identified specific ways to improve motivation, but these could
include increased benefits or access to special activities. Several
officials told us if residents saw an increase in the number of
individuals progressing to the reintegration facilities, it could improve
participation and lead to more individuals progressing through the
program.



Implement a risk assessment tool to evaluate residents’
progress. At the time of this audit, the program did not utilize a risk
assessment tool as part of the treatment process. A risk assessment
would allow staff to appropriately separate residents based on risk,
identify the treatment services and intensity needed, and measure
treatment progress. These measures could help residents progress
through the program. Additionally, a 2013 Task Force appointed by
the Secretary of KDADS made this recommendation for the program.
Program officials said they are in the process of implementing
aspects of a risk assessment tool.

The Sexual Predator Treatment Program employs a number and
variety of staff at various locations. Having adequate staff helps
ensure delivery of treatment and the safety and security of both
residents and staff. Program staff generally fall into one of two
categories:


Direct care staff – These employees tend to residents’ daily
activities. Examples include mental health and developmental
disability (MHDD) technicians and nurses, as well as activity
therapists and psychologists.

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

Non-direct care staff – These employees perform work that does not
directly involve program residents. Examples include administrative
positions and maintenance workers.

Most of the positions are classified as
direct care staff, and salaries and benefits
account for the highest percentage of
expenditures. Figure OV-2 on the left
summarizes the growth in the program
population, staffing and expenditures. As
the figure shows, there has been an
increase in all three areas in the last five
years.
In fiscal year 2014, the program had
about 359 authorized positions, a 36%
increase from 2010. Although there has
been an overall increase in authorized
positions since fiscal year 2010 for
Larned State Hospital program staff,
there has continued to be an increase in
vacant positions. According to unaudited
information from officials, as of
February 2015 the program had about a
38% vacancy rate for nurses and MHDD
technicians. This represents about an 8%
increase in vacancies from April 2013.
The Larned State Hospital
Superintendent told us the vacancies
were due to a limited labor pool.
Our 2013 performance audit of the
program also identified issues with
staffing. That audit found that many
positions were vacant and that staff had
significant overtime. In fact, overtime
increased 80% from 2011 to 2012. Even
with the overtime, the audit found that
the program failed to meet internal minimum staffing goals. We
noted the remote location of the program, the limited pool of
applicants, and undesirable working conditions all likely
contributed to staffing shortages. In this current audit, staff told us
overtime continues to be an issue for the program.
In fiscal year 2014, the program had about $14.8 million total
expenditures, a 15% increase from 2010. Officials explained the
program increase was in part due to adding the reintegration
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facility at Parsons State Hospital and a wage increase for some
direct care staff positions in the last couple of years.
The Constitutionality of
Involuntary Civil
Commitment Has Been
Challenged in Kansas
and Other States

Civil commitment laws have been politically and legally
contentious because they allow for involuntary confinement of
sexually violent predators after they have served their prison
sentence. Despite the controversy, the U.S. Supreme Court has
upheld their constitutionality.
In 1997, the U.S. Supreme Court ruled Kansas’ Sexually
Violent Predator Act was constitutional. In Kansas v. Hendricks,
the court ruled the civil commitment process was not punishment,
as long as treatment was a goal of detainment and individuals were
released upon a showing they were no longer dangerous.
Additionally, the court stated it was not a second prosecution for
the same crime and did not violate an offender’s due process
rights. Since the court ruling, many other states including Iowa,
Missouri, and Nebraska have enacted similar civil commitment
programs. In all, 20 states have implemented programs for sexually
violent predators.
Recent federal lawsuits in Minnesota and Missouri could affect
Kansas’ program. The Minnesota program has more than 700
residents, with only two having been conditionally released since
inception of the program in 1994. Plaintiffs are seeking relief from
the current program as well as punitive and compensatory
damages. They contend Minnesota’s program violates civil rights
and is unconstitutional for several reasons. Plaintiffs argue the
program uses a one-size-fits-all approach that does not provide
adequate treatment, fails to provide for less restrictive alternatives
to confinement, and fails to conduct periodic risk assessments, all
of which contribute to indefinite confinement. Ultimately, the
plaintiffs argue the program is punitive and does not provide
adequate treatment because so few residents have been discharged.
The federal trial started in February 2015 and the judge will have
about 60 days following its conclusion to issue his ruling.
Additionally, a class action federal lawsuit is pending in Missouri
that raises similar constitutional challenges of Missouri’s program.
That case is set for trial in April 2015.

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Question 1: How does Kansas’ Sexual Predator Treatment Program
Compare to Similar Programs in Other States and Best Practices?
The recommended practices for sexual predator programs
emphasize individualized treatment (p. 11). However, Kansas’
program generally did not adhere to the recommended practices,
while other states’ programs we reviewed generally did (p. 12).
The Kansas Sexual Predator Treatment program met many legal
requirements, although there were several exceptions (p. 16).
In addition, residents did not necessarily arrive at the
reintegration facilities with the skills to be successful (p. 18).
Additionally, program officials had not maintained appropriate
records and documentation to effectively manage the program (p.
18). Policies and program guidance were outdated and not
adhered to (p. 20). We also found until recently, KDADS had not
filed annual reports with the legislature as required by statute (p.
20).

The Recommended
Practices for Sexual
Predator Programs
Emphasize
Individualized
Treatment

The purpose of the Sexual Predator Treatment Program is to
provide long-term control, care, and treatment of sexually violent
predators. However, Kansas statutes do not define treatment, and
there are no universally agreed-upon best practices that specify
what a treatment program should include. However, the
Association for the Treatment of Sexual Abusers (ATSA) and
others have put out research-based guidance for the treatment of
sexually violent predators. Officials from three other states we
spoke with generally agreed with the research, which emphasizes
the benefits of individualized treatment. Research indicates
programs with targeted treatments and periodic reviews contribute
to program success. For purposes of this report, we refer to this
guidance as recommended practices. See Appendix D for more
information.


Each resident should be assessed when they enter the program
and periodically reassessed thereafter. Risk assessment tools
identify an individual’s risk of reoffending, which helps to determine
the intensity of treatment they need. Further, comprehensive
assessments identify and measure factors such as cognitive
functioning and the presence of other issues such as substance
abuse or depression. Staff should conduct periodic assessments to
gauge progress, identify specific risk factors, and adjust treatment
plans.



Treatment should be individualized to address the unique needs
of each resident. The risk, need, responsivity (RNR) model is widely
accepted as a guiding principle for sex offender treatment. In this

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model, the risk of reoffending governs the type and intensity of
treatment. Additionally, treatment is further individualized based on
other factors such as an individual’s mental health, learning style and
intellectual ability.

Kansas’ Program
Generally Did Not
Adhere to These
Recommended
Practices, While Other
States’ Programs We
Reviewed Generally Did



Annual evaluations should determine whether the resident
continues to meet criteria for commitment and evaluations
should be conducted by an impartial party. Periodic evaluations
should determine whether the individual still meets the commitment
criteria or should be released to a less restrictive environment. In
addition, the review should be used to continuously evaluate the
individual’s progress and modify their treatment appropriately.
Finally, a qualified individual who is impartial and not responsible for
delivery of treatment services should complete the evaluations. This
helps ensure the review is unbiased.



Residents with intellectual or developmental disabilities should
have separate, specialized treatment programs. Research has
shown residents do best when grouped with other residents who
have similar learning styles, cognitive abilities, or disabilities.
Additionally, to assist an individual’s progress through treatment, the
program should alter the program expectations to the individual’s
skills and abilities. The program criteria for individuals with such
issues as comprehension limitations, or challenges with language,
reading, or completing daily living activities should not be the same
as for those without these disabilities. Simply offering the same
treatment model at a slower pace is not considered sufficient.

Kansas’ treatment program was not individualized, so all
residents received what was essentially the same treatment.
The Kansas program consisted of several phases of treatment. Each
phase requires participating actively in treatment, meeting
specified attendance requirements for certain activities, and
completing a number of tasks. At the time of this audit all residents
had to complete the same requirements to progress from one phase
to the next. As a result, Kansas’ program was not individualized in
several areas:


Kansas did not use an assessment tool that explicitly evaluates
the risk of reoffending. Under the widely recommended RNR
model, each resident’s risk of reoffending governs the type and
intensity of treatment they receive. Further, risk factors should be
assessed for each resident both before and during treatment to
ensure it is appropriately individualized. Kansas’ program used two
assessments that were not designed to assess the risk of
reoffending. One assessment was used in all programs at Larned
State Hospital and measured such areas as risk for falling or suicide.
The other assessment measured such factors as the residents’
outlook and participation. Although these assessments may aid
program staff, they are not tools for assessing the treatment needs
or risk of reoffending.

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Program officials told us they are implementing a new type of risk
assessment tool specific to sex offenders. While this is a good first
step, research holds that comprehensive assessments utilizing
multiple tools are necessary to measure risk of reoffending and
assess treatment needs.


Kansas did not create sufficiently individualized treatment
plans. The program focused solely on treating sexual disorders with
all residents completing the same curriculum. The treatment has
been the same for each resident regardless of individual’s specific
issues such as schizophrenia, alcoholism, borderline personality
disorder, or trauma. This is contrary to recommended practices
which emphasize addressing these specific issues in addition to
sexual predator treatment.



Kansas’ annual review did not appear to meet recommended
practices. Recommended practices indicate the individual’s mental
condition should be reevaluated periodically. These evaluations
measure whether the resident still meets the criteria for commitment,
should be completed by an impartial individual, and should be used
by staff to modify treatment. The annual reviews conducted in
Kansas did not measure the resident’s mental condition to determine
if they met criteria for continued commitment. Instead, staff reviewed
medical records, any available progress notes, previous annual
reviews, and court records. In addition, the reviewer talked with staff
who had regular contact with the resident. Additionally, in Kansas a
staff member who was previously responsible for delivering
treatment services completed the reviews, rather than an
independent third party. The current superintendent of Larned State
Hospital indicated he would be open to contracting out the annual
examinations.



In Kansas, individuals with intellectual and developmental
disabilities had the same requirements and received the same
treatment as all other residents, but at a slower pace. Generally,
these individuals were on what is called the “parallel track.” Contrary
to recommended practices mentioned earlier, Kansas did not employ
a standardized assessment procedure to identify residents’ cognitive
limitations or other type of disabilities. In fact, residents could opt to
transfer between the parallel track and traditional treatment.
Additionally, Kansas did not target the treatment to appropriately
address these additional factors but simply slowed the traditional
program down for this group. Aside from this extended timeframe,
program expectations were the same for these individuals which was
not in line with recommended practices. KDADS officials have
acknowledged a one-size-fits-all approach is no longer appropriate
for these residents, but had not taken steps to modify these
practices.

The treatment programs in three other states provided more
individualized treatment than Kansas. We contacted officials in
several states concerning their entrance criteria, exit criteria, and
treatment model. We also gathered information on the number of
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admissions and discharges. Many of the states we contacted were
reluctant to share information. However, we were able to gather
program-specific information about Iowa, Washington, and
Wisconsin. The programs in those states have between 101 and
312 residents, compared to 243 residents in Kansas. Further, these
states have a similar multi-step commitment process, with a judge
or jury making the final determination about commitment. In
general, these states’ programs were in line with recommended
practices, as described below:


Iowa, Washington, and Wisconsin utilized assessment tools that
evaluate behavior, intelligence and criminal risks. These states
evaluated residents using risk assessments when they enter the
program and as part of the annual review process. This facilitates
placing each individual within the program based on the risk they will
reoffend, as well as other underlying issues such as mental health or
potential disabilities. Kansas did not use a similar type of assessment.



The other states appeared to provide treatment that focused on
the needs of the individual. Generally, the other states used
assessment tools to identify the resident’s individual needs.
Treatment was planned around those identified needs such as
diminished cognitive skills, physical limitations, and other mental
health issues. Washington and Wisconsin’s programs relied on the
professional judgment of the treatment team and occasionally
assessments to determine when a resident was ready to progress to
the next stage. In contrast, residents in Kansas progressed to the
next stage when they had completed specific phase requirements
such as attending a certain number of sessions and completing
assignments.



All three states conducted annual reviews that appeared to be
consistent with recommended practices. Programs in Iowa,
Washington, and Wisconsin used annual risk assessments to
determine if the residents’ mental condition still met the criteria for
continued commitment. Wisconsin and Washington had the
assessments conducted by people who were independent and not
responsible for delivering treatment services.



Two of the three states identified residents with intellectual or
developmental disabilities and modified the treatment program
accordingly. Washington did an assessment to determine whether
residents had special needs and if so, modified treatment to meet
those needs. Further, Washington housed the residents with special
needs in separate units. Wisconsin also assessed residents and
developed the treatment plan to accommodate their disabilities.
Officials emphasized it should not be the same treatment as provided
to individuals without disabilities.

Additionally, other states had some unique programming
approaches. For example, Washington maintained a separate unit
for phase one residents who opt-out of treatment in an effort to
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isolate the negative environment they create from those who want
to participate in treatment. Also, Iowa has expanded vocational
opportunities for residents because program officials think this is
important to ensure success at reintegration.
Kansas placed a greater emphasis on non-clinical requirements
to progress to the next stage than other states we looked at. The
Kansas program had a set curriculum for all residents that required
at least eight hours a week of recreation and leisure classes, which
include walking, swimming, and arts and crafts. Additionally,
residents generally were required to take a minimum of one to four
hours a week of classes such as anger management and
relationship skills, depending on what phase they were in. Finally,
the program requirements for individual and group therapy were
the lowest at zero to three hours per week. Other states we
contacted generally required more frequent individual and group
therapy sessions than Kansas. Further, these states did not require
that all residents complete set hours in recreation and leisure
activities. Instead, in those states, recreation and leisure activities
were encouraged for all residents, but may have been required on
an individual basis.
The recreation and leisure activities in Kansas were managed by
non-clinical staff, but carried a significant amount of weight for the
residents to progress to the next phase of treatment. Program staff
told us even if a resident was ready to progress to the next phase of
treatment from a clinical standpoint, the resident could be held
back for failure to meet the recreation and leisure requirement. For
example, we found three recent instances where residents had
completed all required treatment therapy sessions and courses
(such as anger management), and completed other phase
requirements. These residents applied to the treatment team to
move on to the next phase of treatment, but were denied because
they had not completed enough hours either walking or in the
library. These residents must now wait at least another three
months before they can re-apply to the treatment team. One of
them has been denied advancement for more than a year and a half
because he had not completed the required recreation and leisure
hours. Program officials acknowledged that residents can be
denied advancement to the next treatment phase for failure to meet
the required recreation and leisure hours. However, officials did
not think this happened frequently.
Iowa, Washington, and Wisconsin have conditionally released
and discharged more residents than Kansas. Kansas,
Washington, and Wisconsin began operating their sexual predator
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treatment programs in the early 1990s, and Iowa began operating
its program in 1999. Figure 1-1 below summarizes the conditional
release and discharge information for the four states. Conditional
release is generally a probationary period in the community and
discharge is completion of the program. As the figure shows, none
of the other states had a significantly larger program than Kansas,
and all three have released far more residents. Data on reoffending
was not readily available, though Wisconsin had recently started
capturing limited data and estimated its rate of reoffending was
between 3% to 5%.
Figure 1-1
Conditional Release and Unconditional Discharge of Residents
from Inception of Program to 2014
Wisconsin

Washington

Iowa

Kansas

Year Established

1994

1990

1999

1994

Current Population

312

258

101

243

# Conditionally Released

122

70

12 (a)

2

# Unconditionally Discharged

118

40

20

3

State

(a) This number was calculated in 2013.
Source: Kansas' and other states' Sexual Predator Treatment Program Data (unaudited)

Kansas’ Sexual
Predator Treatment
Program Met Many
Legal Requirements,
Although There Were
Several Exceptions

Kansas’ Sexually Violent Predator Act established the Sexual
Predator Treatment Program. The statutes cover a number of
different areas including commitment, transitional and conditional
release, discharge, resident rights, and rules of conduct. We
reviewed and compared program services and activities to statutes
to determine if legal requirements were met.
Kansas appeared to adequately address most statutory
program requirements. The legal requirements include a multistep review process for commitment, as well as the right to petition
the court for conditional release and discharge from the program.
Additionally, statutes protect rights of the program residents
including the right to refuse treatment, medication, or to perform
labor. Further, residents are to have a grievance process, the right
to individual religious worship, and access to both mail and
telephone. It appears from our on-site visits, interviews with staff,
review of various resident files and demographic records that
Kansas generally met these specific legal requirements.
However, Kansas’ program may not have adequately
addressed other statutory requirements. In addition to the
requirements discussed in the previous section, statutes also
required the program offer rehabilitation and educational services

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that are appropriate for the individual’s condition. However, these
services were not clearly defined by statute. We talked with
program staff about their understanding of these terms. We also
talked with officials in other states about how their states
interpreted similar requirements. Our findings are summarized
below.


Kansas did not provide traditional education services, such as
GED completion. Officials from sexual predator treatment programs
in other states told us educational services typically include high
school diploma equivalents, GEDs, and adult basic education.
Kansas did not provide these types of services. Program staff told us
educational services included classes involving relapse prevention,
anger management, self-concept, relationship skills, budgeting and
money management, stress management, and strategies for
motivation. Kansas also provided vocational training courses and
employment opportunities, which could satisfy the requirement for
education. While these classes and vocational training are important,
we would expect educational services to also include basic adult
education such as reading and GED opportunities, as was done in
other states.



Kansas provided several rehabilitation services, but did not
provide substance abuse rehabilitation which research
recommends. The program provided speech, physical, and
occupational therapy on an individual basis. However, the program
did not provide treatment for drug or alcohol addiction. Two studies
we reviewed stated that sexual predator treatment programs should
also address other risk factors such as addiction. A KDADS official
told us the rehabilitation requirement in statute was fulfilled by
accommodations for physical and cognitive impairments.
Additionally, staff said the program was not designed to provide
rehabilitation such as addiction recovery services. However, other
states we contacted provided a range of services to include physical,
mental and addiction rehabilitation as part of the sexual predator
treatment.



Kansas did not annually evaluate each resident’s mental
condition. Statutes required each resident have an annual exam to
assess the resident’s mental condition. The particulars of the exam
were not defined in statute, but the exam is used to determine
whether the resident still meets the criteria for commitment. Kansas
staff prepared an annual report for each resident, but it was
essentially a progress check on whether the resident was meeting
phase requirements. Other states provided a comprehensive exam
that includes risk assessments to determine if the individual
continued to meet the criteria for commitment.

Senate Bill 149 was introduced in the 2015 legislative session
and would address many aspects of the Sexually Violent
Predator Act. At the time of this report, if SB 149 passes it would
strike the statutory requirements that the program provide both
rehabilitation and educational services.
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OTHER FINDINGS
Residents Did Not
Necessarily Arrive at
the Reintegration
Facilities with the Skills
to be Successful

Residents must transition from Larned State Hospital to one of the
reintegration facilities in order to complete the final two phases of
their treatment. Reintegration is to prepare the residents for
conditional release back into the community. Residents assume
more responsibilities and gain additional privileges, are expected
to obtain a job and display the skills to be able to function in the
community.
Staff at the reintegration facilities stated residents often lacked
some basic skills essential to reintegrate into the community. For
example, staff told us residents often arrived without the skills
necessary to get a job, including a lack of basic computer skills and
knowledge of how to search and apply for jobs. Additionally, they
told us residents generally had not gained basic daily living skills
such as how to cook or shop for themselves, and that they may lack
employment experience because vocational training opportunities
at Larned were limited. Staff also stated residents often arrived
without a realistic plan for how to react to community
circumstances that could put them at risk of reoffending. The lack
of a cohesive program to ensure residents arrive with the proper
skills potentially extends the length of time required at the
reintegration facilities.

Program Officials Had
Not Maintained
Appropriate Records
and Documentation to
Effectively Manage the
Program

Adequate records are an integral part of a treatment environment.
They allow staff to determine what services should be made
available to a resident and to track a resident’s progression through
treatment. Additionally, appropriate documentation permits
management to monitor and adjust the program as necessary.
However, we found several issues concerning adequate
documentation.
The program did not track phase participation or progression.
Instead, residents or individual therapists were charged with
keeping a single paper copy of the document that captured what
tasks a resident has completed in order to progress to the next
phase. Often the document was incomplete or staff could not
produce it. This created a risk residents would have to repeat tasks
because it was not documented what tasks were completed.
Additionally, staff could only estimate the frequency of
participation. As a result, management was unable to determine
how long it took the average resident to complete each phase. For
example, management and staff were unaware that about 50% of

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individuals on the parallel track appeared to participate fully in
treatment, had on average been in the program for about ten years,
yet had not progressed past phase three. Phase participation and
progression information would be necessary to identify and
address programmatic problems and identify individuals, and
groups of individuals, whose progress was delayed.
We could not tell if residents had received the treatment they
should. Treatment plans are completed every 90 days for each
resident. We reviewed 26 treatment plans to check whether
residents were getting the services called for in the plans. Nearly
half the treatment plans and associated progress notes we reviewed
contained insufficient documentation of whether the treatment
services in the plan were actually provided to the resident.
Additionally, we found the files did not always track whether the
resident was participating in treatment, which is necessary for
progress through the program. Our sample is not projectable.
However, this lack of information could cause problems for
treatment providers who lack information about individual
residents’ history and could result in residents having to repeat
requirements.
The program did not maintain thorough records of service
cancellations. Occasionally classes and sessions were canceled for
staff absences or because of weather. Although staff collected
some cancellation data for vocational activities, recreational
activities, and some courses, they did not track cancellations for
individual or group therapy sessions. This prevented management
from ensuring services were made available or knowing the
frequency or reason for such cancellations.
Without sufficient data, management cannot effectively manage
several program aspects. Data on program operations can provide
management with valuable information that would allow them to
continually monitor, evaluate, and modify the program.
Specifically, data allows management to monitor such things as
staffing levels, trends in cancellations, staff performance, the
availability of program services, resident participation, and the rate
of progression. However, management did not generally maintain
adequate documentation or when it was available, they did not
review it. This prevented officials’ from effectively managing the
program. Officials told us they are in the process of reviewing
ways to improve the tracking of phase progression and service
cancellations.

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Policies and Program
Guidance Were
Outdated and Not
Adhered To

Adherence to policies and program guidance ensures residents
receive proper and consistent treatment. Additionally, staff and
residents must be able to rely on the accuracy of information for
meeting program requirements and understanding expectations. It
is essential for management to ensure policies are followed and
program guidance is accurate.
Staff were not adhering to Progress Review Panel policy
requirements. The panel approves resident entrance into,
progression through, and regression back from phases five, six and
seven. According to KDADS policy, the panel should consist of
seven designated voting members and several designated advisory
members. For several years, the panel has been comprised of only
five voting members. Additionally, the role of one of the advisory
members has historically not been filled. This potentially prevents
residents from receiving an adequate review. Officials thought they
had been in compliance with the policy and state they are in the
process of reviewing and updating policies.
Resident handbooks were outdated and inaccurate. The
handbook for residents at Larned was dated November 2013, but it
contained some information that was six years old. For example, it
listed treatment services that were no longer offered and inaccurate
requirements for individual therapy. The handbook for residents in
the reintegration facilities (Parsons and Osawatomie), dated
November 2014, provided inaccurate requirements for attending
support groups. This increased the risk that residents were not
aware of what the expectations were in order to progress to the
next phase. Officials have told us they are in the process of
updating the handbooks.

Until Recently, KDADS
Had Not Filed Annual
Reports with the
Legislature as Required
by Statute

K.S.A. 59-29a11(e) requires KDADS to submit an annual report to
the Governor and to the Legislature detailing activities related to
the transitional release and conditional release of sexually violent
predators. This requirement became effective in 2010 when Larned
was part of the Department of Social and Rehabilitation Services,
but no reports have ever been submitted. Officials at KDADS, who
assumed responsibility for the program in 2012, told us they were
unaware of this requirement. In the course of this audit, they filed a
report in March 2015.

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Question 2: What Actions Could be Taken to Reduce the Resident
Population of the Sexual Predator Treatment Program?
Unless changes are made, the Sexual Predator Treatment Program
will exceed capacity in the next few years and will continue to
grow for the foreseeable future (p. 21). We evaluated the impact of
six different options to reduce the program’s resident population
(p. 24). Option 1 is to treat low-risk residents in a community
setting, which would reduce the resident population and reduce
program costs (p. 26). Option 2 is to treat medically infirm
residents in a secured nursing facility, which would reduce the
resident population but would not significantly affect program
costs (p. 28). Option 3 is to treat residents on the “parallel track”
in a separate secured facility, which would reduce the resident
population, but potentially increase costs (p 29). Option 4 is to
expand the number of reintegration slots from 16 to 32, which
would not reduce the resident population (p. 31). Option 5 is to
limit the time a resident can occupy a slot in a reintegration
facility, which would not significantly reduce the resident
population at Larned State Hospital (p. 33). Finally, Option 6 is to
begin sexual predator treatment before the offender is released
from prison, which would not significantly impact resident
population and could increase costs (p. 34). Finally, we found
statutory housing restrictions make it difficult for residents to leave
the program (p. 36).
Unless Changes Are
Made, the Sexual
Predator Treatment
Program Will Exceed
Capacity in the Next
Few Years and Will
Continue to Grow for
the Foreseeable Future

As of December 2014, the program housed 243 residents –
about 92% of the program’s physical capacity. The program
operates seven housing units at Larned State Hospital, one unit at
Osawatomie State Hospital, and one unit at Parsons State Hospital.
In total, these facilities have the physical capacity to house 264
residents.
The population continues to grow because far more sex
offenders are committed to the program each year than are
released. Since 2005, an average of about 15 sexually violent
predators have been committed to the program each year.
However, only three residents have ever completed the program
since it was established in 1994. Because far more residents enter
the program each year than exit it, the program has grown steadily
over time.
Few residents exit the program because most never progress
past the early phases of treatment. Residents must participate in
treatment to progress through the seven phases necessary to

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complete the program. According to program officials, it should
only take about 2.5 years for residents participating in treatment to
complete the first three phases of the program. As of December
2014, 185 (76%) of the program’s 243 residents were on phases
two and three. On average, these residents have been in the
program for about eight years.
That is due in part to the fact that many residents elect to not
participate in treatment. About half of the residents on phase two
and three were not participating as of December 2014. Low
resident morale or unwillingness to confront the challenges of
therapy may result in non-participation.
Based on current trends, we project the program population
will exceed its current space limits in the next few years and
will continue to grow into the foreseeable future. We created a
computer simulation to project future trends and evaluate options
to reduce the program’s resident population. The underlying data
for the model consists of historical admission data, resident
demographics, death data, mortality tables and treatment
progression data. Based on this historical resident data, the model
simulates future program population with similar characteristics.
Finally, we calculated a 95% confidence interval around the model
data in order to generate a range for the future population. We
made several assumptions in order to project this population,
which are described in more detail in Appendix B.
We first projected what the resident population might look like in
the future if no changes are made to the program. This projection
assumes current population trends remain constant into the future.
Figure 2-1 on the next page shows our analysis. As the figure
shows, if no changes are made to the program, the resident
population would exceed its current physical capacity between
2017 and 2020. Additionally, near the year 2060 the number of
resident deaths and the number of residents committed to the
program will be roughly the same. This will cause the population
to stabilize at about 500 residents, as shown in Appendix C.
Recent changes to the state’s minimum sentencing requirements
under Jessica’s Law could affect the program’s future population.
Passed in 2006, Jessica’s Law increased the minimum sentencing
for certain first time sex crimes to mandatory life imprisonment
with eligibility for parole after 25 years. This law could reduce the
number of offenders committed to the program in the future, as
offenders will remain incarcerated for longer periods under this

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law. As of fiscal year 2014, 376 offenders have been convicted
under Jessica’s Law. As discussed in Appendix B, we accounted
for the effect this law could have on the program population in our
model.
Figure 2-1
Baseline Projection of Resident Population

Projected Resident Population (2016 - 2025)
400

360
Capacity + 2 new units (336)

Residents

320
Capacity + 1 new unit (300)

280
Current Capacity (264)

240
200
2016

2017

2018

2019

2020 2021
Years

Population Range

2022

2023

2024

2025

Population Midpoint

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of resident population.

We further estimate program costs will more than double by
2025. Based on our model, we estimate the population will
increase by 60 to 90 residents over the next 10 years. We also
estimated the increase in program costs associated with this
population growth. These costs represent an increase over the
fiscal year 2014 Larned State Hospital program expenditures of
about $14 million and would make the estimated total program
costs in 2025 between $26 and $34 million. Our cost estimate
included annual operating costs and capital outlay costs.
Specifically,


we estimate the program’s annual operating costs could increase
between $5 and $7 million by 2025. Operating costs include the
ongoing expenses for the staff and services necessary to treat this
population. Expenditure data for the Larned State Hospital program
is likely understated and therefore our estimates are conservative.



we estimate the program would also incur up to $13 million in capital
outlay costs to build additional 36-bed units. We determined that
adding 60 to 90 new residents by 2025 would require program
officials to build one to two additional 36-bed units. We did not inflate
future costs.

An insufficient local labor force will create staffing problems
for the program as it grows. As discussed in the overview on
page 9, the program continued to experience significant vacancy
and overtime issues. Because officials have trouble filling
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positions, it is unlikely officials could staff the additional housing
units needed by 2025. The Superintendent of Larned State Hospital
agreed it is unlikely they could find enough employees in the area
to staff one additional housing unit. Therefore, the additional
capacity may need to be built in a different part of the state.
FINDINGS RELATED TO REDUCING THE RESIDENT POPULATION
We Evaluated the
Impact of Six Different
Options to Reduce the
Program’s Resident
Population

We evaluated six options that could potentially reduce the
program’s resident population. We identified these options through
interviews with program officials, other stakeholders, and officials
from other states. We also reviewed reports from other states
regarding their sexual predator treatment programs. These options
are:


Treat low-risk residents in a community setting (page 26).



Treat medically infirm residents in a secured nursing facility (page
28).



Treat residents with intellectual or developmental disabilities in a
separate secured facility (page 29).



Double the total number of reintegration slots at Parsons and
Osawatomie from 16 to 32 (page 31).



Limit the amount of time residents can occupy a reintegration slot
(page 33).



Begin sexual predator treatment while the offender is still in prison
(page 34).

Using the same population model described on page 22, we
estimated the impact these six options could have on the resident
population and program costs through 2025. We compared the
results of these models to two baseline projections:


the estimated resident population in 2025 if no changes are made to
the program (about 300 to 330 total residents).



the total estimated cost of the program in 2025 if no changes are
made to the program (about $26 to $34 million in 2014 dollars).

Future program costs include both operating costs and capital
costs. Operating costs include the staff and services necessary to
treat these individuals. Capital costs are associated with building
36-bed living units to house residents. These will be incurred to
expand the physical capacity of the program as the population
grows. For the purpose of this report we focus on population and
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cost projections over the next 10 years (through 2025). Appendix
C has additional information for each option with projections out
to 2090. Finally, we did not adjust future program costs to account
for inflation, so all estimates of future costs are in current (2014)
dollars.
The results of these comparisons are discussed in detail in the
following sections. Figure 2-2 below provides a summary of each
option. As the figure shows, not all of the options reduce the
resident population over time.
Figure 2-2
Summary of the Baseline and the Six Options to Reduce the Number of Residents
Committed to the Sexual Predator Treatment Program
Scenario

Population by 2025

Total Cost by 2025 (a)

300 - 330 residents

$26 million - $34 million

Impact on Population by 2025
(compared to baseline)

Impact on Costs by 2025
(compared to baseline)

Option1: Treat low-risk residents in a community setting
(page 26). Under this option, low-risk sexually violent
predators would be treated in a community setting rather
than be committed to Larned State Hospital.

Decrease
35 - 40 residents
(12%)

Decrease
$7.5 to $8 million

Option 2: Treat medically infirm residents in a secured
nursing facility (page 28). This option would remove the
23 current, and any future, residents who are medically
infirm and would treat them in a separate secure nursing
facility.

Decrease
45 - 50 residents
(15%)

No change

Option 3: Treat residents with intellectual or
developmental disabilities in a separate secured facility
(page 29). This option would remove the 37 current, and
any future, residents with intellectual or developmental
disabilities from the main resident population and would
treat them in a separate secure facility.

Decrease
45 - 50 residents
(13 - 16%)

Increase
$6.5 to $8 million

Option 4: Double the total number of reintegration slots
at Parsons and Osawatomie from 16 to 32 (page 31).
This option would double the physical capacity at
reintegration housing to allow more residents to progress
the final phases of program treatment.

No Significant Change

Increase
$5 million

Option 5: Limit the amount of time residents can occupy
a reintegration slot (page 33). This option would send
residents at reintegration housing back to Larned State
Hospital if officials agree the resident is not on track to
complete the program within four to six years. This would
allow more residents to advance to these final phases of
treatment.

No Significant Change

No Change

Option 6: Begin sexual predator treatment while the
offender is still in prison (page 34). This option would
provide sex predator treatment to offenders currently in
prison. Credit for sex predator treatment completed in
prison would carry forward with offenders if committed to
the Sexual Predator Treatment Program.

No Significant Change

Increase
$600,000 to $2 million

Baseline
(if no changes are made to the program)
Options to Reduce the Program Population

(a) We did not adjust future costs for inflation. As such, all future costs are in 2014 dollars.
Source: LPA projection of future program population and costs.

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Option 1: Treating
Low-Risk Residents in a
Community Setting
Would Reduce the
Resident Population
and Reduce Program
Costs

Historically, all offenders who have been determined to be
sexually violent predators were committed to the program at
Larned State Hospital, regardless of the risk they will reoffend.
The option described in this section would establish a second track
for low-risk sexually violent predators to be monitored and treated
in the community rather than Larned State Hospital. Only low-risk
sexually violent predators would be eligible for the community
track, all others would still be committed to the residential program
at Larned.
New York treats low-risk residents separately, assigning them
to a community based model. In 2007, New York established the
Strict and Intensive Supervision and Treatment (SIST) Program to
treat low-risk sexually violent predators in the community.
Officials from New York told us they evaluate several risk factors
to determine which offenders to recommend to the SIST program,
including hostility records, flight risk, and mental health diagnosis.
Since the SIST program began in 2007 through 2013, New York
courts have committed 152 individuals to the program for
community treatment. As of 2013, three of these 152 sexually
violent predators had been charged with a reoffense for a sex crime
while receiving treatment in the community. New York established
a number of strategies and techniques to effectively manage the
risk of reoffense, including:


Consistent check-ins and monitoring of offenders by parole officers.
Parole officers’ caseloads are no more than 10 to ensure adequate
time to monitor each SIST offender.



Mandatory GPS tracking, polygraph testing, specification of
residence, strict curfews, and other related requirements.



Mandatory attendance and participation in treatment.



Failure to meet any mandatory requirements could result in an
offender being committed to the secured treatment facility.

We estimate adopting a similar option in Kansas would
decrease the resident population by about 40 residents (12%)
by 2025. We projected the impact that treating low-risk offenders
in a community setting could have on the future resident
population. We compared the results of this analysis to our
baseline projection in Figure 2-3 on the next page. As the figure
shows, treating low-risk offenders in a community setting could
reduce the resident population at Larned by about 40 residents by
2025 compared to the baseline.
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Figure 2-3
Option 1: Comparison of Projected Resident Populations
without Low-Risk Sexually Violent Predators
Projected Resident Population (2016 - 2025)
400

Residents

360
320
280
240
200
2016

2017

2018

Baseline

2019

2020

2021
Year

2022

Option 1
Population Midpoint

2023

2024

2025

Option 1
Population Range (a)

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of SPTP resident population.

By reducing the population, we estimate this option would also
reduce projected program costs by about $7.5 to $8.0 million
(22% to 31%) by 2025. Without changes the total estimated costs
to the program is $26 to $34 million to operate by 2025 (in 2014
dollars). Treating low-risk offenders in the community would
reduce the Larned population, reduce operating costs and eliminate
additional capital costs for one to two additional units. However,
treating offenders in the community would also include certain
monitoring costs such as GPS tracking, polygraph testing, sexually
violent predator treatment, and specialized parole officers. Taking
all of these factors into account, we estimate total program costs
would be reduced by $7.5 to $8.0 million by 2025, a 22% to 31%
decrease.
Although feasible, serving low-risk residents in the community
would require a significant change in treatment philosophy,
including a willingness to increase the risk of reoffending.
Historically, the state has used a secured institutionalized approach
to treat sexually violent predators. That approach creates very little
risk of reoffending, but is also very costly and likely unsustainable.
By contrast, this option introduces a community-based approach
for treatment. Although this model introduces more risk of
reoffense, it appears manageable by utilizing strategies and
techniques, similar to New York’s method. KDADS officials were
generally agreeable to pursuing this option but stated it would
likely face significant resistance from the community.

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Option 2: Treating
Medically Infirm
Residents in a Secured
Nursing Facility Would
Reduce the Resident
Population, But Would
not Significantly Affect
Program Costs

As of January 2015, 23 residents had severe medical issues and
might be better served in a nursing facility. According to
program officials, the medical needs of this population are
increasingly difficult and expensive to care for and treat at Larned
State Hospital. The option described in this section would transfer
medically infirm residents to a secure nursing facility. There,
residents would receive medical care in a more appropriate setting
while still being offered sexually violent predator treatment.
We estimate treating the medically infirm in a separate
nursing facility would decrease the resident population at
Larned by about 45 to 50 residents (15%) by 2025. We
projected the impact that treating medically infirm residents in a
separate secure facility could have on the future resident
population. We compared the results of this analysis to our
baseline projection in Figure 2-4 below. As the figure shows,
treating medically infirm residents in a secured nursing facility
would reduce the resident population at Larned by about 45 to 50
residents by 2025 compared to the baseline.
Figure 2-4
Option 2: Comparison of Projected Resident Populations
without Medically Infirm Residents
Projected Resident Population (2016 - 2025)
400

Residents

360
320
280

240
200
2016

2017

2018

Baseline
Population Range

2019

2020
2021
Years

2022

Option 2
Population Midpoint

2023

2024

2025

Option 2
Population Range (a)

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of SPTP resident population.

It is unlikely this option would reduce the projected program
costs by 2025, but it could alleviate capacity issues at Larned.
The cost to staff and build a new nursing facility for medically
infirm residents is roughly the same as the cost to treat this
population at Larned under the baseline analysis. Specifically,
under both options the state would need to construct one to two
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units and treat roughly the same number of residents. With this
option one of those units would be off-campus so the medically
infirm could be treated separately. As such, this does not reduce
the program’s projected cost by 2025. However, reducing the
population at Larned could help address issues with a limited local
labor market, which currently contributes to a high rate of
vacancies and excess overtime.
Based on current population and health status of some residents,
we made assumptions about the aging and frail population. As a
result, this option does not require more than one 36-bed nursing
facility. We did not estimate the nursing facility population beyond
2025. However, it is likely the number of residents transferred to a
secure nursing facility would grow significantly over time as the
population ages.
KDADS officials agreed that treating medically infirm
residents in a separate facility would benefit all residents. This
would allow medically infirm residents to receive care and
treatment in a more appropriate setting given their high medical
needs. In addition, this would allow treatment staff at Larned to
focus on providing treatment to residents most capable of
participating. This option would require a new secured nursing
facility be established in the state specifically for this population.
Additionally, the facility would need its own dedicated nursing and
program treatment staff. It is worth noting that several other states
also struggle with how best to treat medically infirm sexually
violent predators. However, at this point no other states we
reviewed have determined the best way to treat this population of
residents.
Option 3: Treating
Residents on the
“Parallel Track” in a
Separate Secured
Facility Would Reduce
the Resident
Population, But
Potentially Increase
Costs

As of December 2014, 38 residents with intellectual or
developmental disabilities were being served on the program’s
“parallel track.” The parallel track is intended to treat residents
with identified learning disabilities. This option would move
residents with intellectual or developmental disabilities from the
main population at Larned, and treat them in two separate secured
facilities. The cost estimate below includes the cost to build these
facilities as well as the cost for treatment staff.
Providing treatment in a separate facility would likely be more
beneficial for residents with intellectual or developmental
disabilities. Residents on the parallel track do not appear to
progress through treatment. As of December 2014, the 38 residents
on the parallel track had been in the program for an average of 10

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years. Although about half of these residents participate in
treatment, they are still on the early phases of the program.
We estimate this option would decrease the resident population
at Larned State Hospital by about 45 to 50 residents (13% to
16%) by 2025. We projected the impact that treating residents
with intellectual or developmental disabilities in a separate secure
facility could have on the future resident population. We compared
the results of this analysis to our baseline projection in Figure 2-5
below. As the figure shows, treating these residents in a separate
secure facility would reduce the resident population at Larned by
about 45 to 50 residents by 2025. In addition, reducing the
population at Larned could help address issues with a limited local
labor market, which has contributed to a high rate of vacancies and
excess overtime.
Figure 2-5
Option 3: Comparison of Projected Resident Populations
without Parallel Track Residents
Projected Resident Population (2016 - 2025)
400

Residents

360
320
280
240
200
2016

2017

2018

Baseline
Population Range

2019

2020 2021
Years

2022

Option 3
Population Midpoint

2023

2024

2025

Option 3
Population Range (a)

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of SPTP resident population.

We estimated on average, the separate facilities to house residents
with intellectual and developmental disabilities over the next 10
years would be about 40 to 60 residents. We did not estimate this
population beyond 2025. However, it is likely the number of
residents transferred to these facilities would grow over time
because the program population continues to grow over time.
We estimate this option would increase program costs by about
$6.5 to $8.0 million by 2025. Without any changes, we estimate
the program will cost a total of $26 to $34 million to operate in
2025 (in 2014 dollars). Treating residents with intellectual and
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developmental disabilities in a separate facility would increase
operating costs and require two to three new facilities. Taking all
of these factors into account, we estimate the total program costs
would be increased by $6.5 to $8.0 million in 2025, a 23% to 26%
increase.
KDADS and Larned officials generally agreed that residents
with intellectual or developmental disabilities would be better
treated in a separate secure facility. Officials with KDADS told
us residents on the program’s parallel track can be taken advantage
of by other residents. As such, treating them separately would
result in a safer, more constructive treatment environment.
Additionally, KDADS officials told us these residents would likely
benefit from treatment designed for individuals with intellectual or
developmental disabilities. It is worth noting that other states also
struggle with how best to treat sexually violent predators with
intellectual or developmental disabilities. However, at this point no
other states we reviewed appeared to have taken action on this
issue.

Option 4: Expanding
the Number of
Reintegration Slots
from 16 to 32 Would
Not Reduce the
Resident Population

Residents must transition from Larned State Hospital to one of
two reintegration facilities in order to complete the final two
phases of their treatment. The reintegration facilities are at
Osawatomie and Parsons State Hospitals and can accommodate
eight residents each. As of February 2015, both facilities were full.
As a result, no additional residents can advance to reintegration
housing until space becomes available. Doubling the number of
residents allowed at each house would give more residents a
chance to advance to the final phases of treatment necessary for
their release.
Because reintegration facilities house so few residents
compared to Larned it does not appear that expanding the
number of slots would significantly reduce the resident
population by 2025. We projected the impact that doubling the
number of reintegration beds could have on the future resident
population. We compared the results of this analysis to our
baseline projection in Figure 2-6 on the next page. As the figure
shows, doubling the number of reintegration beds does not
significantly reduce the resident population by 2025. However, it is
possible given enough time this option could allow more residents
to exit the program. Further, it is possible that in combination with
the option to limit time at the reintegration facilities, discussed
below on page 33, this option could potentially reduce the program
population over time.

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Figure 2-6
Option 4: Comparison of Projected Resident Populations
with 32 Reintegration Beds
Projected Resident Population (2016 - 2025)
400

Residents

360
320
280
240
200
2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

Year
Baseline
Population Range

Option 4
Population Midpoint

Option 4
Population Range (a)

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of SPTP resident population.

However, we estimate doubling the reintegration slots would
increase program costs by $5 million by 2025. Without any
changes, we estimate the program will cost a total of $26 to $34
million to operate in 2025 (in 2014 dollars). Expanding the number
of reintegration slots would not reduce the Larned population nor
would it reduce costs. This is primarily the result of additional
capital costs of roughly $3.5 million to construct or remodel two
new reintegration houses needed to double the number of
reintegration beds. Furthermore, annual operating costs would also
increase by an estimated $1.7 million by 2025 because of the
additional staff the reintegration facilities would need to hire to
treat twice the number of residents. Taking all of this into account,
we estimate the total program costs would be increased to $31 to
$39 million in 2025, a 15% to 20% increase.
Even though this option would increase costs, it may prove
beneficial because it could increase motivation and help avoid
a potential bottleneck. Because both reintegration facilities are
full, no additional residents can advance to the final phases of the
program until space becomes available. Residents are aware that it
could be several years before space at these facilities becomes
available. Program officials told us this knowledge demotivates
them from participating in the treatment necessary to progress to
these final phases. Doubling the beds at each facility creates more
opportunities for residents to progress through treatment. This
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could increase resident morale and participation in treatment, and
possibly reduce the future population of residents in treatment.
This option could require amending state law, but KDADS
officials said it was feasible. As of the time of this audit, statute
limited the number of sexually violent predators on transitional or
conditional release to no more than eight per Kansas County.
Officials with KDADS indicated this limit prevents them from
expanding the number of available beds. Senate Bill 149,
introduced during the 2015 Session, would double the number
from eight to 16 per county. Both KDADS and program officials
agreed that this would benefit residents, as more of them would be
allowed to progress through the program.

Option 5: Limiting the
Time a Resident Can
Occupy a Slot in a
Reintegration Facility
Would Not Significantly
Reduce the Resident
Population at Larned
State Hospital

The program had no limits on how long residents can remain
in the reintegration facilities, which potentially blocks others
who are ready to progress. The 16 beds at the two reintegration
facilities are full. No one has progressed on from reintegration in
the last year. This option would send residents back to Larned
State Hospital if officials agree the resident is not on track to
complete the program within four to six years.
Limiting the time at a reintegration facility would help ensure
slots are available for residents who are more likely to
transition into the community. Because both reintegration
facilities are currently full, no additional residents can advance to
the final phases. One resident has been there for about nine years
and one has been there for five years but still on phase six. Setting
a time limit would create openings in reintegration housing for
residents possibly more capable of progressing through the final
two program phases.
However, because only a few residents would be sent back to
Larned, it does not appear this option would reduce the
projected program resident population or costs. Although this
option potentially allows more residents to enter the reintegration
facilities, it does not appear to be enough to significantly reduce
the resident population. That is because the reintegration facilities
only have 16 residents and it is unlikely very many would need to
be sent back. Additionally, the program needs the same number of
additional housing units and staff in this option as it would in the
baseline. As such, operating and capital costs in 2025 are about the
same as the baseline cost in 2025.

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Agency official agreed that putting a time limit on a resident’s
time at a reintegration facility would benefit the residents.
Program staff and KDADS officials generally agreed with this
option. Specifically, the directors of the reintegration facilities
agreed it would be helpful to send residents that do not appear
ready to complete the reintegration phases back to Larned for
further development. In the meantime, this would open up a space
for any residents who are ready to progress to reintegration.
Further, this is a relatively easy change to make and could be more
effective if done in combination with the option to double the
number of reintegration beds previously discussed on page 31.
Option 6: Beginning
Sexual Predator
Treatment Before the
Offender is Released
From Prison Would
Not Significantly
Impact Resident
Population and Could
Increase Costs

Currently, no treatment for sexually violent predators is
offered while in prison, so offenders cannot start treatment
until they are committed after their release. The Department of
Corrections offers sex offender treatment to inmates in prison.
However, no sexually violent predator treatment is offered. Unlike
sexually violent predators, sex offenders do not necessarily have a
mental abnormality making it likely they will reoffend. As such,
their treatment is very different from sexually violent predator
treatment. This option would allow inmates to participate in sexual
predator treatment in prison. Offenders could then apply credit
earned for completing sexually violent predator treatment in prison
towards their treatment if committed to the state’s Sexual Predator
Treatment Program.
Offenders who began treatment while serving their prison
sentence could shorten their civil commitment time. Under this
option, offenders would begin sexual predator treatment while in
prison. If committed to the Sexual Predator Treatment Program,
credit earned for treatment completed in prison would transfer to
Larned with the offender. For example, if the offender completed
phase one of treatment while in prison, they would begin on phase
two once they were committed to the program.
In 2014, New York established a program to provide sexual
predator treatment to offenders in prison. Officials with New York
told us they are generally pleased with the level of participation in
this program. However, because it is relatively new it is too early
to determine the effect it could have on New York’s sexually
violent predator treatment program resident population.
However, this option does not significantly reduce resident
population because the time savings are small compared to the
time still needed to complete the program. We projected the
impact that providing sexual predator treatment to prisoners could

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have on the future resident population. We compared the results of
this analysis to our baseline projection in Figure 2-7 below. As the
figure shows the resident population slightly increases.
Figure 2-7
Option 6: Comparison of Projected Resident Populations
with Prison Based Sexual Predator Treatment
Projected Resident Population (2016 - 2025)
400

Residents

360
320
280
240
200
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
Year
Baseline
Population Range

Option 6
Population Midpoint

Option 6
Population Range (a)

(a) The population range represents a 95% confidence interval from the midpoint.
Source: LPA generated model of SPTP resident population.

However, given the substantial overlap between the two scenarios,
we do not believe this option would result in any significant
change to the resident population. Receiving treatment while in
prison would in theory reduce the time it takes a resident to
complete the program at Larned by a year or two. However, the
credit received for treatment in prison is only a small portion of the
time needed to complete the program. Additionally, residents also
still need to wait for space to become available at the reintegration
facilities.
In addition, we estimate this option would increase projected
program costs by about $600,000 and $2 million by 2025.
Without any changes, we estimate the program will cost a total of
$26 to $34 million to operate by 2025 (in 2014 dollars). Offering
sexual predator treatment does not significantly reduce the Larned
population overt time, operational costs would be similar to the
baseline. Further, there would be additional costs of $600,000 to
$2 million start treatment programs in the prisons. Taking all of
this into account, we estimate the program costs would be
increased to $26 to $36 million in 2025, a 2% to 5% increase.

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Providing sexually violent predator treatment in the prisons
would require coordination between KDADS and the
Department of Corrections to ensure prison-based treatment is
effectively managed. Additionally, the Superintendent of Larned
State Hospital had concerns regarding the consistency of treatment
residents would receive in prison compared to the treatment
residents receive at Larned. Although a challenge, this option does
appear feasible given New York currently operates a prison based
treatment program for sexually violent predators. However,
KDADS officials should consider the limited benefits, additional
costs, and challenges this option poses before pursuing it.
OTHER FINDINGS
Statutory Housing
Restrictions Make it
Difficult for Residents
to Leave the Program.

Kansas statutes currently prohibit sexually violent predators on
transitional or conditional release from living within 2,000 feet of
specific locations such as a licensed child care facility, a place of
worship, or a residence where a minor resides. Program officials
told us this limitation makes it very difficult for residents to find
housing in the community, which is a requirement for exiting the
program. No such uniform restriction exists for paroled sex
offenders. Rather, any housing restrictions for sex offenders are
made on a case-by-case basis by parole officers. Although we did
not model the impact of a change to this prohibition, applying a
case-by-case approach to sexually violent predators would likely
allow a few more residents to exit the program.

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Conclusion and Recommendations
Conclusion

The Sexual Predator Treatment Program was established more than
20 years ago to protect the public from violent sex offenders with a
high risk of reoffending. The program is meant to provide longterm control, care, and treatment for these offenders. Over time,
the program population has steadily grown as offenders are
consistently committed into the program but few are ever released.
The findings of this audit have identified two important concerns
with the Sexual Predator Treatment Program that need to be
addressed. First, the program’s treatment model has not kept up
with the research-based, recommended practices we saw in other
states. These recommended practices emphasize individualized
treatment plans that address the specific needs of the individual
residents. The treatment plans should be based on robust
assessment tools that identify the risk of reoffending as well as
other factors such as learning styles, intellectual abilities and other
mental health issues. The Kansas program lacks the same level of
individualization.
The second concern is with the continuing growth of the program
population. Given the state’s current statutes and policies on
committing and releasing residents, the population will continue to
grow over time. Without any statutory and policy changes, the
resident population will likely exceed the physical capacity of the
Larned facility in the next couple of years. Given the difficulties
the program has had in keeping adequate staffing levels, it would
appear the program has already grown beyond what the labor
market in and around Larned can support. Whether it is tightening
the statutory commitment criteria, improving the treatment model,
accepting more risk, or relocating the program, something is going
to have to change, because the current model cannot be sustained.

Recommendations for
Executive Action

1. To address better align the program with current researchbased recommended practices, KDADS and program officials
should:
a. Implement appropriate assessment tools that identify
the residents’ risk of reoffending, as well as the
presence of other factors that could affect treatment
such as intellectual and development disabilities,
addiction, trauma, and mental health issues (page 11).

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b. Develop individualized treatment plans based on the
results of the various assessment tools (pages 11 to 12).
c. Conduct periodic reviews to assess the residents’
progress, reassess specific risk factors, and modify the
treatment appropriately (page 11).
d. Modify the annual mental exams to assess whether
resident’s mental condition continues to meet
commitment criteria, and have the exam conducted by
impartial staff (page 12).
e. Establish treatment criteria that is tailored for residents
with intellectual or developmental disabilities (page
12).
f. Reevaluate the need for, and extent of, non-clinical
criteria for residents to advance to the next phase of
treatment (page 15).
g. Develop a plan for implementing these and other
changes deemed appropriate. Identify the need for any
additional resources and develop a strategy for
obtaining those resources.
2. To address issues related to management of the program,
KDADS and program officials should:
a. Implement a process to review the program’s services
to ensure residents have the necessary skills to progress
successfully to reintegration facilities and eventually
transition back into the community (page 18).
b. Develop and implement a process to ensure appropriate
program data are maintained to track treatment services,
cancellation of services, phase progression and
participation data (pages 18 to 19).
c. Utilize this program data to continually evaluate
staffing and program services (pages 18 to 19).
d. Establish and implement a process to periodically
review policies and procedures as well as resident
documents to ensure accuracy and proper
implementation (page 20).

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3. To address the population growth KDADS and program
officials should
a. Develop a strategic plan for addressing the program’s
population growth. As part of that plan, consider the
options presented as part of this audit (page 24).
b. Examine the feasibility of relocating some or all of the
Sexual Predator Treatment Program to an area of the
state with a larger labor market that will increase the
number of potential job applicants (pages 23 to 24).

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APPENDIX A
Scope Statement
This appendix contains the scope statement approved by the Legislative Post Audit Committee
for this audit on March 22, 2013. The audit was requested by the House Appropriations
committee and Senate Ways and Means committee.
Larned State Hospital: Reviewing the
Operations of the Sexual Predator Treatment Program
Kansas’ Sexual Predator Treatment Program was established in 1994, and has been provided
primarily through the Larned State Hospital. The program provides treatment for convicted sex
offenders who have completed their prison sentences but have been determined by the courts to
be violent sexual offenders in need of involuntary inpatient treatment.
In 2005, Legislative Post Audit issued a report on the Sexual Predator Treatment Program. In
that report, we estimated that the size of the offender population could increase to about 235
offenders or more by 2015. The reasons for this included the continuing commitment of new
offenders to the program and Kansas’ stringent requirement that the risk of a re-offense be
reduced to “practically nil.”
As of January 2011, the Sexual Predator Treatment Program at Larned State Hospital had almost
reached full capacity with 200 of 214 available beds filled. SRS officials estimate that, in the
coming years, the program will grow by about 18 offenders per year.
Legislators have expressed concern about the growing size of the offender population, employee
workload, and working conditions at the Larned facility. They would like to know how Kansas’
program compares to other state programs in terms of cost and treatment, what actions could be
taken to limit program growth, and whether the Larned facility is being adequately managed.
A performance audit in this area would address the following questions:
1.

2.

How does Kansas’ Sexual Predator Treatment Program compare to similar
programs in other states and best practice? To answer this question, we would work
with Larned State Hospital Officials to determine the program’s statutory requirements,
its cost, admission and exit criteria, treatments provided, and the effectiveness of those
treatments. As part of that work, we would determine whether the program provides
services to offenders that are not required by the Kansas Constitution. Further, we would
review program data to determine how many offenders have been committed, released,
returned, or are still in the program since it began. We would work with officials in a
sample of other states to collect similar information. We would also review academic
literature and contact officials from relevant organizations such as the Center for Sex
Offender Management to identify best practices or benchmarks related to sex offender
programs. Based on that cumulative information, we would assess how Kansas’ program
compares to other states and best practices in terms of its structure, cost, treatment, and
results. We would perform additional work in this area as needed.
What actions could be taken to reduce the number of offenders committed to

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Kansas’ Sexual Predator Treatment Program? To answer this question, we would
assess possible long- and short-term options for reducing offenders committed to the
program. One long-term option we would assess is amending Kansas Sentencing
Guidelines to lengthen the time that a convicted offender stays in prison. We would work
with officials from the Department of Corrections, the Kansas Sentencing Commission,
and any other relevant agencies to determine how changing sentencing guidelines for sexrelated crime might affect the program’s offender population over time. A short-term
alternative we would assess is making changes to the process for committing a sex
offender to the Sexual Predator Treatment Program. We would work with officials from
the Attorney General’s office and any other relevant agencies to determine the
consequences of adopting stricter screening criteria and other similar program changes.
To the extent possible, we would develop cost estimates for any long- or short-term
options we identify. We would perform additional work in this area as needed.
3.

Is the Sexual Predator Treatment Program appropriately managed to ensure the
safety and well being of program staff and offenders? To answer this question, we
would look for or would work with other states to develop acceptable workload standards
and staffing ratios. We would compare the program’s current staffing level to those
standards and identify any potential problem areas. We would also survey program staff
and review offender complaints to identify issues concerning employee and offender
safety, as well as employee working conditions. To the extent possible, we collect
program information relevant to any potential issues we identify such as security or
safety incidents, regulatory citations, offender complaints, and program accreditation
results. For concerns raised by staff or offenders that have merit based on information we
are able to collect, we would follow-up with program managers to determine what actions
they have taken or plan to take to address these issues. We would perform additional
work in this area as necessary.

Estimated Resources:
Estimated Time:

3 LPA staff
6 months (a)

(a) From the audit start date to our best estimate of when it would be ready for the
committee. This time estimate includes a two-week agency review period.

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APPENDIX B
Population Model Methodology
This appendix contains a detailed description of the methodology used and assumptions made in
our work to project the future resident population of the Sexual Predator Treatment Program
(program).
Methodology and Assumptions for the Population Model
Number of Residents Entering the Program:
We used historical resident data to estimate how many residents would enter the program in each
of the years we modeled. Specifically, we determined the total number of residents committed to
the program per year from 2007 – 2014. This time frame assures that we capture the early effects
of Jessica’s Law, which lengthens the prison sentence. This would potentially reduce the future
number of offenders entering the program annually. As a result, our model assumed that between
11 and 18 new residents would enter the program each year. Every number in this range had an
equal chance of being selected.
Resident Age:
We used historical resident data to determine the average age of residents when they entered the
program. We determined that the average age at entry is 44 years old. The minimum age at entry
is 18. Once in the model, each resident ages one year for every year modeled.
Resident Age at Death:
We used historical resident data to determine the age at death for the 28 residents that have died
in the program since it opened in 1994. We calculated the cumulative probability of dying at
each age and plotted a line through these probabilities. The equation of this line is the basis for
how lifespans are generated in the simulation. This method may understate residents’ true
lifespans because in the years the program has been operational only 28 people have died.
Therefore, the living residents may yet have long lifespans. Without any empirical measure to
suggest how long their lifespan may be, we added 10% to the randomly generated age to account
for this uncertainty. (Example: if a resident was projected to die at age 60, we adjusted that to
66.)
Resident Progression Through Treatment:
We assumed that not all residents would progress through treatment once in the model.
Specifically, non-participating, medically infirm, and parallel track residents do not progress
through treatment in the model. These residents are randomly selected based on probabilities
derived from historic resident data. Any resident able to progress has a randomly determined
number of years needed to complete their treatment at Larned State Hospital and in reintegration
facilities. The number of years to complete the program was also derived from historic resident
data. Each year a resident may make one year’s worth of progress through treatment. Finally, in
our model a resident that completed treatment at Larned State Hospital is not allowed to progress
to reintegration facilities until space becomes available.

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Recidivism:
There is a chance that residents who complete the program could reoffend in the community, go
back to prison, and ultimately end up back at the Sexual Predator Treatment Program. To
account for this we analyzed a meta-analysis examining 85 other offender recidivism studies.
This analysis concluded that 36% of sex offenders would commit another offense. As such, we
assumed any resident that completes the program would have a 36% chance of reentering the
program at a later time. If a modeled resident was selected as a recidivist, they would be entered
back into the program the same year that they completed the program. This is because our model
could not assess the time it would take for the resident to complete the criminal justice process
and come back at a later date after serving a prison sentence.
Back to Corrections:
Residents of the program sometimes commit a criminal offense while committed at Larned State
Hospital. It is likely that residents are sent to the Department of Corrections to serve a new
prison sentence. We used historical resident data to determine that 5% of residents reoffended
while in the Sexual Predator Treatment Program and were sent back to the Department of
Corrections. We applied this percentage to the modeled resident population.
Methodology and Assumptions Specific to our Six Options
Treating Low Risk Offenders in the Community:
This option would allow low-risk sexually violent offenders to be treated in a community model
rather than at Larned State Hospital. We assumed that roughly 30% of incoming residents would
be considered low-risk. We built this assumption into the model. During modeling, any new
resident assigned as low-risk was diverted from the main resident population. Our 30%
assumption was based on the proportion of offenders that entered New York’s community
treatment program for sexually violent predators in the program’s first year (2007 – 08).
Treating Medically Infirm Residents in a Secured Nursing Facility:
As mentioned previously, residents age one year for every year modeled. We assumed that when
a resident reaches 65 years old they would have a two-thirds chance of becoming medically
infirm. This assumption is based on an AARP data report. In this option, the model removes any
residents that become medically infirm from the population.
Expanding Reintegration Housing Slots from 16 to 32:
This option required us to manually increase the available number of slots in reintegration
housing from 16 to 32. Under this model, residents cannot progress to reintegration housing until
space becomes available.
Treating Residents on the Program’s Parallel Track in Separate Secured Facility:
This option would remove the residents with intellectual or developmental disabilities assigned
to the program’s parallel track. We assumed that every incoming resident had a 16% chance of
being assigned to the program’s parallel track. We built this assumption into the model. During
modeling, any resident assigned to the parallel track was removed from the model. Our

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assumption of 16% was based on actual resident data regarding the number of residents currently
on the parallel track.
Limiting Time in Reintegration Housing:
For this option we limited the time residents could stay in reintegration housing to six years. This
limit was based on estimates provided from the directors of the reintegration houses regarding
the absolute maximum amount of time it should take a resident to complete the reintegration
phases. Residents in reintegration housing were returned to the Larned State Hospital if they did
not reach their completion date within six years.
Receiving Sexual Predator Treatment in Prison:
Running this option assumes that 70% of incoming residents for each year modeled received
credit for Phases I and II of sexual predator treatment while in prison. To account for this we
reduced the time it would take for these residents to complete the treatment at Larned State
Hospital by between 9 months and 3.5 years with an average credit of 1.75 years. This range and
its distribution are based on historical treatment progression at Larned State Hospital.

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Appendix C
Long-term Projection Comparison Between the Baseline Population and the Population for
Each of the Six Options (2016 - 2090)
Baseline Projected Program Population
(2016 - 2090)
600

Residents

500
400
300
Resident Population
(Baseline)

200
100
0
2016

2026

2036

2046

2056
Years

2066

600

600

500

500

400

400

300
Resident Population
(Baseline)

200

Resident Population
(w/o low-risk of f enders)

100

0
2016

2026

2036

2046 2056
Years

2066

2076

300

0
2016

600

500

500

400

400

Residents

Residents

600

300

100

Resident Population
(w/o parallel)

0
2016

2026

2036

2046 2056
Years

2066

2076

400

Residents

Residents

500

Resident Population
(Baseline)
Resident Population
(with 6 y ear limit)

2046

2056
Years

2066

2076

2086

Resident Population
(with 32 beds)

400

2036

2076

100

500

2026

2056 2066
Years

Resident Population
(Baseline)

600

0
2016

2046

200

600

100

2036

2026

2036

2046 2056
Years

2066

2076

2086

Projected Program Population
With Prison Based Sex Predator Treatment (2016 - 2090)

Projected Program Population
With Six Year Reintegration Limit (2016 - 2090)

200

2026

300

0
2016

2086

300

Resident Population
(w/o med. inf irm)

Projected Program Population
With 32 Reintegration Slots (2016 - 2090)

Projected Program Population
Without Parallel Track Residents (2016 - 2090)

Resident Population
(Baseline)

Resident Population
(Baseline)

200
100

2086

200

2086

Projected Program Population
Without Medically Infirm Residents (2016 - 2090)

Residents

Residents

Projected Program Population
Without Low-Risk Residents (2016 - 2090)

2076

300

Resident Population
(Baseline)

200
Resident Population
(with prison treatment)

100
0
2016

2086

2026

2036

2046 2056
Years

2066

2076

2086

Source: LPA generated model of SPTP resident population.

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APPENDIX D
Research-Based Guidelines
This appendix contains citations to the guidelines, studies and reports the Association for the
Treatment of Sexual Abusers (ATSA) and others have put out regarding the treatment of
sexually violent predators. We relied on this research-based guidance in our efforts to answer
question one presented in this audit.
1. ATSA Practice Guidelines for the Assessment, Treatment and Management of Male
Adult Sexual Abusers 2014 (Association for the Treatment of Sexual Abusers)
2. A Model of Static and Dynamic Sex Offender Risk Assessment; Robert J. McGrath et al.,
(Published by the U.S. Department of Justice)
3. ATSA: Assessment, Treatment, and Supervision of Individuals with Intellectual,
Disabilities and Problematic Sexual Behaviors 2014
4. Rule 706 Expert Report and Recommendations, November 2014, United States District
Court, District of Minnesota, Civil No. 11-3659:
a. Andrews and Bonta 2010. The psychology of criminal conduct 5th edition;
b. Marlatt & Gordon 1985. Relapse Prevention: Maintenance strategies in the
treatment of addictive behaviors;
c. Marques, Wideeranders, Day, Nelson & Van Ommeren 2005. Effects of relapse
prevention program on sexual recidivism: Final results from California’s sex
offender treatment and evaluation project (SOTEP);
d. Marshall, Marshall, Serran & O’Brian 2011. Rehabilitating sexual offenders: A
strength-based approach;
e. GLM – Yates, Prescott & Ward 2010. Applying the Good Lives and Self
Regulation Models to sex offender treatment: a practical guide for clinicians;
f. Grove, Zald, Lebow, Snitz & Nelson, 2000. Clinical versus mechanical
predication: A meta-analysis.
g. Doren, D.M., 2005. What weight should courts give treaters’ testimony
concerning recidivism risk?
h. Greensberg & Shuman, 2007. When worlds collide: Therapeutic and forensic
roles.
i. Mann, Hanson & Thornton, 2010. Assessing risk for sexual recidivism.

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APPENDIX E
Agency Response
We provided copies of the draft audit report to the Kansas Department of Aging and Disability
Services (KDADS) on April 1, 2015 and to the Kansas Attorney General’s Office on April 8,
2015. Both agencies’ responses are included as this Appendix. In addition, we have included a
table listing the KDADS’ specific implementation plan for each recommendation immediately
after its written response.
KDADS stated they disagreed with a number of the report’s findings. These findings were based
on audit work generally covering program data from 2013, 2014, and early 2015. The agency
appears to have made a number of recent changes to the program, many of which were
implemented after the time period covered by our audit. Although we commend the agency for
making these changes, we do not believe they affect the report’s findings, conclusions or
recommendations. As required by our audit standards, we are providing the following
explanations for the six findings for which the department raised substantive disagreements:


KDADS disputes the finding that residents are not given assessments. KDADS states that
residents are assessed immediately before and upon entry to the program and are periodically
reassessed thereafter. We reviewed program requirements, interviewed staff and reviewed resident
assessment forms. We acknowledge that the program does some assessment on residents.
However, on page 12 we detail the assessments in place at the time of our audit, and how those
assessments fell short of research-based guidance in several areas. Specifically we found that
Kansas did not use an assessment tool that explicitly assesses treatment needs or the risk of
reoffending.



KDADS disputes the finding that the program lacks individualized treatment. KDADS states
each resident is provided individual treatment for their specific mental abnormality or disorder through
individualized treatment plans and therapeutic assignments. As noted in the report on page 13,
Kansas program focused solely on treating sexual disorders with all residents completing the same
curriculum. Unlike the other states we reviewed, Kansas’ program did not provide treatment for
individual issues such as schizophrenia, alcoholism or borderline personality disorder.
Recommended practices emphasize addressing specific issues in additional to sexual predator
treatment.



KDADS disputes the finding that the annual review fails to meet statutory criteria. KDADS
states an annual examination is performed by clinical staff on each resident to determine whether the
resident continues to meet the criteria for commitment in accordance with statutory requirements.
LPA based this finding on interviews with program staff and detailed reviews of resident annual
reviews conducted in 2013 and 2014. That work showed the agency was not assessing mental
condition. The agency response details some changes the program has made in this area as of
March 2015.



KDADS disputes the finding that the program is not abiding by recommended practices for
those with intellectual or developmental disabilities. KDADS states the treatment is comparable
to many other states’ programs, which also modify the pace of treatment. LPA based this finding on
review of research-based guidance and detailed discussions with other state officials. The report
notes several important areas where Kansas’ program did not adhere to guidance or compare with
these others states. These included Kansas housing residents with the general population, and not
providing more specialized treatment (essentially the same treatment at a slower pace). During our
work, KDADS officials acknowledged a one-size-fits-all approach is no longer appropriate for these
residents.

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

KDADS disputes the finding that Kansas places greater emphasis on non-clinical
requirements. KDADS states that while the program utilizes psycho-educational courses along with
activity therapy, these are components of the overall comprehensive treatment process. LPA based
this finding on review of program guidelines and detailed review of resident treatment plans and
progress notes. Those reviews showed many more hours were required for non-clinical activities than
therapy. For example, Kansas required at least eight hours a week of walking or swimming, yet only
0-3 hours a week of individual or group therapy. We also talked with program staff and officials from
other states regarding non-clinical services. Those states recommended these activities, but did not
require them for all residents.



KDADS disputes the finding that education offered by the program may not be statutorily
adequate. LPA agrees with KDADS that the statutes do not define education. However, other states
have similar statutes and we talked with officials from other states about the interpretation of
“education.” LPA based the finding on how other states interpret “education” for their programs.
Officials from those programs in other states told us educational services typically include high school
diploma equivalents, GEDs, and adult basic education.

Because the agency has made several program and process changes since our audit work was
conducted, we altered the wording of our findings somewhat. Essentially, we changed the
presentation of our findings from present tense to past tense. For example, we changed
report language from “Kansas does not use an assessment tool that explicitly evaluates the
risk of reoffending” to “Kansas did not use an assessment tool that explicitly evaluates the
risk of reoffending.” Because of these slight changes, the agency response language will not
match the report finding language exactly.

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Itemized Response to LPA Recommendations
Audit Title: Larned State Hospital: Review of the Sexual Predator Treatment Program, Part 2

LPA Recommendation

Agency Action Plan

1. To better align the program with research-based
recommendations practices, KDADS and program
officials should:
a. Implement appropriate assessment tools that
identify the residents’ risk of reoffending, as well as
the presence of other factors that could affect
treatment such as intellectual and development
disabilities, addiction, trauma, and mental health
issues.

Each resident is assessed immediately before and upon entry to the
program and is periodically reassessed thereafter. The assessment
takes into account the presence of factors that could affect the
treatment of each resident, including but not limited to, factors that
aid in determining whether a resident has an intellectual or
developmental disability. As indicated above, SPTP has begun
incorporating SOTIPS, an additional measure to identify the level of
risk each resident displays as he moves through the therapeutic
program, along with the Static-99, and other relevant psychological
measures such as the following: the Minnesota Multiphasic
Personality Inventory, Second Edition (MMPI-2), WAIS (Wescheler
Adult Intelligence Scale), Substance Abuse Subtle Screening
Inventory (SASSI), Trauma Symptom Inventory, Second Edition
(TSI-2), Wide Range Achievement Test (WRAT), and other relevant
measures.

b. Develop individualized treatment plans based on
the results of the various assessment tools.

The SPTP currently provides individualized treatment plans for all
residents. SPTP has been incorporating SOTIPS into each
individual treatment plan to assist staff in identifying specific,
objective, measurable goals for each resident. In addition, we will
continue researching and reviewing additional programming
concepts that will be built into our program.

c. Conduct periodic reviews to assess the residents’ SPTP staff have and will continue to review and revise treatment
progress, reassess specific risk factors, and modify plans every 90 days and will continue to update the plans as
the treatment appropriately.
needed to ensure individualized treatment is being provided. The
SOTIPS risk assessment tool, along with the other mental status
and risk assessment tests previously identified, will assist staff in
periodic reviews of resident progress. These tools provide objective
measures to reassess specific risk factors and will assist staff in
modifying individual treatment when appropriate.

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d. Modify the annual mental exams to assess
whether resident’s mental condition continues to
meet commitment criteria, and have the exam
conducted by impartial staff.

The annual examination has always been and continues to be
administered in accordance with K.S.A. 59-29a08. In recent months,
as a result of recommendations from the Post-Task Force Internal
Committee, KDADS has developed an independent Chief Forensic
Psychologist position to work with clinical examiners to ensure a
thorough clinical interview is performed on each resident, each
resident’s treatment records are reviewed, and that treatment staff
who work closely with the resident are interviewed regarding the
resident’s treatment progression. The examiners are currently
performing additional risk assessments and mental status exams,
including such tests as the Static 99, Sex Offender Treatment
Intervention and Progress Scale (SOTIPS), and Millon Clinical
Multiaxial Inventory (MCMI), as needed. The examiners are
assessing the continued presence of psychiatric conditions and or
mental abnormalities that increase the risk of reoffending. The Chief
Forensic Psychologist does not provide treatment to the residents
and is not officed at Larned State Hospital, which adds a level of
independence to the annual review process.

e. Establish treatment criteria that is tailored for
residents with intellectual or developmental
disabilities.

Kansas’ program provides curriculum that is tailored to meet the
needs of residents who may require additional accommodations for
their treatment plan based on an intellectual or developmental
disability. Residents are assessed before being placed in the
parallel program. SPTP will continue to consult with other Sexual
Predator Treatment Programs, including those specifically
mentioned in the report to explore treatment options, processes,
and procedures to enhance the parallel treatment program.

f. Reevaluate the need for, and the extent of, nonclinical criteria for residents to advance to the next
phase of treatment.

During the March retreat, the SPTP Post-Task Force Internal
Committee began reviewing and reassessing the clinical phases
and criteria required in each. While the provision of
psychoeducational courses and activity therapy are valuable
components to the overall treatment process, the extent to which
these courses and sessions are utilized is currently being reviewed.

g. Develop a plan for implementing these and other
changes deemed appropriate. Identify the need for
any additional resources and develop a strategy for
obtaining those resources.

Based on findings from the SPTP Task Force, the Post-Task Force
Committee has already reached out to several states regarding
programming. LSH will continue to consult with these states, as well
as reach out to the specific states mentioned in the report to gather
information on the programming and recommended practices their
programs are utilizing. The Post-Task Force Internal Committee will
continue to meet monthly to review all data collected and continue
to work on meeting our goals and objectives stemming from both
the Task Force Report and the LPA audit. Therefore, we will
continue to develop a plan for implementing Recommendation 1
and other changes deemed appropriate by the Post-Task Force
Internal Committee.

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2. To address issues related to management of the
program, KDADS and program officials should:
a. Implement a process to review the program’s
services to ensure residents have the necessary
skills to progress successfully to reintegration
facilities and eventually transition back into the
community.

The current SPTP curriculum is designed to provide residents with
the necessary skills and resources to successfully progress to the
reintegration facility. On March 25-27, 2015, the Post-Task Force
Internal Committee held a retreat and identified additional
curriculum enhancements. Additional courses will be offered to
increase the residents’ readiness for reintegration. By June 30,
2015, we will reassess and make modifications to programming as
needed regarding work and life related skills.

b. Develop and implement a process to ensure
appropriate program data are maintained to track
treatment services, cancellation of services, phase
progression and participation data

The SPTP program currently tracks program data. By August 1,
2015, SPTP will have a system to improve tracking of treatment
service hours, cancellation of services, phase progression, and
participation data. This process will be based on computerized
tracking using the Plexus system at LSH (internally developed
computer program).

c. Utilize this program data to continually evaluate
staffing and program services.

By August 1, 2015, SPTP will have in place a system to track
treatment service hours, cancellation of services, phase
progression, and participation data. This data will be reviewed on a
quarterly basis to evaluate staffing and program services.

d. Establish and implement a process to periodically
review policies and procedures as well as resident
documents to ensure accuracy and proper
implementation.

The program has a policy review process in place in which a weekly
meeting is held with the Program Director to review policies,
however, additional meetings are held when necessary. Every two
years, the collective policies for SPTP will be reviewed. Staff will
receive training on new SPTP policies as they are implemented
(e.g. computer based training, hands on training, or classroom
instruction depending on the policy/staff needs). During the periodic
reviews, if there are issues concerning the application of the
policies, the issues will be resolved and staff will be retrained.

3. To address the population growth KDADS and
program officials should:
a. Develop a strategic plan for addressing the
program's population growth. As part of that plan,
consider the options presented as part of this audit.

KDADS is currently tracking program growth for SPTP. KDADS will
work with key stakeholders in developing a strategic plan to address
population growth. Moving forward with any of the options listed on
pages D-23-24, would require collaboration with the Governor, the
Attorney General, the Legislature, and the community.

b. Examine the feasibility of relocating some or all of
the Sexual Predator Treatment Program to an area
of the state with a larger labor market that will
increase the number of potential job applicants.

KDADS will examine the feasibility of relocating the SPTP program.
However, relocating some or all of the program would be costly and
would require collaboration with the Governor, the Attorney General,
the Legislature, and the community. In addition, there are zoning
statutes that may affect this process.

PERFORMANCE AUDIT REPORT
Larned State Hospital: Review of the
Sexual Predator Treatment Program (R-15-006), Part 2

63

Legislative Division of Post Audit
April 2015

PERFORMANCE AUDIT REPORT
Larned State Hospital: Review of the
Sexual Predator Treatment Program (R-15-006), Part 2

64

Legislative Division of Post Audit
April 2015