In re: J.C.N.

Argued before: Barbera, C.J., Greene Adkins McDonald Watts Hotten Getty, JJ. Barbera, C.J. *³⁷⁴ We are presented here with a second opportunity in a span of several weeks to address the operation of the involuntary admission provisions of the Maryland Mental Health Law, found within Subtitle 6 of Title 10 of the Health-General Article, §§ 10-601 -633. We begin by repeating the opening lines of the first of our opinions: Civil commitment of an individual to a mental institution against the individual's will may be sought when it appears necessary for treatment of the individual's mental disorder and for the safety of that individual or others. However, a decision on involuntary admission must take account not only of health and safety concerns, but also of the individual's *³⁷⁵ right to liberty under the State and federal constitutions.

Bell v. Chance , 460 Md. 28 , 34, 188 A.3d 930 , 2018 WL 3409919 , at ¹ (2018). The competing concerns addressed above-the individual's liberty interest and society's concern for the ³³² health and safety of the individual and others-lay at the center of the case before us. Petitioner in the present case is J.C.N., who challenges her involuntary admission to the psychiatric unit of the University of Maryland Baltimore Washington Medical Center in December 2015. Respondents are the Baltimore Washington Medical Center and the Maryland Department of Health.

J.C.N.'s involuntary admission was pursuant to the decision of an administrative law judge who, following a hearing, determined that she met the requirements for involuntary admission, including that she was at that time a danger to the life or safety of herself or others. J.C.N., represented by counsel then and throughout judicial review of the administrative law judge's decision, argues that there were errors of procedure and substantive law on the part of Respondents and the administrative law judge. On judicial review in the Circuit Court for Anne Arundel County and on appeal to the Court of Special Appeals, both courts determined that there was no error. For reasons that follow, we likewise find no error.

I. The Statutory and Regulatory Scheme Resolution of the parties' dispute turns largely on the proper interpretation and application of the Health-General Article ("HG") of the Maryland Code, Title 10, Subtitle 6, in particular the provisions found in Parts III ("Involuntary Admissions") and IV ("Emergency Evaluations"). We outline the pertinent statutory and regulatory provisions here. *³⁷⁶ The Petition for Involuntary Admission An involuntary admission may be initiated by application. HG §§ 10-614 (permitting an application for involuntary admission to be made "by any person who has a legitimate interest in the welfare of the individual"), 10-615 (listing the requirements of an application). The process also may be initiated by a petition for emergency evaluation.

J.C.N. was admitted under the procedures governing petitions for emergency evaluations. Those procedures are found in Part IV of Subtitle 6, HG §§ 10-620 -630, and associated regulations adopted by the Secretary of Health. 1 Peace officers and other enumerated professionals may make a "petition for emergency evaluation" of an individual. HG § 10-622(b). The petition may be made if the petitioner 2 believes that the individual has a mental disorder and "presents a danger to the life or safety of the individual or of others." HG § 10-622(a).

Once lawfully executed, the petition is presented to a peace officer, 3 who is authorized to transport the ³³³ individual against his or her will "to the nearest emergency facility." HG § 10-624(a). "If the petition is executed properly, the emergency *³⁷⁷ facility shall accept the emergency evaluee." HG § 10-624(b)(1). An "emergency facility" is one that the Department of Health ("Department") "designates, in writing, as an emergency facility," and "includes a licensed general hospital that has an emergency room." HG § 10-620(d). Within six hours of the individual's arrival at the emergency facility, "a physician shall examine the emergency evaluee, to determine whether the emergency evaluee meets the requirements for involuntary admission." HG § 10-624(b)(2).

If the evaluee does not meet the requirements for involuntary admission, the emergency facility "shall" release the individual unless the individual requests voluntary admission. HG § 10-624(b)(3). "An emergency evaluee may not be kept at an emergency facility for more than 30 hours." HG § 10-624(b)(4). The Start of the Involuntary Admission Process If it is determined that the emergency evaluee meets the requirements for involuntary admission, the examining physician at the emergency facility "shall take the steps needed for involuntary admission of the emergency evaluee to an appropriate facility, which may be a general hospital with a licensed inpatient psychiatric unit." HG § 10-625(a) ; see HG § 10-101(g)(1) (defining "facility," "[e]xcept as otherwise provided in this title," to mean "any public or private clinic, hospital, or other institution that provides or purports to provide treatment or other services for individuals who have mental disorders").

An "inpatient facility" is defined in the regulations, much as it is in the statute, as "an inpatient institution that provides evaluation, care, or treatment for individuals who have mental disorders." COMAR 10.21.01.02B(11)(a). An application to initiate the process for involuntary admission must be in writing and accompanied by the certificates of two physicians (or other statutorily enumerated health care providers) who have examined the individual and believe that the individual has a mental disorder; the individual requires inpatient care; and "admission to a facility ... is needed for the protection of the individual or another." HG §§ 10-615 -616. *³⁷⁸ Once confined initially in an appropriate inpatient facility, the individual remains in "observation status" pending a hearing to determine whether the individual should be admitted involuntarily. COMAR 10.21.01.07F(3). Notice and the Involuntary Admission Hearing Within twelve hours after the individual's "initial confinement," the facility must present to the individual a standard form providing notice of admission and advising of various rights, including the right to consult with a lawyer.

HG § 10-631(a), (b). The notice includes the date of the individual's scheduled involuntary admission hearing, COMAR 10.21.01.05 - .06, "to determine whether the individual is to be admitted to a facility ... as an involuntary patient or released without being admitted," HG § 10-632(a). The procedures attendant to the involuntary admission hearing are spelled out in HG § 10-632 and COMAR 10.21.01.09. The hearing "shall be conducted" by an administrative law judge ("ALJ") 4 "within ³³⁴ 10 days of the date of the initial confinement of the individual." HG § 10-632(b).

This requirement is repeated in the regulations: "When an individual is confined on observation status in an inpatient facility on the basis of application and certificates for [involuntary admission], inpatient facility staff shall: (a) Schedule a hearing to take place within 10 days of the individual's initial confinement in the inpatient facility[.]" COMAR 10.21.01.08A(1). Unless the ALJ for good cause orders otherwise, "the hearing shall take place in the inpatient facility where the individual is confined." COMAR 10.21.01.09B. At the hearing, the ALJ shall: (1) Consider all the evidence and testimony of record; and *³⁷⁹ (2) Order the release of the individual from the facility unless the record demonstrates by clear and convincing evidence that at the time of the hearing each of the following elements exist as to the individual whose involuntary admission is sought: (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] (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). 5 The regulations add that the ALJ shall "[o]rder the release of the individual from the inpatient facility" if there was an "error in the process"; the error "is substantial"; and "[n]o other available remedy is consistent with due process and the protection of the individual's rights." COMAR 10.21.01.09G(3).

II

The Present Case Factual Background In the summer of 2015, J.C.N. suffered a stroke and "thyroid storm"-a rare medical condition stemming from an overactive thyroid. Her brain swelled, she suffered partial paralysis on the right side of her body, 6 and she experienced partial loss of sight in her right eye. Her treatment included prescription steroids. *³⁸⁰ Four months later, J.C.N. began exhibiting symptoms of steroid-induced psychosis, a serious mental illness characterized by defective or lost contact with reality and often accompanied by hallucinations or delusions. A clinical social worker 7 filed a ³³⁵ petition for emergency evaluation of J.C.N., and, on November 17, 2015, the Anne Arundel County Police Department transported her to the emergency department of the University of Maryland Baltimore Washington Medical Center ("Hospital").

Once in the emergency department, J.C.N. was determined not to be "medically stable" and was transferred that same day to a medical unit of the Hospital. There, she was observed and treated to address what was at that time her hypothyroid state, as is typically done with patients who present with steroid-induced psychosis. J.C.N. was evaluated by an endocrinologist and neurologist to evaluate possible somatic complications deriving from her then-recent stroke and thyroid storm and to address her hypothyroid condition. Two endocrinologists recommended that J.C.N. take a thyroid medication, Methimazole.

She initially complied but, when a few days later her thyroid levels returned to normal, she refused to take the medication notwithstanding her physicians' recommendation that she continue it to ensure stability. On November 19, 2015, Doctors Sandeep Sidana, a board-certified psychiatrist, and Anisha Bassi, also a physician, evaluated J.C.N. and diagnosed her with bipolar disorder. Both doctors signed certificates stating that J.C.N. met the criteria for involuntary admission. They stated that J.C.N. suffered from "Bipolar 1 Disorder recent episode manic, severe with psychotic symptoms, with a differential diagnosis of steroid-induced psychosis or substance-induced mood disorder with manic features," and they noted her refusal to take the psychiatric medications prescribed to stabilize her manic episode *³⁸¹ .

Dr. Sidana further noted that it was necessary for J.C.N. to remain in the medical unit at that time because there was "no safe alternative for her in that she wasn't medically stable or clear-so she wasn't able to be transferred to any other psychiatric unit including ours-she was kept on the medical floor while we stabilized her medically." While J.C.N. was in the Hospital's medical unit, her family attempted to have her admitted to either Johns Hopkins Hospital or Sheppard Pratt Hospital for inpatient mental health treatment. For different reasons, both hospitals declined to accept J.C.N.: Johns Hopkins did not have an available bed, and Sheppard Pratt denied J.C.N. admission because, at the time of the family's request, she was receiving medical treatment to address the somatic effects of her steroid-induced psychosis. On November 20, 2015, the Hospital's discharge coordinator signed an application for J.C.N.'s involuntary admission to the psychiatric unit of the Hospital. A psychiatric bed became available at the Hospital on November 24.

J.C.N., who was by then medically stable, was transferred that same day to the psychiatric unit for proposed involuntary admission. The Involuntary Admission Hearing J.C.N.'s involuntary admission hearing was held at the Hospital on December 1, 2015, before an ALJ. J.C.N. attended and was represented by counsel. J.C.N. and Dr. Sidana, who had signed one of the November 19 diagnoses and certificates, testified at the hearing.

Ms. Diane Bolger, a psychiatric social worker, testified and conducted questioning on behalf of the Hospital. Ms. Bolger began with a brief statement of facts, including the relevant dates. Dr. Sidana, a stipulated and accepted expert in psychiatry, testified that J.C.N. suffers from "Bipolar 1 Disorder recent episode manic, severe with psychotic symptoms, with a differential diagnosis of steroid-induced psychosis or substance-induced mood disorder with manic features." ³³⁶ He testified that J.C.N., currently in a Ph.D. program, had "grandiose delusions and psychosis about her accomplishments," finances, and *³⁸² abilities. He stated that, influenced by those delusions, J.C.N. had tried to make unrealistic "plans to give these grand talks at various prestigious institutions" in the United States and abroad, for which she believed she would receive monetary compensation.

Dr. Sidana further testified that J.C.N. fired her academic advisor because he did not support her efforts to arrange the talks; she attempted to have her academic committee write letters recommending her for research positions for which she was "clearly unqualified"; she had delusions that she personally knew President Obama and "[v]arious other high-esteemed figures"; and she had attempted to place phone calls to U.S. Senators and the White House. Based on what he had learned from a letter written by J.C.N.'s parents, Dr. Sidana reported that J.C.N. had attempted to make purchases beyond her means, including an automobile valued at $55,000. He explained that, notwithstanding her belief to the contrary, J.C.N. could not safely drive an automobile given the limited use of her right arm and hand, right "foot drop," and partial loss of sight in her right eye resulting from her recent stroke. J.C.N.'s attempt to purchase the car was thwarted by her parents, as they described in the letter.

J.C.N. also had "contacted a company" that would provide chauffeur service, which she believed would cost twenty dollars per month. Dr. Sidana also testified about J.C.N.'s lack of awareness of her mental and physical health: [J.C.N.] has shown very little insight or, actually, has shown no insight into her diagnosis, does not believe at all that she is manic, and therefore, has refused to take her psychiatric medications ... [and] thyroid medications that were prescribed to her.... She was admitted first to the medical floor because she had a stroke around July and she also had a thyroid storm. So, that's a serious thyroid condition in which thyroid hormones skyrocket, and that can actually be very detrimental to her medical health. * * * *³⁸³ [M]y concern for her would be ... she is already demonstrating to me that she is having impaired judgment in managing her thyroid state ....

Dr. Sidana confirmed that J.C.N. had been refusing medications. He was then asked by Ms. Bolger, "[h]as she behaved in an unsafe way other than that since coming to the hospital?" (Emphasis added). Dr. Sidana answered, "No, she has not been unsafe other than that." Dr. Sidana opined that given her history, J.C.N., if released, would not take her prescribed medications and would not comply with follow-up psychiatric care. He further opined that J.C.N. would "quickly damage herself financially" if released.

Dr. Sidana added that J.C.N. needed institutional care because she presented a danger to her own life or safety or the lives or safety of others. He acknowledged that J.C.N. could "safely care for her own basic needs." Dr. Sidana ultimately concluded that J.C.N. was unable or unwilling to be voluntarily admitted, and there was no less restrictive form of intervention available consistent with her welfare and safety. J.C.N. next testified. She stated that she had been seeing doctors regularly since her stroke and was not a danger.

She testified that, if released, she would have her "own apartment, which is in downtown Baltimore." She also believed that in January she would return to Yale as a seventh-year Ph.D. student and live in New Haven. J.C.N. further testified that she "would ³³⁷ love to get out of" the Hospital because she was "very excited" to return to Yale where she would continue working on her dissertation. J.C.N. inconsistently testified that she would "keep a distance from [her] parents," that she would see her parents once a week, and, when told the downtown apartment was not available, that she could live with her parents. Following the conclusion of testimony, Ms. Bolger and J.C.N.'s counsel presented closing arguments.

Counsel for J.C.N. argued a violation of the statutory requirement that the involuntary admission hearing be conducted within ten days of J.C.N.'s initial confinement, which, in counsel's view, was when *³⁸⁴ J.C.N. was taken to the emergency department on November 17. See HG § 10-632(b). Regarding whether J.C.N. should be involuntarily admitted to the psychiatric unit of the Hospital, counsel argued that although J.C.N. "may be a danger to her career" and "may be a danger to her finances," the Hospital had failed to demonstrate that she presented a danger to the life or safety of herself or others as required for involuntary admission under HG § 10-632(e).

Following the parties' arguments, the ALJ announced his decision. He first considered J.C.N.'s argument that the hearing was conducted beyond the ten-day period mandated by HG § 10-632(b). The ALJ found that there had been no such procedural violation. He specifically noted the following: J.C.N. required medical treatment before she could be moved to the psychiatric unit; once she was considered medically stable, she was transferred on November 24 to the psychiatric unit; and the involuntary admission hearing was held on December 1, within the required timeframe for conducting such hearings.

The ALJ then turned to whether the Department had established that J.C.N. should be involuntarily admitted. The ALJ found, based on the required standard of clear and convincing evidence and "the record as a whole," that J.C.N. met the requirements for involuntary admission under HG § 10-632. The ALJ credited the certifying physicians' diagnosis of a mental disorder, "Bipolar Disorder type 1" characterized by grandiose delusions. The ALJ also credited Dr. Sidana's testimony, finding, among other facts, that J.C.N. did not have "any insight into [her] mental illness, and that [she] might decide to drive a motor vehicle.

That is inadvisable at this time." The ALJ determined that J.C.N.'s "lack of judgment, lack of insight, and these issues about finances as well," demonstrated that she did not have "sufficient judgment" to "maintain [her]self" outside of an institutional setting. The ALJ, directing his remarks to J.C.N., concluded: This is an atypical case where there is not one particular incident, or one particular idea of threatening behavior, or being a danger because one is fighting with other individuals, *³⁸⁵ or threatening someone with a weapon, or so forth, but the entire global nature of this case, your lack of insight, and the things that you are indicating that you might do, and I believe it is credible that you might do these things. You are not taking any medication now. Depakote and Risperdal have been prescribed.

So, I conclude that you do present a danger to your own safety and life, and the life of others, particularly if you decide to drive and you are not fit to do so. The ALJ added that there was no less restrictive form of intervention, and he was not convinced that J.C.N. would be suitable for outpatient treatment because she was not taking medications, was in a manic state, needed treatment, and was suffering from stroke and thyroid storm complications. The ALJ therefore determined ³³⁸ that J.C.N. met all criteria for involuntary admission. Judicial Review Because, as we shall see, we "look through" the judgments of the circuit court and the Court of Special Appeals to review directly the decision of the ALJ, there is no need to summarize the proceedings at either of those levels of judicial review.

It is enough to note that J.C.N. filed a timely petition for judicial review in the Circuit Court for Anne Arundel County, raising in that court the claims that she timely presented to the Court of Special Appeals and raises here. We granted J.C.N.'s petition for writ of certiorari to address several questions, two of which we rephrase as follows: 1. Did the Hospital comply with the ten-day deadline for an involuntary admission hearing? 2. Was there substantial support in the record for the ALJ's finding that J.C.N. presented a danger to the life or safety of herself or of others? *³⁸⁶ We answer "yes" to both questions. 8 III.

Standard of Review When this Court has before it the decision of an administrative agency, we review directly the agency's decision and not that of the lower courts. Sturdivant v. Md. Dep't of Health & Mental Hygiene , 436 Md. 584 , 587, 84 A.3d 83 (2014). "When this or any appellate court reviews the final decision of an administrative agency ..., the court looks through the circuit court's and intermediate appellate court's decisions, although applying the same standards of review, and evaluates the decision of the agency." Kor-Ko Ltd. v. Md. Dep't of the Env't , 451 Md. 401 , 409, 152 A.3d 841 (2017) (quoting People's Counsel for Balt. Cty. v. Surina , 400 Md. 662 , 681, 929 A.2d 899 (2007) ).

"A court's role in reviewing an administrative agency adjudicatory decision is narrow." Cosby v. Dep't of Human Res. , 425 Md. 629 , 638, 42 A.3d 596 (2012) (quoting Bd. of Physician Quality Assurance v. Banks , 354 Md. 59 , 67-68, 729 A.2d 376 (1999) ). It is "limited to determining if there is substantial evidence in the record as a whole to support the agency's findings and conclusions, and to determine if the administrative decision is premised upon an erroneous conclusion of law." Id. (quoting Banks , 354 Md. at 67 -68 , 729 A.2d 376 ). In applying the substantial evidence test, we decide whether the ALJ's determination was "supported by evidence which a reasonable person could accept as adequately supporting [the] conclusion." Kenwood Gardens Condos., Inc. v. Whalen Props., LLC , 449 Md. 313 , 325, 144 A.3d 647 (2016).

We *³⁸⁷ "must review the agency's decision in the light most