Despite three warnings and a multimillion-dollar fine a few years ago, Kaiser Permanente still fails to provide members with appropriate access to mental health care, according to a recent survey of the HMO by the state of California.

The routine survey, released by the state Department of Managed Health Care, found that Kaiser Foundation Health Plan did not provide enrollees with “timely access” to behavioral health treatment, in violation of state law. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

The matter has now been referred back to the state Office of Enforcement for further action, which could include an additional fine.

California’s timely access laws require insurers to provide patients access to a medical appointment within 48 hours for an urgent problem, or within 10 business days for a non-urgent issue. Kaiser patients, however, often have to wait longer, according to the department.

The survey looked at Kaiser’s behavioral health files through Jan. 1, 2015. The department found that while the HMO had “undertaken extensive and meaningful efforts” to improve access to mental health care, the problems remain.

Headquartered in Oakland, Kaiser Permanente is one of the largest not-for-profit managed health care plans in the country, with an annual operating revenue of $64.6 billion and 8.5 million members in California.

In a formal response to the watchdog agency, Kaiser listed more than 10 changes it has made to improve members’ access to mental health care, including contracting with providers outside of the organization and aggressively recruiting and hiring clinicians. The plan cited internal audits finding that they complied with timely access laws more than 90 percent of the time and stated “a corrective action plan is not warranted.”

“We have made great progress over the nearly two years since this survey was begun to improve access by hiring over 1,030 new psychiatrists and therapists, expanding our network of community practitioners, and introducing more convenient ways to access treatment,” John Nelson, vice president of government relations for Kaiser, wrote in an email to Kaiser Health News.

The department, however, responded in its report that while Kaiser Permanente has been working with Office of Enforcement to correct the problems, “the access issues remain unresolved.”

In 2013, Kaiser agreed to pay a $4 million fine for several deficiencies in the plan’s delivery of mental health services — one of the largest ever paid by an insurer in the state. In 2015, the department found that some Kaiser patients still had to wait weeks or even months to see a psychiatrist or a therapist.

In one case cited by the department in a 2015 survey, a child was brought in by her father because of “aggressive behaviors, sexualized behaviors and significant behavioral problems in both the home and school environment.” The family told providers that they were “in crisis” and “pleaded for treatment.” The child, however, was not seen for therapy until seven weeks later.