J.H. v. Prince George's Hospital Center

Leahy, J. Suffering 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 1 (“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 ⁵⁵³ 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. 2 pach 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 pread-mission procedure violations warranted Appellants’ release.

Counsel 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. Before this Court, Appellants challenge the ALJs’ decisions and present issues 3 derivative of one overarching question: During involuntary admission hearings are hospitals required to affirmatively prove compliance with preadmission proce ⁵⁵⁴ dures beyond the statutorily prescribed involuntary admission elements contained in Health-Gen. § 10-632(e)? For the 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. BACKGROUND A. Involuntary Admission Hearings The following is a summary of the testimony presented at each hearing and the ALJ’s findings as to each Appellant. 1. J.H.’s Involuntary Admission Hearing Before 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. On 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[.]” ⁵⁵⁵ Dr. 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 for her. Next, 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, Doctor?” K.H. 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. After 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 ⁵⁵⁶ 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 hearing. The ALJ 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.” J.H. 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 right.” With 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). 4 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 ⁵⁵⁷ ... 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. Fourth, 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. 2.

C.B.’s Involuntary Admission Hearing Before G.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 Hospital. On September 16, 2015, an ALJ held an involuntary admission hearing to determine whether C.B. should be involuntari ⁵⁵⁸ ly 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. The 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.” * ⅜ * [By counsel]: Does the record reflect that two qualifying physicians did the certifications for [C.B.]? Dr. Mirmirani: Yes, ma’am. ⁵⁵⁹ [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. Dr. 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. Mirmi-rani testified that there was no less restrictive alternative. On cross-examination, C.B.’s counsel inquired into the alleged procedural error in the petition filed by C.B.’s father: [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 is? 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. ⁵⁶⁰ [C.B.’s counsel]: Number 10, her dangerousness, it says is not applicable. Dr. Mirmirani: Not applicable. C.B.’s 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.” After 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. The ALJ 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 ⁵⁶¹ “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 it.” Next, 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 professionals] except when she’s forced to in a hospital. 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. After reciting his findings, the ALJ ordered the involuntary admission of C.B. 3.

M.G.’s Involuntary Admission Hearing A 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. 5 On September 16, 2015, an ⁵⁶² 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. The 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 6 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. On 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. Mir-mirani 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. M.G.’s 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 ⁵⁶³ must be released unless the Hospital could demonstrate that it complied with the preadmission procedures. The ALJ 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 explained: 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. The 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 presentation. ⁵⁶⁴ 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 evidence. ... 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. The 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 28-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. Each 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 ⁵⁶⁵ 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 release. (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 M.G. was unwilling and unable to be voluntarily admitted. Lastly, the ALJ determined that there was no available less restrictive form of intervention because M.G. was still psychotic and she lacked insight and judgment.

After announcing his findings, the ALJ ordered the involuntary admission of M.G. 4. B.N.’s Involuntary Admission Hearing B.N.’s family member petitioned for her emergency evaluation on December 30, 2015. On January 13, 2016, an ALJ held an involuntary admission hearing. This time, as a preliminary matter, B.N.’s counsel asserted his argument that the Hospital had the burden of proof to establish compliance with the preadmission procedures in Health-Gen. § 10-601 et seq. before the parties could address the merits (the five elements enumerated in Health-Gen. § 10-632(e)(2)).

The Hospital’s position was that it bore the burden of proof, by clear and convincing evidence, to establish the five elements contained in ⁵⁶⁶ Health-Gen. § 10—632(e)(2), but neither the statute nor the corresponding regulation placed the burden on the Hospital to establish compliance with the preadmission procedures. The ALJ reviewed the applicable regulations and determined that COMAR 10.21.01.09G is silent as to which party-bears the burden of proof as to the preadmission procedures and the applicable evidentiary standard for proving whether the Hospital followed those procedures (i.e., by clear and convincing evidence or by a preponderance of the evidence). Without placing the burden of proof on either party or articulating the applicable evidentiary standard, the ALJ then requested that the Hospital present testimony regarding the preadmission procedures followed by the Hospital. The Hospital called its only witness, Dr. Maddineni, B.N.’s treating physician and a board certified doctor in the field of psychiatry.

He testified that B.N.’s family member petitioned for her emergency evaluation on December 80, 2015, and that she was brought to the Hospital on January 1, 2016. B.N. was evaluated in the emergency room on the same day at 11:30 a.m. After she was medically cleared in the emergency room, B.N. was transferred to the Assessment Stabilization Center (“ASC”), which is part of the psychiatric emergency room. On January 2, 2016, Dr. Rahman evaluated B.N, and determined that she qualified for involuntary admission.

Dr. Rahman took the steps to transfer B.N. to the inpatient unit on January 2, 2016; however, there were no available inpatient beds at the Hospital or any nearby facilities. B.N. remained in the ASC until she was admitted to the inpatient unit on January 4, 2016. In regard to the prerequisites in Health-Gen. § 10-632(e)(2), Dr. Maddineni testified that B.N. was presenting manic symptoms—rapid speech, flood of ideas, extremely disorganized, irritable, agitated, and insomnia—and psychotic symptoms—hearing voices, actively hallucinating, paranoid delusions, and religious delusions. For example, B.N. had the delusion that “God healed her of all medical and psychological problems” including her HIV, hypertension, and bipolar disor ⁵⁶⁷ der such that she no longer requires medication.

Because of these symptoms, Dr. Maddineni opined that B.N. needed inpatient treatment. Dr. Maddineni testified that B.N.’s failure to manage her HIV and hypertension with medication could result in contracting AIDS, or an increased opportunity for infections, a stroke, or organ failure. B.N. was not voluntarily taking her medication and was not cooperating with treatment. Additionally, Dr. Maddineni testified to an instance on January 8, 2016, in which B.N. required involuntary medication because she became agitated, hallucinated, invaded the personal space of other patients and staff, and accused other patients and staff of trying to harm her.

In addition to being a danger to herself, Dr. Maddineni testified that B.N. threatened other patients and staff. In Dr. Maddineni’s opinion, there was no less restrictive form of psychiatric care appropriate for B.N. After the Hospital rested its case, B.N.’s counsel moved for B.N.’s release, reiterating that there were preadmission procedure violations, including “there was no indication [B.N.] was given her notice of admission status [and] no indication [B.N.] was ever given her notice of the hearing.” Further, B.N.’s counsel argued that B.N. had remained in the emergency room for 75 or 76 hours. The ALJ then permitted the Hospital to reopen its case to conduct a re-direct examination of Dr. Maddineni. On re-direct, Dr. Maddineni testified that the Hospital completed the application for involuntary admission on January 4, 2016; that the application provided B.N. with notice of a hearing; and that the Hospital gave B.N. the notice on January 4, 2016.

At the completion of this redirect testimony, counsel for the Hospital asked: [Hospital’s Counsel:] Your Honor, are there any other items that we need to address procedurally? Judge; Any questions from the doctor on—based on that testimony, [counsel for B.N.]? [B.N.’s Counsel:] No, Your Honor. ⁵⁶⁸ The only witness who testified in B.N.’s case was B.N. herself. She testified that she was not a danger to herself or others; and that she “is not a psychiatric patient” and she “[doesn’t] have problems like [schizophrenia].” B.N.’s counsel proceeded to raise, through argument, additional procedural violations not raised earlier in the hearing without asking his witness or the Hospital’s witness, Dr. Maddineni, any questions about the alleged violations. He argued that Dr. Maddi-neni’s testimony did not establish that B.N. was evaluated within six hours of admission as required by Health-Gen. § 10-624(b)(2).

He also asserted that B.N.’s hearing was not held within the 10-day statutory period because she was brought to the hospital on January 1, 2016, for an emergency evaluation, and that the hearing was held on January 13, 2016. At the conclusion of the hearing, the ALJ announced his findings, determining that there were no procedural violations and that all of the conditions for admission were met by clear and convincing evidence. With respect to the procedural violations raised by B.N.’s counsel, the ALJ found that although B.N. spent 75-76 hours in the emergency room—well in excess of the 30-hour statutory limit—the violation did not warrant release because there was “no other available space in any other hospitals for her.” Regarding the 10-day hearing requirement, the ALJ found that B.N.’s hearing occurred within the 10-day statutory requirement because although B.N. was brought to the inpatient unit for emergency evaluation on January 1, after 75-76 hours she was admitted to the Hospital on January 4, and the hearing was held on January 13, 2016. On the merits, the ALJ made express findings on each element contained in Health-Gen. § 10-632(e)(2) that: 1) B.N. had schizophrenia and bipolar disorder; 2) B.N. required inpatient care and treatment; 3) there was no less restrictive form of intervention because B.N. would not seek out mental health care or take medication on her own, 4) B.N. was unwilling to voluntarily admit herself; and 5) B.N. was a danger to herself because of her inability to sleep and seek treatment.

He found that she was possibly a danger to others ⁵⁶⁹ because of her manic and agitated behavior. The ALJ then ordered the involuntary admission of B.N. B. Judicial Review in the Circuit Court On September 28, 2015, J.H., C.B., and M.G. separately petitioned the circuit court for judicial review and jointly filed a motion to consolidate their cases on November 19, 2015. The Hospital consented to the consolidation, which the circuit court granted on December 7, 2015. On January 19, 2016, B.N. petitioned the circuit court for judicial review.

B.N.’s counsel—who represented all Appellants during their involuntary review hearings—moved to join the consolidated cases on February 2, 2016, and the circuit court granted this motion on February 28, 2016. 7 After hearing argument on March 16, 2016, the circuit court issued its memorandum opinion and order affirming the ALJ’s determinations in each case on June 14, 2016. The circuit court concluded that during the involuntary admission hearings, the Hospital was only required to prove the relevant Health-Gen. § 10-682 elements because “[njeither [Health-Gen.] § 10-632 nor COMAR 10.21.01.09 mention that the facility has a burden to produce evidence of procedural compliance with any other conditions.” The circuit court also concluded that COMAR 10.21.01.09G(3) “affirmatively placed the burden of production on the individual patient to raise the issue and produce evidence of a substantial procedural error.” Although the circuit court noted that Appellants’ counsel “broadly raised the possibility of numerous procedural errors,” counsel failed to “provide evidence to establish exactly what, if any, procedural ⁵⁷⁰ errors actually occurred that required [Appellants’] release.” The order was docketed on June 22, 2016, Appellants noted their timely appeal on July 11, 2016. DISCUSSION I. Appellants contend that the ALJ erred by ordering the involuntary admission of Appellants without first finding that the Hospital complied with the preadmission procedures contained in Health-Gen. § 10-601 et seq. Appellants’ argument, reframed for clarity, is that the preadmission procedures are procedural safeguards, such that noncompliance results in “a substantial deprivation of due process” prohibiting involuntary admission.

Appellants assert that establishing the Hospital’s compliance with the preadmission procedures is a “jurisdictional prerequisite.” The Hospital counters that a plain reading of the involuntary admission statute indicates that a hospital is required to prove only the elements enumerated in Health-Gen. § 10-632(e). Whether hospitals are required to affirmatively prove compliance with preadmission procedures during involuntary admission hearings presents a novel question. Before we undertake an analysis of Title 10, Subtitle 6 of the Health General Article and its concomitant regulations, we consider the history that culminated in their passage. A. The Evolution of Law on Involuntary Admission in Maryland During the 1960s and 1970s, the purpose of involuntary commitment changed from “achieving social control by compelling treatment” to an emphasis on individuals’ constitutionally protected right to liberty.

Donald H. J. Hermann, Barriers to Providing Effective Treatment: A Critique of Revisions in Procedural, Substantive, and Dispositional Criteria in Involuntary Civil Commitment, 39 Vand. L. Rev. 83 , 85 (1986). 8 The shift toward protecting the constitutional rights of ⁵⁷¹ individuals facing involuntary commitment is reflected, for example, in the Supreme Court’s decision in 1967 in Specht v. Patterson, 386 U.S. 605 , 87 S.Ct. 1209 , 18 L.Ed.2d 326 (1967). The Specht case involved a petitioner who had been convicted for indecent liberties under one Colorado statute that carried a maximum sentence of 10 years, but who was then committed under another Colorado sex offender statute for an indeterminate term of “from one day to life” without notice and full hearing. Id. at 607 , 87 S.Ct. 1209 .

Specht filed a writ of habeas corpus, which was dismissed by the trial court and affirmed by the Court of Appeals. The Supreme Court reversed, recognizing that “[t]hese commitment proceedings whether denominated civil or criminal are subject both to the Equal Protection Clause of the Fourteenth Amendment ... and to the Due Process Clause.” Id. at 608 , 87 S.Ct. 1209 (citation omitted). In 1975, the Supreme Court considered an action brought under 42 U.S.C. § 1983 by Mr. Donaldson, who, at the initiation of “his father, who thought that his son was suffering from ‘delusions,’ ” was confined as a mental patient in a Florida State Hospital in 1957 and kept in custody there against his will for nearly 15 years. O’Connor v. Donaldson, 422 U.S. 563, 564-66 , 95 S.Ct. 2486 , 45 L.Ed.2d 396 (1975).

Throughout his confinement Mr. Donaldson repeatedly, but unsuccessfully, demanded his release. Id. Donaldson’s challenge was not to the initial commitment, but instead, focused upon the nearly 15 years of confinement that followed. Id. at 567 , 95 S.Ct. 2486 .

A jury in the United States District Court for the Northern District of Florida found that O’Connor, the hospital superintendent, and others, violated Mr. Donaldson’s constitutional right to freedom and the Court of Appeals affirmed. In the Supreme Court, Justice Stewart writing for the majority queried, “may the State fence in the harmless mentally ill solely to save its citizens from exposure to those whose ways are different? One might as well ask if the State, to avoid public unease, could incarcerate all who are physically ⁵⁷² unattractive or socially eccentric.” Id. at 567 , 95 S.Ct. 2486 . The Court held that “mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty....

In short, a State cannot constitutionally confine without more a nondangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.” Id. at 576 , 95 S.Ct. 2486 . In Maryland, the development of the right to procedural due process for persons involuntarily committed occurred during the 1970s and the early 1980s. Prior to this change in the law, regulations did not provide, for example, for mandatory involuntary admission hearings before patients were formally admitted to inpatient psychiatric facilities. See Neil Solomon, Involuntary Commitment and Due Process: The New Maryland Regulations, 8 Md. L. P. 115, 115-16 (1973) [hereinafter Solomon, Involuntary Commitment]. 9 Rather, Maryland employed an ex parte commitment procedure. 10 Before he became a judge, then-practicing attorney Howard S. Cha-sanow commented a decade before the law finally changed in Maryland, that Maryland “permit[ted] an indeterminate commitment without a judicial hearing[,]” and that “[t]he problem of hospitalization of the mentally ill is one that is ever growing in scope, and because of its magnitude, should be of vital interest to doctors and lawyers as well as the general public.” Howard Chasanow, Civil and Criminal Commitment of the ⁵⁷³ Mentally III in Maryland, 21 Md. L. Rev. 279 , 279, 281 (1961).

Chasanow acknowledged that the primary criticism of ex parte commitment procedures was “that they [we]re unconstitutional as violative of the Due Process clause of the Fourteenth Amendment.” Id. at 282-84. Although he ultimately concluded in that article that Maryland’s involuntary commitment laws were adequate to protect the rights of patients, he foreshadowed the need to promulgate the very regulations at issue in this appeal, observing that Maryland should develop “some type of emergency commitment procedure for those in need of immediate treatment but who do not submit to examination at the request of near relatives or friends[.]” 11 Id. at 305. ⁵⁷⁴ A class action filed in the United States District Court of Maryland in 1970 while Neil Solomon served as Secretary of DHMH precipitated the ensuing regulatory reforms. Anderson v. Solomon, 315 F.Supp. 1192 (D. Md. 1970); see Solomon, Involuntary Commitment, supra, at 116. In Anderson , a class of patients involuntarily admitted to state mental institutions challenged the constitutionality of the involuntary commitment statute (then codified at Article 59, §§ 12-13), that permitted their involuntary admission without a hearing or any due process of law.

Id. at 1193. The State moved to dismiss the complaint on the grounds that the General Assembly had enacted recent changes to Article 59 effective July 1, 1970. Id. Acknowledging that Article 59 had been completely rewritten (see 1970 Md. Laws, ch. 407 (S.B. 210)), the Court denied the motion to dismiss, reasoning that the allegations in the complaint were still applicable to the revised law.

Id. The Court explained that a “particularly serious constitutional question [was] raised by those provisions in both the old and the revised law which permit the involuntary commitment of persons for an indefinite period on the certificate of two physicians, without a prior judicial or administrative hearing, or a mandatory subsequent judicial or administrative hearing.” Id. at 1194 (footnote omitted). The Court then identified the statutory provisions, which raised constitutional concerns. Id.

First, the revised statute “d[id] not provide for a mandatory hearing, at any time, for persons who have been involuntarily committed[.]” Id. The Court opined that “[i]t can hardly be doubted that procedural due process requires that a hearing be held at some reasonable point in time before a person can be indeterminately committed.” Id. (citations omitted). Second, it “d[id] not require that a check be made by an independent agency (legal, medical or administrative) charged with the duty of looking out for the interests of patients unable for one reason or another to institute and prosecute such proceedings as necessary to protect their rights.” Id.

Third, the revised statute limited involuntary admission to people requiring treatment for the protection of themselves or another, but the statute did not require the ⁵⁷⁵ physicians’ certification to include that determination. 12 Id. at 1194-95. The Anderson class-action suit prompted the Office of the Attorney General to conduct a study of Maryland’s existing involuntary civil commitment procedures. Solomon, Involuntary Commitment, supra, at 116. According to Solomon’s article, the Office of the Attorney General concluded that Maryland’s involuntary commitment law was likely unconstitutional and the law should be updated to “afford greater protection” to involuntarily admitted patients.

Id. Following Anderson , Maryland’s involuntary admission procedures first appeared as regulations published by DHMH. 13 The regulations were signed on June 12, 1973, and became effective October 1, 1973. 14 A primary focus in revising the ⁵⁷⁶ involuntary admission regulations was creating procedures to protect a patient’s due process rights. 15 Added to the law were new procedural safeguards, including the requirement of a mandatory hearing conducted by a hearing officer 16 within 5 working days of confinement and optional periodic review hearings at the request of the patient. MARR 10.04.03.03G (1974). The regulations placed the burden on the State, by clear and convincing evidence, to establish at the involuntary admission hearing that the patient had a mental illness, required inpatient treatment, and was a danger to him or herself or others.

Id; see also Solomon, Involuntary Commitment, supra, at 117. Through these regulations, DHMH attempted to strike a balance between protecting the rights of patients who were involuntarily admitted, and “society’s interest in minimizing potential injury to its members by involuntarily hospitalizing persons genuinely in need of care or treatment for the protection of themselves or others.” Solomon, Involuntary Commitment, supra, at 118. At the time Solomon published his article, the parties to Anderson agreed to settle the case in light of the revisions to the regulations, pending the court’s approval. Id. at 116. ⁵⁷⁷ In 1979, another lawsuit against Dr. Solomon in his capacity as Secretary, Johnson v. Solomon triggered the next wave of reforms. 484 F.Supp. 278 (D. Md. 1979).

A class action was initiated on behalf of children in civil confinement. Id. at 280 . The class alleged that its members were “denied periodic review as to whether continued hospitalization is necessary” once civilly committed. Id. at 281 .

The class argued, inter alia, that the lack of mandatory periodic review (“meaning a review that is automatically initiated by the court at the appropriate time rather than having to wait for the committed person ... to initiate such review”) in the Maryland Juvenile Causes Act and State civil commitment laws violated the Fourteenth Amendment due process rights of the litigants and all members of the class. Id. at 288 . The Court found that “[sjince commitments must now be made in terms of constitutionally adequate standards, mandatory periodic review is a necessary complement to this overall approach.” Id. at 290 (footnote omitted). Accordingly, the Court concluded that “the absence of a mandatory review of juveniles committed to mental institutions by juvenile courts is unconstitutional.” Id. at 313 .

The Court ordered the State to “adopt a review process satisfying constitutional prerequisites!)]” Id. at 313 . DHMH then amended the regulations in 1981. See 8 Md. Reg. 1635 (Oct. 2, 1981) (notice of final regulations on involuntary admission to mental health facilities and adoption by the Secretary of DHMH); 8 Md. Reg. 1244 -46 (July 10, 1981) (notice of re-proposed regulations on involuntary admission to mental health facilities); 7 Md. Reg. 2268 -71 (Nov. 28, 1980) (notice of proposed regulations on involuntary admission to mental health facilities). The 1981 revisions required, among other things, that the record must demonstrate by clear and convincing evidence three additional elements to establish that a patient qualified for involuntary commitment.

COMAR 10.21.01.07M (1981); 7 Md. Reg. 2271 (Nov. 28,1980). Thus, in addition to establishing that the person 1) had a mental disorder, 2) was in need of institutional inpatient care or treatment, and 3) presented a danger to him or herself or others, the new regulations also required that the record ⁵⁷⁸ demonstrate that 4) the patient was unwilling or unable to be voluntarily admitted, 5) there is no less restrictive form of treatment available, and, 6) for patients over 65 years of age, an additional evaluation was conducted. Id. In 1982, the General Assembly re-codified the State’s health laws into the Health-General Article (civil commitment laws are located in Title 10) and simultaneously codified the involuntary admission regulations in the new statute.

See Comm’n to Revise Annotated Code Report on H.B. 200 (Dec. 10,1981). The purpose of this “revision” was to “basically codif[y] the most significant parts of current agency regulation.” Summary of S.B. 437, Bill File (1982). The 1981 regulations governing involuntary admissions and the corresponding statute enacted in 1982—Health-Gen. § 10-601 et seq.—remain substantially the same today. B. Standard of Review We next consider the applicable standard of review, which, in this appeal, requires some statutory interpretation.

Although a well-reasoned opinion in the circuit court is clearly helpful to the parties and this Court on appeal, our review is limited to the ALJs’ decisions in the underlying cases. Bd. Of Physician Quality Assurance v. Banks, 354 Md. 59, 68-69 , 729 A.2d 376 (1999) (citing United Parcel v. People’s Counsel, 336 Md. 569, 576-77 , 650 A.2d 226 (1994)); see also Comptroller of Md. v. Miller, 169 Md.App. 321, 343 , 901 A.2d 229 (2006). We apply a different standard to the ALJs’ findings of fact from the standard we apply to their conclusions of law.

In regard to the findings of fact, our role “ ‘is limited to determining if there is substantial evidence in the record as a whole to support the agency’s fmdings[.]’” Banks, 354 Md. at 67-68 , 729 A.2d 376 (quoting United Parcel, 336 Md. at 577 , 650 A.2d 226 ). Our review of the ALJs’ conclusions of law is not so narrow—especially in the context of the underlying involuntary admission hearings. We explain. Ordinarily, when a commission or board of review within an administrative agency sits in a quasi-judicial role in a contest ⁵⁷⁹ ed case, appellate courts accord deferential review to the decision of that commission or board interpreting the agency’s enabling statute and the corresponding regulations.

See Adventist Health Care Inc. v. Md. Health Care Comm’n, 392 Md. 103, 118-120 , 896 A.2d 320 (2006). Chief Judge Bell, writing for the Court of Appeals in Adventist, thoroughly explained the rationale for this: Administrative agencies possess an “expertise” and, thus, have a greater ability to evaluate and determine the matters and issues that regularly arise, or can be expected to be presented, in the field in which they operate or in connection with the statute that they administer. ⅜ ⅜ ⅜ Moreover, “th[e] authority delegated to executive branch agencies may include a broad power to promulgate legislative-type rules or regulations in order to implement the statute. Such rules or regulations will often, of necessity, embody significant discretionary policy determinations.” Christ v. Dep’t of Natural Resources, 335 Md. 427, 445 , 644 A.2d 34 (1994). This Court has stated that, in the exercise of that authority, “[a] great deal of deference is owed an administrative agency’s interpretation of its own regulation.” Maryland Transp.

Authority v. King, 369 Md. 274, 288 , 799 A.2d 1246 (2002). Furthermore: “[AJgency rules are designed to serve specific needs of the agency, are promulgated by the agency, and are utilized on a day-to-day basis by the agency. A question concerning the interpretation of an agency’s rule is as central to its operation as an interpretation of the agency’s governing statute. Because an agency is best able to discern its intent in promulgating a regulation, the agency’s expertise is more pertinent to the interpretation of an agency’s statute than to the interpretation of its governing statute.” Md Comm’n on Human Relations v. Bethlehem Steel Corp., 295 Md. 586, 593 , 457 A.2d 1146 (1983).

See also Pollock v. ⁵⁸⁰ Patuxent Inst. Bd. of Review, 374 Md. 463 , 477 n.6, 823 A.2d 626 (2003) (“[A]n agency is best able to discern its intent in promulgating a regulation. Thus, an agency’s interpretation of the meaning and intent of its own regulation is entitled to deference [citations omitted]”); Maryland Transp. Authority v. King, 369 Md. 274, 288-289 , 799 A.2d 1246 (2002) (“[A]n agency’s interpretation of an administrative regulation is ‘of controlling weight unless it is plainly erroneous or inconsistent with the regulation.’ [citations omitted]”).

Id. The rationale undergirding the deference normally accorded agencies in interpreting the statutes and regulations they administer does not apply to the ALJs’ decisions in the underlying cases. In other administrative review regulatory schemes by which the Office of Administrative Hearings (“OAH”) is delegated authority to conduct hearings on