State of Maryland — Department of Health and Mental ... - DHMH

St at e of Mar yland — Depar t m ent of Healt h and Ment al Hygiene
MENTAL HYGIENE ADMINISTRATION
Cat onsville, Mar yland 21228
NOTIFICATION TO INDIVIDUAL OF ADMISSION STATUS AND RIGHTS
Healt h -Gener al Ar t icle, Tit le 10 and Cr im inal Pr oced ur e Art icle, Tit le 3, Annot at ed Cod e
of Mar yland ar e t he law s w hich p er t ain t o individ uals w ho ar e conf ined in m ent al
hygiene f acilit ies. All r ef er ences in t his d ocum ent ar e t o t hose st at ut es.
Healt h -Gener al Ar t icle (H-G), Tit le 10, “Ment al Hygiene Law ,” Sub t it le 6. “Ad m ission
Pr oced ur es,” Sub t it le 7. “Right s of Ment ally Ill Ind ivid uals in Facilit ies,” and Sub t it le 8.
“Release and Tr ansf er s”
Cr im inal Pr oced ur e(C-P) Ar t icle, Tit le 3. “Incom p et ency and Cr im inal Resp onsib ilit y
Cr im inal Cases”
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Wit hin 12 hour s af t er an ind ivid ual is conf ined in a f acilit y, a st af f m em b er shall inf orm
t he ind ivid ual of :
The b asis f or ad m ission and t he p r ovisions of t he law p er t aining t o t he ad m ission
[H-G, §10-631(a)(1)];
The r ight t o consult w it h an at t orney of t he ind ivid ual’s choice [H-G, §631(a)(2)];
The r ight s of an ind ivid ual in a f acilit y [H-G, §§10-631(c) & 10-701—713].
This not if icat ion shall b e given t o:
The ind ivid ual and r ead in English or w hat ever language and t er m s ar e
ap p r op r iat e t o t he ind ivid ual’s cond it ion and ab ilit y t o und er st and [H-G, §§10-
631(c) & 10-701(f )];
If t he ind ivid ual d oes not und er st and t he not if icat ion :
o t he p ar ent , guar d ian, or next of kin of t he ind ivid ual;
o The p er son w ho signed t he ap p licat io n f or ad m ission t o t he f acilit y, if t he
ind ivid ual has b een conf ined on t he b asis of cer t if icat es f or involunt ar y
ad m ission; and
o Any ot her p er son w ho has signif icant int er est in t he st at us of t he
ind ivid ual [H-G, §10-631(b )(2)]; and
The ind ivid ual again at t he t im e of new ap p licat ion f or volunt ar y ad m ission or
t he execut ion of new cer t if icat es f or involunt ar y ad m ission [H-G, §10-631(e)].
DHMH 33 (Revised March 19, 2013) 1 of 5

NOTICE OF ADMISSION STATUS
_______________________________________ has b een conf ined in _________________________________________
Nam e of Ind ivid ual
Nam e of Facilit y
on t he b asis of :
A Volunt ar y Agr eem ent f or Tr eat m ent w hich has b een read and signed b y t he
ind ivid ual and t he ind ivid ual is 16 years old or old er (Healt h -Gener al Ar t icle, §10-
609);
A Volunt ar y Agr eem ent f or Tr eat m ent w hich has b een read and signed b y t he
p ar ent or guar d ian of t he p er son, and t he ind ivid ual is a m inor (H-G Ar t icle, §10-
610);
2 cer t if icat es f or Involunt ar y Ad m ission (H-G Ar t icle, §§10-616—619);
Civil com m it m ent at hear ing (C-P Ar t icle, §3-106)
An Or d er of t he Cour t :
For exam inat ion as t o com p et ence t o st and t r ial (C- P Ar t icle, §3-105);
Follow ing a f inding t hat t he ind ivid ual is incom p et ent t o st and t r ial and,
b ecause o f a m ent al d isord er , is a d anger t o self or t o t he p er son or p r op er t y
of anot her (C- P Ar t icle, §3-106);
For exam inat ion as t o cr im inal r esp onsib ilit y and com p et ence (C-P Ar t icle, §3-
111);
Follow ing a f ind ing of Not Cr im inally Resp onsib le (C-P Ar t icle, §3-112); or
An Or d er of t he Cour t f or a juvenile.
I cer t if y t hat t his d ocum ent , inf orm ing m e of m y ad m ission st at us and r ight s, has
b een r ead and exp lained t o m e. I w as given t he op p ort unit y t o ask q uest ions and t o
r eceive ad d it ional inf orm at ion on t he ab ove list ed r ight s.
________________________________________ ________________________________________________________________
Dat e and Tim e
Signat ur e of Ind ivid ual
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Ind ivid ual d id not sign ab ove b ecause: __________________________________________________________________
________________________________________________________________________________________________________________________
I cer t if y t hat I have inf orm ed __________________________________ of his/her ad m ission
st at us and r ight s in accord ance w it h t he p r ovision of Healt h -Gener al Ar t icle Tit le 10
and /or Cr im inal Pr oced ur e Ar t icle Not ice of Ad m ission .
has has not b een given t o p ar ent , guar d ian, or next of kin.
____________________________________________ ______________________ _________
(Signat ur e of St af f) (Dat e) (Tim e)
DHMH 33 (Revised March 19, 2013) 2 of 5

PATIENTS’ RIGHTS
AN INDIVIDUAL IN A MENTAL HYGIENE FACILITY HAS THE RIGHT TO:
♦ Receive ap p r op r iat e hum ane t r eat m ent and ser vices t hat r est r ict t he individ ual’s
lib er t y only t o t he ext ent necessar y and consist ent ly w it h t he individ ual’s t r eat m ent
need s and ap p licab le legal req uir em ent s [H-G, §10-701(c)(1)];
♦ Receive t r eat m ent in accord ance w it h an ind ivid ualized t r eat m ent p lan (ITP)
[H-G,§10-701(c)(2)];
♦ Be f r ee f r om r est r aint s and seclusion excep t :
► In an em er gency w her e t he ind ivid ual p r esent s a d anger t o t he lif e and saf et y
of t he ind ivid ual or of ot her s; or
► To p r event serious d isr up t ion of t he t her ap eut ic envir onm ent [H-G, §10-
701(c)(3)];B
♦ Be f r ee f r om p r one r est r aint or rest r aint t hat :
► Ap p lies p r essur e t o t he ind ivid ual’s b ack;
► Ob st r uct s t he airw ay of t he ind ivid ual or im p air s t he ind ivid ual’s ab ilit y t o
b r eat he;
► Ob st r uct s a st af f m em b er ’s view of t he ind ivid ual’s f ace; or
► Rest r ict s t he ind ivid ual’s ab ilit y t o com m unicat e d ist r ess
[H-G, §10-701(c)(4) & (5)]
♦ Be f r ee f r om m ent al ab use and b e p r ot ect ed f r om har m and p hysical and sexual
ab use [H-G, §10-701(c)(6) & (7)];
♦ Have an ad vocat e of t he individ ual’s choice p ar t icip at e in t he t r eat m ent p lanning &
d ischar ge p lanning p r ocess, excep t w hen t he:
► Ind ivid ual is a m inor or an ad ult und er guar d ianship in accord ance w it h
§13-705 of t he Est at es & Tr ust s Ar t icle;
► Par ent of t he m inor or t he legal guar d ian of t he ind ivid ual has r eq uest ed t hat
t he ad vocat e not p ar t icip at e;
► Ad vocat e is an at t or ney act ing in t he cap acit y of legal counsel t o t he
ind ivid ual; or
► Ad vocat e has engaged in b ehavior t hat is:
◘ Disr up t ive t o t he individ ual, ot her p at ient s, or st af f at t he f acilit y; or
◘ Poses a t hreat t o t he saf et y of t he ind ivid ual, ot her p at ient s, or st af f at
t he f acilit y [H-G, §10-701(c)(8) & (d )]
♦ Sub ject t o t he p r ovisions of H-G, §10-708, r eceive t r eat m ent in accord ance w it h t he
p r ef er ences in t he ind ivid ual’s ad vance d ir ect ive f or m ent al healt h ser vices, if one
exist s [H-G, §10-701(c)(9)]
♦ Have access t o t he r esid ent gr ievance p r oced ur e t hat has b een est ab lished at t he
f acilit y [Coe vs Hughes, COMAR 10.21.14];
♦ Have r easonab le access t o w r it ing m at er ials and p ost age, and t o have m ail sent out
p r om p t ly and , excep t at t he d ir ect ion of t he ad d r essee, w it hout b eing op ened ,
unless lim it ed f or m ed ical r easons [H-G, §10-702(a)];
♦ Have r easonab le access t o a t elep hone t o call anyone w ho has not given w r it t en
not ice of b eing unw illing t o b e called , unless lim it ed f or m ed ical r easons
[H-G, §10-702(b )];
DHMH 33 (Revised March 19, 2013) 3 of 5

♦ At all r easonab le hour s, visit and have p r ivat e conver sat ion w i t h a law yer or cler gy of
choice [H-G, §10-703(a)(1) & (2)];
♦ At r easonab le visit ing hour s, visit and have p r ivat e conver sat ion w it h any visit or
w hom t he ind ivid ual w ishes t o see, unless lim it ed f or m ed ical r easons [H-G, §10-
703(a)(3)];
♦ Vot e and r eceive, hold , and d isp ose of p r op er t y [H-G, §10-704] (NOTE: Access t o
p er sonal p r op er t y m ay b e r est rict ed f or m ed ical and /or secur it y r easons);
♦ Par t icip at e in t he d evelop m ent and p er iod ic up d at ing of t he ITP, and b e t old , in
ap p r op r iat e t er m s and language, of :
► The cont ent and ob ject ives of t he p lan;
► Then nat ur e and signif icant p ossib le ad ver se ef f ect s of recom m end ed
t r eat m ent s;
► The nam e, t it le, and r ole of t he p er sons r esp onsib le f or car r ying out t he
t r eat m ent ; and
► When ap p r op r iat e, alt er nat ive t r eat m ent s or m ent al healt h ser vices t hat ar e
availab le [H-G, §10-706(c)];
♦ Ref use t o p ar t icip at e as a sub ject in p hysically int r usive resear ch cond uct ed at t he
f acilit y [H-G, §10-707];
♦ Choose t o r ef use m ed icat ion used f or t he t r eat m ent of a m ent al d isord er excep t
w hen:
► The m ed icat ion is or d er ed b y a p hysician in an em er gency w her e t he
ind ivid ual p r esent s a d anger t o t he lif e or saf et y of t he ind ivid ual or of
ot her s, or
► The ind ivid ual is hosp it alized involunt ar ily or b y ord er of a cour t , and
m ed icat ion is ap p r oved b y a clinical r eview p anel [H-G, §10-708];
♦ An af t er car e p lan in accord ance w it h Healt h -Gener al Ar t icle, §10-809, b ef ore b eing
d ischar ged [H-G, §10-709]; and
♦ If a m inor in a resid ent ial St at e f acilit y, b e p laced in a un it f or m inors, unless t he
ind ivid ual t r eat m ent p lan p r ovid es ot her w ise [H-G, 10-710].
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
ADVANCE DIRECTIVE FOR MENTAL HEALTH SERVICES:
Sub ject t o t he p r ovisions of Healt h -Gener al Ar t icle, § 10–708, Annot at ed Cod e of
Mar yland , if t he individ ual has an ad vance d ir ect ive f or m ent al healt h ser vices
p r ovid ed f or in Healt h -Gener al Ar t icle, § 5–602.1, Annot at ed Cod e of Mar yland , t he
ind ivid ual shall receive t reat m ent in accord ance w it h t he p r ef er ences in t he ad vance
d ir ect ive [H-G, §10-701(c)(9)].
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AN INDIVIDUAL WHO HAS ENTERED A FACILITY ON THE BASIS OF CERTIFICATES FOR
INVOLUNTARY ADMISSION HAS THE RIGHT TO:
♦ An ad m inist r at ive hear ing t o b e held w it hin 10 d ays of init ial conf inem ent t o
d et er m ine if t he ind ivid ual w ill b e involunt ar ily ad m it t ed or r eleased . The hear ing
m ay b e p ost p oned f or good cause f or no m ore t han 7 d ays, and t he p ost p onem ent
shall b e on t he record [H-G, §10-632];
DHMH 33 (Revised March 19, 2013) 4 of 5

♦ Ap p ly t o a cour t of com p et ent jur isd ict ion f or a w r it of hab eas corp us t o d et er m ine
t he cause and legalit y of d et ent ion [H-G, §10-804];
♦ Pet it ion t he cour t f or a jud icial release f r om t he f acilit y so t hat a jud ge or jur y can
d et er m ine if t he ind ivid ual has a m ent al d isord er necessit at ing inp at ient care or
t r eat m ent f or t he p r ot ect ion of t he ind ivid ual or anot her [H-G, §10-805].
RIGHT TO LEGAL COUNSEL:
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An ind ivid ual w ho has b een conf ined in a m ent al hygiene f acilit y has t he right t o
consult w it h an at t orney of choice. If t he ind ivid ual is unab le t o af f ord an at t o r ney,
t he Of f ice of t he Pub lic Def end er shall p r ovid e legal r ep r esent at ion at t he
com m it m ent hear ing. If t he ind ivid ual d oes not have an at t orney, t he ind ivid ual m ay
cont act t he Legal Aid Bur eau, Law yer Ref er r al Ser vice, Maryland Disab ilit y Law Cent er,
and ot her agencies t hat exist f or t he r ef er r al of individ uals w ho need legal counsel.
Each ind ivid ual shall b e given t he op p ort unit y t o call or w r it e a law yer or a r ef er r al
agency or t o have som eone d o so on b ehalf of t he ind ivid ual [H-G, §10-631(a)(2)-(4)].
The services and program s of t he Depart m ent of Healt h and Ment al Hygiene are provided on a non discrim inat ory basis and in
com pliance w it h Tit le VI of t h e Civil Right s Act of 1964. An y com plaint s regardin g alleged discrim ina t ion m ay be f iled in w rit ing
w it h t he Direct or, Ment al Hygiene Adm inist rat ion, Sprin g Grove Hospit al Cent er, 55 Wade Avenue, Dix Buildin g, Cat onsville, MD
21228 and t he Of f ice of Civil Right s, U.S. Depart m ent of Healt h and Hum an Services, 150 S. Indepen den ce Mall West , Suit e 372,
Philadelp hia, PA 19106-3499.
Notice of Admission Status and Rights must be on this form [Health-General Article, §10-631(s)].
DHMH 33 (Revised March 19, 2013) 5 of 5