Court Opinion

ID: 5142247
Source: CourtListenerOpinion
Date Created: 2021-12-31 01:12:01.149922+00
Date Added: 2024-06-11T08:24:34.723775
License: Public Domain

J.H. v. TidalHealth Peninsula Regional, Inc., No. 754, Sept. Term 2020. Opinion by
Ripken, J.
MENTAL HEALTH — ADMISSION OR COMMITMENT PROCEDURE —
ERROR
The ALJ must order the release of the proposed admittee when (1) a procedural error
occurred, (2) the error is substantial, and (3) no other available remedy is consistent with
due process and the protection of the individual’s rights. The lack of a written application
for admission was a procedural error, but the ALJ did not err in concluding that the error
was not a substantial error warranting the proposed admittee’s release.
MENTAL HEALTH — ADMISSION OR COMMITMENT PROCEDURE —
EVIDENCE
An inpatient facility may not admit an individual involuntarily unless: (1) the individual
has a mental disorder; (2) the individual needs inpatient care or treatment; (3) the individual
presents a danger to the life or safety of the individual or of others; (4) the individual is
unable or unwilling to be admitted voluntarily; and (5) there is no available, less restrictive
form of intervention that is consistent with the welfare and safety of the individual.
MENTAL HEALTH — ADMISSION OR COMMITMENT PROCEDURE —
EVIDENCE
The requirements for involuntary admission were met where the treating physician reached
a provisional diagnosis of a mental disorder requiring inpatient treatment based on short-
term care and available patient history. Evidence also showed that the patient suffered from
delusions, had recently stopped taking medications, and made repeated threats of harm
towards his family. A family member testified that the patient’s threatening behaviors were
escalating. According to the treating physician, the proposed admittee lacked insight into
his illness and could not provide consent for his voluntary admission.
Circuit Court for Wicomico County
Case No. C-22-CV-19-000448

                                                                                                REPORTED

                                                                                   IN THE COURT OF SPECIAL APPEALS

                                                                                             OF MARYLAND

                                                                                                  No. 0754

                                                                                           September Term, 2020

                                                                                                    J.H.

                                                                                                     v.

                                                                                   TIDALHEALTH PENINSULA REGIONAL,
                                                                                                 INC.

                                                                                      Leahy,
                                                                                      Ripken,
                                                                                      Wright, Jr., Alexander
                                                                                         (Senior Judge, Specially Assigned),

                                                                                                     JJ.

                                                                                            Opinion by Ripken, J.

                                                                                      Filed: November 18, 2021

 Pursuant to Maryland Uniform Electronic Legal
Materials Act
(§§ 10-1601 et seq. of the State Government Article) this document is authentic.

                       2021-11-18
                       10:48-05:00

Suzanne C. Johnson, Clerk
       Peninsula Regional Medical Center (“the Hospital”)1 admitted J.H. for psychiatric

treatment based on a petition for an emergency evaluation. After the hearing, an Office of

Administrative Hearings (“OAH”) Administrative Law Judge (“ALJ”) ordered that J.H. be

involuntarily admitted.2 J.H. petitioned for judicial review in the Circuit Court for

Wicomico County. The circuit court held a hearing and affirmed the ALJ’s decision. For

the following reasons, we shall affirm.

                 FACTUAL AND PROCEDURAL BACKGROUND

       J.H. was admitted to the hospital upon a petition for emergency evaluation executed

by Deputy Sheriff Howser. The petition recited a series of concerning statements attributed

to J.H. The petition also stated that J.H. was not taking medication as prescribed, and that

he had threatened to beat up his father. J.H. was examined by an attending psychiatrist, Dr.

Murdock, who determined that J.H. met the criteria for involuntary admission. Two other

physicians certified that J.H. was suffering from an unspecified psychotic disorder and

delusional paranoid hallucinations. Both physicians also certified that J.H. wanted to leave

1
 Peninsula Regional Medical Center was renamed to TidalHealth Peninsula Regional, Inc.
during the course of this litigation.

We refer to the appellant by his initials, per his motion to change the case caption and seal
the record, to preserve his privacy. We note that appellant, J.H., in this appeal was not
involved in J.H. v. Prince George’s Hospital Center, 233 Md. App. 549 (2017), to which
we often refer.
2
 The Department of Health delegated the role of the impartial hearing officer to OAH,
which held the hearing at the inpatient facility. See J.H. v. Prince George’s Hosp. Ctr., 233
Md. App. at 580–81.
the hospital, that outpatient treatment could harm him, and that he could harm his family

or himself, if untreated.

       Four days after the Hospital admitted J.H. for emergency evaluation, the ALJ

presided over a hearing to determine whether J.H. should be involuntarily admitted for

continued inpatient treatment. A representative for the Hospital acknowledged the record

did not contain a written application for J.H.’s involuntary admission and stated that he had

not seen such an application. Dr. Murdock testified at that hearing as an expert in

psychiatry. Dr. Murdock regularly evaluated J.H. during J.H.’s time at the hospital. Dr.

Murdock said that during an initial interview with a social worker, J.H. expressed

delusional thoughts “such as being Jesus, being 200 years old, [and] the notion that his

parents and others were coming into his room every night and raping him.” Dr. Murdock

provisionally diagnosed J.H. with “psychotic disorder, most likely on the spectrum of

schizophrenic disorders.”

       Dr. Murdock explained that J.H.’s history of polysubstance dependence and head

injuries complicated the diagnosis. When J.H. entered the emergency room, his drug test

was positive for marijuana. J.H.’s mother reported that J.H. often used synthetic marijuana.

Dr. Murdock said that there was no standard test for detecting synthetic marijuana use. The

doctor stated that synthetic marijuana can cause psychosis lasting for a week or longer and

that synthetic marijuana can worsen psychotic symptoms in those predisposed to

mental illness.

       Based on J.H.’s paranoia and delusional thinking, Dr. Murdock believed that J.H.

presented a danger to himself or others. Dr. Murdock further testified that when J.H.’s

                                             2
mother visited J.H. at the hospital, the meeting was confrontational. J.H. claimed that she

was an imposter. J.H.’s mother reported that J.H. threatened to kill his family when he left

the hospital. J.H. denied making the threat.

       J.H.’s mother also testified at the hearing. She explained that J.H. was diagnosed

with bipolar disorder and had been self-medicating. She stated that, in the weeks before his

hospital admission, J.H. had stopped taking his medication prescribed for bipolar disorder.

She testified that J.H. had been banging on windows, making threats, and yelling. She said

that J.H. has “been threatening my life, and my husband’s life, and his brother’s life, and

wanted to take his little sister away with him.”

       J.H. testified at the hearing. He stated that his mother was lying to keep him locked

up at the hospital. He denied threatening to kill people and stated he had no intention of

harming himself or others. He maintained that the nightly assaults he described were

ongoing and not a delusion. He explained that he had stopped taking medication for bipolar

disorder because of side effects. He testified that if he was released, he would continue to

see a psychiatrist and accept treatment.

       The ALJ noted that the record did not contain an application to involuntarily admit

J.H. The ALJ concluded that this procedural error did not require J.H.’s release. The ALJ

found that J.H. met the requirements for involuntary admission and ordered that he be

involuntarily admitted.

       J.H. petitioned for judicial review. The circuit court affirmed the ALJ’s order. J.H.

timely appealed. We describe additional facts below as needed.

                                               3
                        ISSUES PRESENTED FOR REVIEW

       J.H. presents two issues for our review:

       I.     Did the ALJ err in finding that the lack of an application for [J.H.’s]
              involuntary admission was not a substantial procedural error requiring
              [J.H.’s] release?

       II.    Did the ALJ err in finding that the Hospital proved the grounds for
              involuntary admission under Health-General Art[icle] § 10-632?

                               STANDARD OF REVIEW

       When an administrative agency’s decision is before this Court, we review the

agency’s decision; we do not review the circuit court’s decision. In re J.C.N., 460 Md. 371,

386 (2018). Substantial evidence in the record must support the agency’s factual findings.

J.H. v. Prince George’s Hosp. Ctr., 233 Md. App. 549, 578 (2017). Substantial evidence

exists when “the facts in the record allow reasoning minds to reach the same determination

as the ALJ.” Id. at 596. We review the ALJ’s legal conclusions de novo. Id. at 581.

                                      DISCUSSION

I.     THE LACK OF AN APPLICATION FOR J.H.’S INVOLUNTARY ADMISSION WAS NOT
       A SUBSTANTIAL ERROR IN THE PREADMISSION PROCESS.

       The parties agree that an error occurred—the record lacks an application for J.H.’s

involuntary admission and the Hospital’s representative stated that he had not seen such an

application—but they dispute whether the error was substantial. On appeal, J.H. identifies

two reasons that the lack of an application was a substantial error requiring his release.

First, J.H. argues that the application is a mandatory first step, without which the ALJ did

not have authority to order admission. Second, J.H. argues that the application is necessary

because it requires the applicant to disclose his or her identity and relationship to the

                                             4
proposed admittee, which helps to ensure that the admission is not sought for an improper

purpose. The Hospital argues that the ALJ correctly determined that the error was not

substantial based on the evidence in the record including the emergency petition and two

physician certificates. We first review the law concerning involuntary admission, and then

address J.H.’s arguments in turn. As we shall explain, the ALJ’s decision was legally

correct and supported by substantial evidence.

       A.     The Procedures for Involuntary Admission

       The Health General Article (“HG”) details the procedures for emergency evaluation

and involuntary admissions for treatment of mental health disorders. Md. Code, Health-

General Article (“HG”) §§ 10-613 to 630 (2019 Repl. Vol.). A peace officer may petition

for the emergency evaluation of a person when the officer reasonably believes that person

suffers from a mental health disorder and presents a danger to the life and safety of that

person or of others. HG § 10-622. If the petition is properly executed pursuant to HG

§ 10-622(c)(1), an emergency facility must accept the person identified in the petition, and

a physician must evaluate the person within six hours of arrival to determine if the person

meets the requirements for involuntary admission. HG § 10-624(b). A person may only be

involuntarily admitted if: (1) the person has a mental disorder, (2) the person needs

inpatient care or treatment, (3) the person presents a danger to his or her life or safety or

that of others, (4) the person is unable or unwilling to be admitted voluntarily, and (5) there

is no available, less restrictive form of intervention consistent with the person’s welfare

and safety. HG § 10-617(a). If a person meets these criteria, “the examining physician shall

take the steps needed for involuntary admission[.]” HG § 10-625. The steps are as follows.

                                              5
       The statute requires the completion of an application for involuntary admission,

which may be submitted by anyone with a “legitimate interest in the welfare of” the

proposed admittee. HG § 10-614(a); see In re J.C.N., 460 Md. at 377, 381 (application

signed and submitted by hospital discharge coordinator). The inpatient facility must

provide an application form, which must be signed and dated and must state the relationship

of the applicant to the person proposed to be admitted. HG § 10-615. The application must

be accompanied by certificates from two mental health professionals who personally

examined the person, including at least one physician, diagnosing a mental disorder. HG

§§ 10-615, 10-616(a). Regulations promulgated by the Secretary of Health require that one

of the certificates shall have an attached medical report explaining, among other things,

why the proposed admittee needs inpatient care and why the proposed admittee presents a

danger to the admittee’s own life or safety or that of others. COMAR 10.21.01.04C(4)(c).3

       The proposed admittee has a right to a hearing, “to determine whether . . . to be

admitted to a facility . . . as an involuntary patient or released without being admitted[.]”

In re J.C.N., 460 Md. at 378 (second alteration in original) (quoting HG § 10-632(a)).

Within twelve hours of the person’s initial confinement, the facility must give the person

notice of their status in the proposed admission process and notice of various rights

including the right to counsel. HG §§ 10-631(a)–(b); COMAR 10.21.01.05; see also HG

3
  The certifying professional must also certify that he or she “(a) Has no financial interest,
through ownership or compensation, in a proprietary inpatient facility, and admission to
that proprietary inpatient facility is sought for the individual whose status is being
certified”; and (b) he or she “[i]s not related, by blood or marriage, to the individual or to
the applicant[.]” COMAR 10.21.01.04B(8).

                                              6
§§ 10-701 to 714 (concerning the rights of mentally ill people in inpatient facilities). The

hearing occurs before an ALJ and the proposed admittee must receive notice of the hearing.

COMAR 10.21.01.06 (requiring that the notice provide, among other things, “[a] short

statement explaining why the individual’s involuntary admission is being sought” and the

standards “that govern whether the individual shall be involuntarily admitted[]”); COMAR

10.21.01.08–.09; see HG § 10-632.

       “[T]he hospital’s non-compliance with a preadmission procedure does not

automatically result in the release of the individual from the hospital.” J.H. v. Prince

George’s Hosp. Ctr., 233 Md. App. at 590. When a hospital does not comply with a

preadmission procedure, an ALJ shall “[o]rder the release of the individual from the

inpatient facility” if (1) an “error in the process occurred”; (2) the error “is substantial”;

and (3) “[n]o other available remedy is consistent with due process and the protection of

the individual’s rights.” COMAR 10.21.01.09G; In re J.C.N., 460 Md. at 379. The patient

must raise alleged violations of preadmission procedures with particularity. J.H., 233 Md.

App. at 593. Then, “the burden shifts to the hospital to establish, by a preponderance of the

evidence,” that it followed the appropriate procedure, that the violation was not substantial,

or that some other remedy would be consistent with due process and the protection of the

individual’s rights. Id. at 590–91.

       This Court previously addressed whether an error in the involuntary admission

process was substantial in J.H. v. Prince George’s Hospital Center. 233 Md. App. at 596–

599. There, patient M.G. argued at her admission hearing that the hospital failed to follow

the proper preadmission procedures. She alleged that the hospital kept her in the emergency

                                              7
room for forty-one hours after her emergency evaluation, failed to introduce evidence that

medical professionals certified her for admission, and failed to introduce evidence that she

received notice of her admission status and hearing. Id. at 562. The hospital did not enter

the emergency petition, petition for involuntary admission, or physician certificates into

evidence. Id. at 561 n.5. The hospital called M.G.’s treating physician, who testified that

M.G. may have stayed in the emergency room beyond the statutory thirty-hour limit but

she began to receive psychiatric treatment there. Id. at 596–97. The treating physician

“could not clearly state when the emergency physician gave M.G. notice of her admission

status” but he testified that “two licensed physicians certified M.G.” Id. at 597. The ALJ

reasoned that the alleged errors were not substantial because neither the failure to transfer

M.G. from the emergency room nor the failure of notice prejudiced M.G.’s challenge to

her proposed admission. Id. at 565. We affirmed the ALJ’s determination as legally correct

and supported by the evidence. Id. at 597. In other words, an error is not substantial as long

as it does not deprive the proposed admittee of the opportunity for a full and fair hearing.

       B.     The ALJ Had Authority to Hear J.H.’s Challenge to His
              Involuntary Admission.

       Contrary to J.H.’s first contention, the ALJ’s authority to adjudicate J.H.’s challenge

to his involuntary admission followed from J.H.’s status as a proposed involuntary admittee

confined at an inpatient institution. Section 10-632(a) states that “[a]ny individual proposed

for involuntary admission under Part III of this subtitle shall be afforded a hearing to

determine whether the individual is to be admitted to a facility . . . as an involuntary patient

or released . . . .” Here, J.H. was “an individual proposed for involuntary admission under

                                               8
Part III,” § 10-632(a), because after his emergency evaluation it was determined that he

met the requirements for involuntary admission and was not released, two physicians

certified that J.H. required involuntary inpatient treatment, J.H. received notice of his legal

status, and he appeared at the hearing. See In re J.C.N., 460 Md. at 393 (initial confinement

occurs when an emergency evaluee is transferred to an inpatient institution that provides

evaluation, care, or treatment for people with mental disorders); J.H., 233 Md. App. at

582–83 (describing two pathways to involuntary admission). The lack of written

application did not deprive the ALJ of authority to adjudicate J.H.’s challenge to his

proposed involuntary admission.

       J.H. compares the lack of written application in an involuntary admission to the

absence of a charging document in a criminal prosecution or juvenile delinquency

proceeding. See Stickney v. State, 124 Md. App. 642 (1999); In re Areal B., 177 Md. App.

708 (2007). But a written application in an involuntary admission proceeding is not subject

to the same due process requirements as a criminal charging document and does not play

the same fundamental jurisdictional role. First, concerning due process, in criminal and

juvenile proceedings, Article 21 of the Maryland Declaration of Rights and the Due Process

Clause of the 14th Amendment require that an accused receive fair notice of the allegations

brought against her. In re Roneika S., 173 Md. App. 577, 587 (2007). “[E]very criminal

charge must, first, characterize the crime; and, second, it must provide such description of

the criminal act alleged to have been committed as will inform the accused of the specific

conduct with which he is charged, thereby enabling him to defend against the accusation[.]”

Id. at 591–92; see also Md. Rules 4-201(a), 4-202(a) (stating that an offense may be tried

                                              9
only based on a charging document and requiring, among other things, that the charging

document “contain a concise and definite statement of the essential facts of the offense

with which the defendant is charged”). Second, concerning its jurisdictional function, a

charging document must “sufficiently characterize” the crime as one within the court’s

common law or statutory jurisdiction to “invest[] the [] court with jurisdiction to try the

offense.” Williams v. State, 302 Md. 787, 793 (1985).

       Involuntary admissions are not criminal proceedings subject to Article 21, but due

process and the Secretary’s regulations nonetheless require fair notice for the impartial

hearing to which proposed admittees are entitled. J.H., 233 Md. App. at 572–77 (reviewing

the development of Maryland’s involuntary admissions procedures). Regulations require

that the proposed admittee receive “[a] short statement explaining why the individual’s

involuntary admission is being sought” and “[t]he standards . . . that govern whether the

individual shall be involuntarily admitted.” COMAR 10.21.01.06B(2)(c)–(d). These

notices are separate from the written application, and they are triggered upon a person’s

initial confinement in an inpatient facility. COMAR 10.21.01.08A. J.H. did not allege

deficiency in these notices before the ALJ or in his briefing before this Court. As noted

above, every proposed admittee must be afforded a hearing. HG § 10-632. The ALJ’s

jurisdiction does not depend upon the offense charged. We cannot agree that the lack of a

written application deprived the ALJ of authority to hold a hearing.

                                            10
       C.     The Lack of Written Application Did Not Deprive J.H. of the
              Opportunity for a Full and Fair Hearing and Did Not Warrant
              J.H.’s Release.

       J.H.’s second contention regarding substantial error is also unavailing. J.H. argues

that a written application is necessary because, in requiring that the applicant have a

“legitimate interest” in the proposed admittee’s welfare, HG § 10-614(a), and state their

relationship to the proposed admittee, HG § 10-615(4), the contents of the application help

ensure that admission is not sought for an improper purpose.

       The process J.H. received was, in substance, that which is required under the Health-

General Article and the controlling regulations, and his hearing included the opportunity

to challenge the interests and motives of parties seeking his admission. J.H. was admitted

for evaluation based upon a properly executed petition for emergency evaluation. An

attending psychiatrist determined that J.H. met the requirements for involuntary admission.

Two physicians certified that J.H. suffered from an unspecified psychotic disorder and

delusional paranoid hallucinations that required inpatient treatment and that J.H did not

want to stay in the hospital. J.H. appeared at the hearing with counsel to challenge his

proposed admission. J.H.’s mother and treating physician testified. At the end of the

hearing, referring to the emergency petition, certifications, and “other checks and

balances,” the ALJ ruled that the lack of a written application did not warrant J.H.’s release.

       There is no indication in this case that the lack of a written application hindered

J.H.’s ability to contest his admission or challenge the motives of the Hospital’s witnesses.

The testimony of J.H.’s mother provided detail and assurances far beyond the basic

information required in the written application. J.H.’s mother directly explained why she

                                              11
wanted her son to receive inpatient treatment. J.H. had the opportunity to cross-examine

his mother about her statements or about the information she provided to Dr. Murdock. But

he declined to cross-examine her. The ALJ found her credible. The other evidence

suggested that at other stages J.H.’s case was advanced by parties with a legitimate interest

in his welfare. In preparing the emergency petition, Deputy Howser indicated under penalty

of perjury that he believed J.H. required inpatient treatment. See HG § 10-622(a) & (c)(2).

Once Dr. Murdock determined that J.H. met the criteria for involuntary admission, he was

statutorily required to take the steps needed for J.H.’s admission. HG § 10-625. Based on

these facts, the ALJ’s determination that the error did not warrant J.H.’s release was legally

correct and supported by substantial evidence.4 See J.H., 233 Md. App. at 596–599.

II.    THE ALJ DID NOT ERR IN FINDING THAT THE HOSPITAL SUFFICIENTLY
       PROVED THE REQUIREMENTS FOR INVOLUNTARY ADMISSION.

       J.H. argues that the Hospital did not prove by clear and convincing evidence any of

the requirements for involuntary admission under HG § 10-632. As noted above, the ALJ

must order the release of a person proposed for admission, unless a hospital establishes by

clear and convincing evidence that:

       (i) The individual has a mental disorder;
       (ii) The individual needs in-patient care or treatment;
       (iii) The individual presents a danger to the life or safety of the individual or
             of others;
       (iv) The individual is unable or unwilling to be voluntarily admitted to the
            facility; [and]

4
  Nothing in this opinion suggests that the lack of a written application might not lead to
reversible error on different facts.

                                              12
       (v) There is no available less restrictive form of intervention that is
           consistent with the welfare and safety of the individual[.]

HG § 10-632(e)(2).5 “To be clear and convincing, [the] evidence should be ‘clear’ in the

sense that it is certain, plain to the understanding, and unambiguous and ‘convincing’ in

the sense that it is so reasonable and persuasive as to cause one to believe it.” Mathis v.

Hargrove, 166 Md. App. 286, 312 (2005). The ALJ did not err in finding that the Hospital

proved the requirements for involuntary admission by clear and convincing evidence.

       A.     The Evidence Sufficiently Established That J.H. Had a Mental Disorder.

       J.H. first argues that the ALJ erred in finding by clear and convincing evidence that

J.H. had a mental disorder because Dr. Murdock’s diagnosis was provisional and J.H.’s use

of synthetic marijuana may have caused or exacerbated his psychotic symptoms. Mental

disorder means “behavioral or other symptoms” that indicate to a physician conducting an

examination of a patient, “at least one mental disorder that is described in the version of

the American Psychiatric Association’s ‘Diagnostic and Statistical Manual—Mental

Disorders’ that is current at the time of the examination.” HG § 10-620(f)(1).

       At the involuntary admission hearing, the ALJ accepted Dr. Murdock as an expert

in psychiatry. Dr. Murdock testified that he provisionally diagnosed J.H. with “psychotic

disorder, most likely on the spectrum of schizophrenic disorders.” This diagnosis matched

the diagnosis of “unspecified psychotic disorder [and] delusional paranoid hallucinations”

that the Hospital’s representative described in the medical certificates. Dr. Murdock’s

5
  An additional element, inapplicable here, must be met “[i]f the individual is 65 years old
or older.” HG § 10-632(e)(2)(vi).

                                            13
diagnosis was based on his observations, J.H.’s documented history, and history provided

by J.H.’s family members. For example, J.H.’s mother described symptoms occurring a

year before the hearing date. Dr. Murdock explained that these symptoms were indicative

of an ongoing chronic illness. The doctor said that “the primary target symptoms that we’re

seeing right now are disorganized behavior, what appears to be paranoid and grandiose

delusions consistent with schizophrenia.” Dr. Murdock recited examples of recent

delusional behaviors and statements.

       J.H.’s medical history also included a series of head injuries and polysubstance

dependence, which, as Dr. Murdock explained, complicated the diagnosis. J.H. tested

positive for marijuana when he entered the emergency room. The test could not determine

whether the marijuana was synthetic or organic. According to J.H.’s mother, he had a

history of using synthetic marijuana. Dr. Murdock said that use of both types of marijuana

can cause psychosis and synthetic marijuana use can exacerbate symptoms in those

predisposed to psychosis. He explained that a period of sustained abstinence from drug use

is necessary to make a definitive diagnosis.6 At the time of the involuntary admission

hearing, J.H. had not been under observation for enough time for Dr. Murdock to reach a

definitive diagnosis.

6
  Additionally, Dr. Murdock explained that a diagnosis of schizophreniform disorder
typically requires “at least six months of . . . persistent psychotic behavior meeting [the]
criteria . . .” But, he continued, “we do have people that we are fairly certain about the
diagnosis if we have a reasonable history of ongoing symptoms that have persisted more
than six months.”

                                            14
       J.H. has not offered any authority to suggest that a provisional diagnosis may not

constitute clear and convincing evidence of a mental disorder. On the contrary, Dr.

Murdock’s diagnosis accounted for the complicating factors that J.H. raises. The evidence

is sufficient to support the ALJ’s finding to a clear and convincing standard that J.H.

suffered from a mental disorder. See Mathis, 166 Md. App. at 312.

       B.     The Evidence Sufficiently Established That J.H. Was a Danger to
              Himself or the Life or Safety of Others.

       J.H. next argues that there was insufficient evidence to find that he was a danger to

himself or others, particularly because J.H. had never previously acted violently and the

evidence did not show an “imminent and likely danger.” The Hospital argues that based on

the testimony of Dr. Murdock and J.H.’s mother, there was sufficient evidence for the ALJ

to find that J.H. presented a danger to the life or safety of others.

       J.H.’s mother testified as follows:

       . . . [J.H. has] been threatening my life and my husband’s life and his
       brother’s life and wanted to take his little sister away with him.
                He’s made accusations of other people doing things to him and other
       people doing bad behavior, and none of it’s true. So we’re scared for him,
       scared of him. Although he has never done anything violent, we were very
       afraid. It was just escalating to the point of we couldn’t sleep at night. He’s
       banging on our windows making threats.

       Dr. Murdock testified that J.H.’s mother reported a direct threat made by J.H. that

he would harm her once released from the hospital. When Dr. Murdock questioned J.H.

about that threat, he denied it. J.H. also denied making that threat in his direct examination.7

7
  The ALJ found J.H. and his mother to be credible, but did not make an explicit finding as
to whom he believed regarding this threat.

                                              15
Dr. Murdock opined that, considering J.H.’s delusional behavior and threats, there is “a

great probability that if not treated . . . these delusions will continue and that violence

would ensue.” The evidence showed that J.H.’s delusions involved a belief that he was

being recurrently attacked and that his parents were involved. The paranoid delusions

focused on his parents in other ways, including that his mother was an imposter and

was dangerous.

       The ALJ found that although J.H. had improved during his hospital stay,

       there is that psychotic delusional factor that’s out there. And so with that and
       with I can tell some legitimate anger on the part of [J.H.] regarding, you
       know, some of the stuff with his parents right now and all. What is
       concerning to everybody is that the delusion will take over, you know, and,
       you know, potentially cause him to act on some delusional thoughts. . . . And
       I find that it’s clear and convincing evidence that at least until he gets a little
       bit more treatment, which doesn’t sound like it’s going to take very long, he
       can be considered to be a danger to others.

The evidence supported the ALJ’s conclusion to a clear and convincing degree.

       J.H.’s reliance on an Oregon case, State v. B.P., 211 P.3d 975 (Or. Ct. App. 2009),

is unpersuasive. During an interview with a mental health worker, B.P. said he was going

to kill hundreds of people and that then police would kill him. Id. at 976. Further

questioning from the mental health worker suggested that B.P. had a plan to acquire a

weapon to harm an employee of a correctional facility. Id. At a psychiatric hospital two

days later, B.P. denied making that threat. Id. B.P., however, admitted that he had thoughts

of killing Bill Gates and the employees of ITT Technical Institute. Id. In another interview,

a psychiatrist found B.P. so aggressive and angry that she found him “potentially-

threatening” and terminated the interview. Id. at 976–77. The trial court found that B.P.

                                               16
had a mental disorder that made him dangerous to others, and it committed him to the

Mental Health and Developmental Disability Services Division for a period not to exceed

six months. Id. at 975.

       The Oregon Court of Appeals reversed the trial court, finding that the evidence was

insufficient to prove that B.P. was dangerous. Id. at 978. The appellate court held that

“[g]enerally, threats of future violence do not establish clear and convincing evidence of

danger to others unless they are accompanied by some overt act indicating intent to follow

through on the threat or they are made under unusual circumstances that make actual future

violence highly likely—that is, the threats clearly form a foundation for predicting future

dangerousness.” Id. at 977–78 (citations omitted).

       The requirement that threats of future violence be accompanied by overt acts is not

found in Maryland law nor do we find the reasoning in B.P. to be persuasive. In this case,

we are not deciding whether one-off threats could ever satisfy the standard for

dangerousness in Maryland. Rather, here, there was evidence upon which the ALJ could

find that J.H.’s recent threatening behavior “clearly form[ed] a foundation” for predicting

his future dangerousness. J.H.’s mother testified about repeated threatening behavior

directed towards J.H.’s family members. She testified that his family, familiar with him

outside of an institutional context, were “very afraid” and that J.H.’s behavior had become

“more erratic and threatening.” J.H.’s behavior escalated to the point that his parents could

not sleep at night. The ALJ’s decision is supported by the evidence, and the Hospital was

not required to present evidence that J.H. committed an overt act.

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       C.     The Evidence Sufficiently Established That J.H. Could Not Be
              Voluntarily Admitted to the Hospital.

       J.H. argues that the ALJ erred in finding that J.H. was unable to voluntarily admit

himself because insight into one’s illness is not a legal prerequisite for voluntary admission

and J.H. never testified that he was unwilling to pursue voluntary admission.

       Dr. Murdock testified that J.H. lacked the capacity to make an informed decision

about voluntary admission. The doctor testified that he spoke with J.H. about J.H.’s

admission status:

       We’ve discussed the patient’s legal status with him on multiple occasions.
       He was under the impression that he was already voluntary and did not want
       to sign anything additional. In my conversation with him, I felt that he did
       not have capacity to make an informed decision regarding a legal status
       because of his lack of understanding and his disorganized behavior. So, in
       addition to him not wanting to sign a voluntary admission, he demonstrated
       the lack of capacity to understand and to make that decision.

Dr. Murdock described the first criteria in determining whether an individual can give

informed consent to treatment: an individual must possess “a rational and factual

understanding of their diagnosis and what they’re actually being treated for.” Although Dr.

Murdock stated that J.H. could weigh the risks and benefits of taking antipsychotic

medications, Dr. Murdock concluded that J.H. failed the first criteria in determining

whether an individual can give informed consent to treatment. That conclusion was based

on several observations: J.H. believed that he was already voluntarily admitted; J.H.

exhibited disorganized behavior; and J.H. denied having a mental illness. For these reasons,

Dr. Murdock determined that J.H. could not make an informed decision about

voluntary admission.

                                             18
       J.H. argues that Dr. Murdock’s determination did not meet the legal standard

governing voluntary admissions. Under HG § 10-609, individuals who are sixteen years or

older may apply for voluntary admission to a facility. That statute provides, in pertinent

part, that a facility may not admit the individual voluntarily unless the individual

understands the nature of the request for admission. HG § 10-609(c)(3). Dr. Murdock’s

observations showed that J.H. could not understand the nature of a request for admission.

The evidence was sufficient to prove by clear and convincing evidence that J.H. could not

be voluntarily admitted.8

       D.     The Evidence Sufficiently Established That J.H. Needed Inpatient
              Treatment and No Less Restrictive Form of Intervention Was Available
              Consistent with His Welfare and Safety.

       J.H. last contends that outpatient treatment was a suitable and less restrictive form

of   intervention.   He     argues    that   Dr.    Murdock   did   not   state   whether   he

considered alternatives.

       Dr. Murdock concluded that J.H. needed institutional care or treatment. This

conclusion was based on several of J.H.’s behaviors: delusional comments, confrontational

visits with his mother at the hospital, statements to staff that his mother was an imposter,

and repeated threats to his family.

8
  Other evidence indicated that J.H. was unwilling to be admitted, even if he were able to
be voluntarily admitted. For example, he was asked on direct examination whether he
would be willing to seek treatment and take medications if released. J.H. responded that he
could agree to seeing someone “a couple of days a week.” But he did not want to be “locked
up again in rehab” and did not want “to be sent back into a treatment facility.” He
previously testified that his mother had gotten him “locked up in a hospital” “a couple of
times” before.

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       Dr. Murdock testified that, at the time of the hearing, there was no less restrictive

alternative to inpatient treatment available for J.H. The treatment plan included titrating

J.H.’s antipsychotic medication to stabilize him and then introducing a “long-acting

injectable antipsychotic which would hopefully prevent him from having to come back to

the hospital at some point.” Dr. Murdock explained the conditions and relative timeframe

of J.H.’s release from hospitalization:

       From my standpoint, if we continue to see cooperation and compliance with
       medications, if these delusions resolve and if there is appropriate behavior in
       which there are no threats made to the mother and they seem to be getting
       along and he’s . . . amenable to outpatient treatment, then I think his
       hospitalization would be relatively short.

The intent of the treatment was “to restore the patient to capacity to alleviate these

delusions and allow him to live in the community where he can get on with his life.” Based

on Dr. Murdock’s testimony, reasoning minds could find by clear and convincing evidence

that J.H. needed inpatient treatment and that no less restrictive form of intervention was

available consistent with J.H.’s welfare and safety.

                                          JUDGMENT OF THE CIRCUIT COURT
                                          FOR WICOMICO COUNTY AFFIRMED.
                                          COSTS TO BE PAID BY APPELLANT.

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