J.H., ET AL.
PRINCE GEORGE'S HOSPITAL CENTER
Court for Prince George's County Case Nos. CAL15-25618,
CAL15-25619, CAL15-25620, CAL16-00341
Reed, Rodowsky, Lawrence F., (Senior Judge, Specially
from the harmful effects of mental illness, J.H., C.B., M.G.,
and B.N. (collectively "Appellants"), were brought
to Prince George's Hospital Center ("Appellee" or the
"Hospital") on separate occasions for emergency
mental health evaluations to determine whether each should be
admitted for involuntary psychiatric treatment. Each
Appellant was afforded a hearing before an administrative law
judge ("ALJ"), during which their counsel argued
for their release on the ground that the Hospital failed to
comply in various respects with the preadmission procedures
set out in Maryland Code (1982, 2015 Repl. Vol.),
Health-General Article ("Health-Gen."), §
10-601 et seq. Each ALJ concluded the evidence
established that Appellants qualified for involuntary
admission to the Hospital's inpatient psychiatric unit in
accordance with Health-Gen. § 10-632(e), and that none
of the alleged preadmission procedure violations warranted
filed a petition for judicial review for each Appellant and a
motion to consolidate their cases in the Circuit Court for
Prince George's County. The circuit court granted the
motions to consolidate and, after argument, affirmed the
ALJs' decisions with respect to each Appellant.
this Court, Appellants challenge the ALJs' decisions and
present issuesderivative of one
overarching question: During involuntary admission hearings
are hospitals required to affirmatively prove compliance with
preadmission procedures beyond the statutorily prescribed
involuntary admission elements contained in Health-Gen.
reasons that follow, we affirm the decisions ordering the
involuntary admission of each Appellant. We hold that at an
involuntary admission hearing, the Hospital has the burden to
prove the involuntary admission elements enumerated in
Health-Gen. § 10-632(e) by clear and convincing
evidence, and that the patient has the burden, pursuant to
Code of Maryland Regulations ("COMAR")
10.21.01.09G(2), to raise with particularity any alleged
violations of preadmission procedures. Once raised, the
burden shifts to the Hospital to demonstrate, by a
preponderance of the evidence, its compliance with the
particular procedural violations raised.
Involuntary Admission Hearings
following is a summary of the testimony presented at each
hearing and the ALJ's findings as to each Appellant.
J.H.'s Involuntary Admission Hearing
J.H. was involuntarily admitted into the psychiatric unit at
the Hospital, she lived with her daughter, K.H., and her
two-year-old granddaughter. K.H testified that she witnessed
her mother's ability to care for herself decline over the
last several years. J.H. was not taking her medications for
her psychiatric and other medical conditions, and refused to
attend scheduled doctors' appointments. After her mother
became "very aggressive and verbally abusive, "
K.H. filed a petition for the emergency evaluation of J.H. on
September 2, 2015. That same day, the police brought J.H. to
the Hospital's emergency room for evaluation.
September 16, 2015, an ALJ held an involuntary admission
hearing for J.H. At the outset of the hearing, J.H.'s
counsel stated that he "[would] be bringing up that the
notice of admission status and the detention in the emergency
room both exceeded the time limits[.]"
Prasad, J.H.'s treating physician, testified for the
Hospital. In regard to J.H.'s eligibility for admission
under Health-Gen. § 10-632(e)(2)(i)-(v)-the controlling
statute in this case-Dr. Prasad testified that J.H. has been
diagnosed with chronic schizophrenia, diabetes, and
hypertension. She had been admitted to the Hospital several
times during the year-and-a-half prior to the hearing. He
explained that upon discharge, J.H. would refuse to comply
with her treatment regimen of psychiatric medication and
outpatient care, resulting in her readmission. J.H. failed to
maintain her personal hygiene, often stayed in bed, and only
occasionally ate meals. Dr. Prasad presented J.H. with the
option to voluntarily admit herself, but she refused because
she was unable to "appreciate the nature of her mental
illness and need for current treatment." He testified
that J.H. also refused to accept outpatient treatment for her
mental illness and medical conditions, which, if left
untreated, posed a considerable threat to her health. In Dr.
Prasad's professional opinion, J.H. needed institutional
care and there was no less restrictive treatment available
Dr. Prasad testified that J.H. was certified by two
physicians and given notice of her admission status. He did
not know how long J.H. waited in the emergency room and said
that he would need to "look in the record" for that
information. Neither counsel revisited this open issue. In
fact, on cross-examination, J.H.'s counsel asked only one
question: "How did my client get to the hospital,
testified that she could not provide the care J.H. required
and that J.H. could no longer live with her. K.H. also raised
a concern regarding her two-year-old daughter's safety,
referencing J.H.'s cavalier attitude toward storing and
disposing of her prescription medications in places
accessible by the child.
the conclusion of the Hospital's case, J.H's counsel
moved to have her released. He alleged that J.H.'s
involuntary admission hearing was not conducted within 10
days of J.H.'s initial confinement. He also stated that
the Hospital failed to demonstrate when the certifications
were completed, or when the Hospital gave J.H. notice of her
admission status, or how long J.H. was in the emergency room.
Because the Hospital failed to comply with the applicable
preadmission procedures, counsel for J.H. argued the ALJ was
deprived of jurisdiction to conduct the involuntary admission
denied J.H.'s motion for release, finding that although
"the time periods aren't really crystal clear . . .
[J.H.] is having her hearing in a timely fashion."
was the only witness offered in support of her case. J.H.
testified that she intended to continue with her outpatient
psychiatric and medical treatment, but she no longer required
medication for schizophrenia or diabetes. Her primary reason
for no longer taking Haldol-a prescription for
schizophrenia-was the unpleasant side-effects. As for the
medication for her other medical conditions, J.H. said she no
longer had diabetes or high blood pressure because
"[she] lost about 79 pounds and that put [her] sugar
respect to the alleged preadmission procedure violations, the
ALJ declined to make a finding on J.H.'s admission date
because "[h]er admission date wasn't testified
to[.]" Then the ALJ made express findings for each
involuntary admission element the Hospital is required to
prove pursuant to Health-Gen. §
10-632(e)(2)(i)-(v). First, the ALJ
found that J.H. "has a mental disorder diagnosed as
schizophrenia chronic." Second, the ALJ determined that
J.H. requires inpatient care and treatment. Regarding the
third element, the ALJ found that although J.H. "is
mentally ill and unpredictable,  she hasn't really done
anything to anybody . . . that would make her dangerous to
others." But he did find that she posed a danger to
herself, reasoning that he did not
. . . believe the patient's testimony that she is no
longer diabetic. Her daughter testified that she has chronic
kidney disease, which is often caused by diabetes. She also
has hypertension, and the diabetes, both of which . . . can
kill you if they're not controlled and treated.
Not bathing, not eating, the patient doesn't look like
she's starving, but . . . not taking your medication for
medical conditions, thinking that you don't have these
medical conditions, which are serious and life threatening,
does threaten your own life and safety and it's caused by
[J.H.'s] mental illness.
he concluded that J.H. was "unwilling and unable to be
voluntarily admitted." Lastly, the ALJ reasoned that
"there [wa]s no less restrictive form of intervention
for her [based on] Dr. Prasad's testimony about her
continued history of being discharged and not taking
medication and relapsing." After reciting his findings,
the ALJ ordered the involuntary admission of J.H.
C.B.'s Involuntary Admission Hearing
C.B. was involuntarily admitted into the psychiatric unit at
the Hospital on September 12, 2015, she lived alone. A.B.,
her father, testified that although he and her mother helped
C.B. with cutting the grass and grocery shopping, C.B. was
not able to maintain the cleanliness of her home. On one
visit, A.B. noticed that dirt was visible on the floors and
the kitchen sink was clogged and the "water smell[ed]
like it [had] been in there for three months." A.B.
became increasingly concerned for his daughter's
wellbeing after one shopping trip she went on with her
mother. Apparently C.B. opened the car door while the car was
moving and got out. A.B. also explained that one grocery
store banned C.B. for three years after an incident in which
she became verbally aggressive with other store patrons.
After observing C.B.'s "gradual deterioration,
" C.B.'s parents filed a petition for emergency
evaluation on September 11, 2015, and brought her to the
September 16, 2015, an ALJ held an involuntary admission
hearing to determine whether C.B. should be involuntarily
admitted for psychiatric treatment. C.B. was not present at
the hearing. At the outset of the hearing, C.B.'s counsel
requested her release, vaguely asserting there was an error
in the emergency petition and notice of admission.
Hospital called as its witnesses Dr. Mirmirani, director of
psychiatric services and C.B.'s treating physician, and
A.B. Dr. Mirmirani testified to the circumstances of
C.B.'s admission and emergency evaluation. When
evaluating C.B., Dr. Mirmirani was not able to have a
meaningful conversation with C.B. regarding voluntary
admission because "she [wa]s very psychotic, very
preoccupied, refused to engage in conversation[, ]" and
"she has . . . no insight, very poor judgment about her
psychiatric condition[.]" Dr. Mirmirani confirmed that
two physicians signed the certification and that C.B. was
notified of her rights and refused to sign the consent as
reflected in the following testimony:
[By counsel]: . . . Before you is the petition for emergency
evaluation filed by [C.B.'s] father?
Dr. Mirmirani: That's correct.
[By counsel]: And the date of that petition?
Dr. Mirmirani: Is 9/11/2015.
[By counsel]: Okay. Does the record reflect that she was
given her notification of admission status and rights?
Dr. Mirmirani: Yes, ma'am.
[By counsel]: Did she sign it?
Dr. Mirmirani: She refused to sign.
[By counsel]: Thank you. Could you please read what - what it
says? What the completer of this document had [sic] wrote?
Dr. Mirmirani: Yes. She said she refused, is paranoid, and
she "said she was tricked."
* * *
[By counsel]: Does the record reflect that two qualifying
physicians did the certifications for [C.B.]?
Dr. Mirmirani: Yes, ma'am.
[By counsel]: Was [C.B.] given her notice of hearing today?
Dr. Mirmirani: Yes. Yes, ma'am.
[By counsel]: Does the record reflect that?
Dr. Mirmirani: Yes, ma'am.
Mirmirani then testified to the Health-Gen. §
10-632(e)(2)(i)-(v) involuntary admission elements. Dr.
Mirmirani indicated that C.B. was diagnosed with chronic
schizophrenia. Dr. Mirmirani prescribed anti-psychotic
medication to C.B., but she refused to take the medication.
He testified that C.B. "walk[s] around . . . talking to
herself" and is "under the influence of internal
stimuli . . . which is a psychotic process that she's
responding [to] and . . . [she] continues to be
psychotic." Although she had wandered to the
neighbor's home and the shopping center and caused a
disturbance, Dr. Mirmirani testified that he did not believe
C.B. presented a risk to others. However, Dr. Mirmirani
opined that C.B. was a danger to herself because she had lost
a lot of weight, was not eating, and was preoccupied with her
"internal psychotic process." He also opined that
C.B. required institutional treatment because she was not
caring for herself and her psychosis rendered her
"incapable of even believing that she has mental illness
and needs treatment." Based on C.B.'s six or seven
year history of mental illness and severe psychosis, Dr.
Mirmirani testified that there was no less restrictive
cross-examination, C.B.'s counsel inquired into the
alleged procedural error in the petition filed by C.B.'s
[C.B.'s counsel]: Doctor, you mentioned there's an
emergency petition. The question number 10 on the emergency
petition which says the petitioner or the person to be
evaluated is a danger. What does it say as to what her danger
Dr. Mirmirani: Well, it says she's disturbing the
neighbors - -
[C.B.'s counsel]: Is that number 9, Doctor, or is - -
Dr. Mirmirani: Number 10, I'm sorry.
[C.B.'s counsel]: Number 10, her dangerousness, it says
is not applicable.
Dr. Mirmirani: Not applicable.
counsel then asked a set of questions, presumably to show
that C.B.'s name and status did not appear on the notice
of admission status form. Dr. Mirmirani clarified on
redirect, however, that the patient's first name was at
the end of the notice of admission status form, where, below
the nurse's signature it read "I certified that I
have informed [C.B.] of his or her admission status and
rights [in] accordance with the provision of Health General
Article 10 and Criminal Procedure Article, Notice of
Admission." During the hearing, C.B.'s father also
testified that his daughter posed a danger to herself and
others, and the "not applicable" "could have
been a mistake."
the close of the Hospital's case, C.B.'s counsel did
not call any witnesses and proceeded directly to closing
arguments. C.B.'s counsel demanded C.B.'s release,
reasserting that there was an error in the emergency petition
because it did not state how C.B. was a danger to others, and
alleging generally that the Hospital did not prove compliance
with all relevant preadmission procedures. He also argued,
for the first time, that there was no evidence that the
petition had been presented to a judge, or that Dr. Mirmirani
saw C.B. within 48 hours of her admission.
denied C.B.'s motion for release, finding that the
Hospital demonstrated that the proper procedures were
followed. The ALJ noted that no one from the patient's
side testified to any alleged errors, and that "if the
patient wishes to challenge [the Hospital's compliance
with preadmission procedures], it's up to the patient to
present evidence that the procedures were not, in fact,
followed and that the error was of severe magnitude to
require release because no other remedy would be sufficient
and that has not been done in this case." With respect
to the alleged error in the petition, the ALJ determined the
error did not require C.B.'s release because the petition
was completed by A.B. and noted that "I'm willing to
assume that [the petition] was summoned by a judge because
[A.B.] doesn't have any authority to  have the police
or the sheriff pick up his daughter off the street and bring
her into - - to an emergency room for evaluation. When a
civilian fills out that petition, the court has to approve
the ALJ made express findings for each involuntary admission
element enumerated in Health-Gen. § 10-632(e)(2)(i)-(v).
First, the ALJ found that C.B has chronic schizophrenia.
Then, he determined that C.B. required institutional care and
treatment. With respect to the third element, the ALJ found
that C.B. was a danger to herself because of her inability to
care for herself, and because she "got out of a moving
car" and was so "disruptive and hostile" that
a grocery store banned her. Fourth, he concluded that C.B
"is unwilling to be voluntarily admitted." Lastly,
the ALJ determined that
there is no less restrictive form of intervention that's
available for her that's consistent with her welfare
because she does not cooperate with mental health
professional[s] except when she's forced to in a
Dr. Mirmirani said his plan is to take her to a clinical
review panel and have her involuntarily medicated if
necessary. [A.B.] testified that she hasn't seen an
outpatient psychiatrist or taken her medications in the last
six months at least and certainly she has decompensated.
reciting his findings, the ALJ ordered the involuntary
admission of C.B.
M.G.'s Involuntary Admission Hearing
police officer found M.G. on the street, walking shoeless in
traffic. She appeared confused and was almost hit by a car.
The officer brought M.G. to the emergency room of the
Hospital and filed an emergency petition for M.G.'s
involuntary admission in September 2015. On September 16, 2015, an ALJ held an
involuntary admission hearing for M.G. In his opening
statement, M.G.'s counsel alleged the Hospital violated
the preadmission procedures by keeping M.G. in the emergency
room for 41 hours.
Hospital called Dr. Mirmirani, the director of psychiatric
services and M.G.'s treating physician, as its only
witness. Dr. Mirmirani diagnosed M.G. with substance-induced
psychosis and psychotic chronic mental
illness. M.G. may have had an additional mental illness,
according to Dr. Mirmirani, however, M.G. was unable to
relate her medical history.
admission, M.G. was psychotic and agitated. The Hospital
staff had to restrain M.G. and administer medication
intramuscularly. On the day of the hearing, M.G. was still
experiencing psychosis but had agreed to voluntarily take the
prescribed antipsychotic medication. Despite M.G.'s
improvement-resulting from the medication and treatment- Dr.
Mirmirani testified that M.G. did not agree to voluntarily
admit herself and that she "[had] very poor judgment
about the need for psychiatric care at this time." Dr.
Mirmirani testified that M.G. was a threat to her own safety
because the officer found her incoherent, walking in the
street and that she was still experiencing psychosis at the
time of the hearing. He opined that M.G. requires
institutional care and treatment for daily monitoring to
stabilize her psychosis and to accurately diagnose her
additional mental illnesses.
counsel did not call any witnesses, moved to release M.G.,
and argued in closing that M.G.'s time in the emergency
room exceeded the statutorily prescribed time, and
"[t]here's no evidence that [M.G.] . . . was ever
certified here, whether [M.G.] was ever given notice of her
admission status, [and notice] of this hearing."
Maintaining that the preadmission procedures are
jurisdictional, M.G.'s counsel argued that she must be
released unless the Hospital could demonstrate that it
complied with the preadmission procedures.
agreed that the Hospital did not present evidence regarding
the procedural issues. Caught off-guard by M.G.'s
procedural error arguments, the Hospital's counsel
requested clarification on the specific procedural issues. A
lengthy colloquy then ensued between the parties and the ALJ.
The ALJ reiterated his prior conclusion that the Hospital did
not present evidence regarding the procedural issues, which
"are affirmative obligations by . . . the
Hospital." The ALJ told the Hospital that the procedural
issues "are necessary to make a case for me to find that
the patient needs to stay here. Anyone can testify to that
effect, but I think you need to alert your witnesses that
those items are necessary." Acknowledging that the law
and medicine dictated conflicting outcomes, the ALJ
I can't really have the Hospital reopen their case
because [M.G.] didn't present a case. [She] just
presented argument. [She] didn't present any evidence, so
there's no evidence for the Hospital to rebut. So,
legally, I must find that [M.G.'s counsel] is correct
that the necessary procedures have not been shown to have
been followed, and that [M.G.] is entitled to be discharged.
Hospital's counsel objected, arguing that "[M.G.]
clearly is not in any condition to leave the hospital at this
time[.]" The ALJ then determined that "[t]he only
remedy that [he] could grant would be to allow the Hospital
to reopen their case and present that evidence." The ALJ
permitted the Hospital to continue its direct examination of
Dr. Mirmirani on the limited issue of "how [M.G.] came
to be admitted, " reasoning that:
[M.G.] raises a preliminary issue, the amount of time that
she allegedly spent in the emergency room. It's not up to
the Hospital to rebut that point during your case in chief.
That's an affirmative defense, if you will, by which
[M.G.] could move for release based on being outside the
statutory limits in the emergency room. So, I don't fault
the Hospital for not addressing that during their
As an administrative law judge, my function is basically to
try to dispense low level justice and do the best for all the
parties. I don't think it would be good for either the
patient or the hospital to discharge her based on the
possible technical deficiency and the hospital's
. . . I'll allow [the Hospital] to reopen [its] case if
you want to recall Dr. Mirmirani on the issue of how [M.G.]
came to be admitted here to this unit.
. . . I'll allow cross examination to include the issue
of how [M.G.] came to the emergency room and how long she was
there before she was transferred. I can only assume that
those answers are in the medical records.
Hospital's counsel then recalled Dr. Mirmirani, who
explained that the Hospital's emergency room differed
from others in that it had a two-step process. The first step
is triage and initial assessment by an emergency room
physician in the main emergency room. The second step is a
23-hour stabilization unit where the patient is treated by a
psychiatrist. In M.G.'s case, she was treated by both an
emergency room physician and Dr. Ganjoo, a psychiatrist. Dr.
Mirmirani was not able to testify to the length of M.G.'s
stay in either the first or second step.
party then presented closing arguments. M.G.'s counsel
reiterated that the ALJ should grant M.G.'s release
because of preadmission procedural errors-the length of stay
and the notice of admission. After closing arguments, the ALJ
denied M.G.'s motion for release, finding that procedural
deficiencies were not "prejudicial to [M.G.]" and
did not require her release. Addressing the primary
violation-that [M.G.] was in the emergency room allegedly for
41 hours-the ALJ found:
Dr. Mirmirani testified about the uniqueness of this
hospital's emergency room, having a 23-hour stabilization
bed where [M.G.] apparently spent some time. That doesn't
really circumvent the necessity of getting the patient out of
the emergency room if she's going to be admitted to a
psychiatric unit. But it does show that she -- even if she
was in that unit for 41 hours, which is not really
established by any evidence, she hasn't been prejudiced
by it, nor has she been prejudiced by any possible failure to
inform her of her admission status or her rights.
As I said, she is represented. She is here at the hearing.
She has the same outlook as far as being released or retained
as she would have if all those procedures were followed.
I'm not sure that they weren't followed. So, I do not
grant the motion for release based on any procedural errors.
So, I find that any procedural errors, if there were any, are
not of such magnitude as to require the patient's
(Emphasis added). Then the ALJ made express findings
pertaining to each involuntary admission element enumerated
in Health-Gen. § 10-632(e)(2)(i)-(v). First, the ALJ
found that M.G. had "substance abuse psychosis with
possible underlying schizophrenia." Second, the ALJ
determined that M.G. required inpatient care and treatment.
Third, the ALJ concluded that M.G. was a danger to herself
because, among other reasons, an officer found her walking in
traffic unaware of her surroundings. Fourth, he concluded
that J.H. was unwilling and unable to be voluntarily
admitted. Lastly, the ALJ determined that there was no
available less restrictive form of ...