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Home My WebLink About96-00975 ~)~~T~ 4;~? " , :~tY,- .' ; ~ , ." .,'" :". ., -,-',' .,. ,:' ~ ;. '0 't. > ~ V) ~ ~ UJ ~ 0 -t rJ) ..... L\J - ....0 ] .~ 'CU' cD . . . ... 0 0 -l ~ ... <.,) VI ~ &i LLI z ~ J..' .. .. ,.' , J '.,- : IN TilE COIJRT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA : ORPIIANS' COURT DIVISION IN RE: LOUELLA 1', SMITII : CIVIL ACTION - ADJUDICATION : OF INCAPACITY AND : APPOINTMENT OF A GUARDIAN : NO. 21-96-975 CIVIL ORPIIANS' COURT CERTIFICATE OF SEIWICE I hereby certify thtltl served tltrlle tlnd correct copy of the Citation tlnd Petition for GlItlrdianship on the following: Pam Shenk ClImberltlnd/l'elT)' Associtltion of Retarded Citizens 117 N. Hanover Street Carlisle, PA 17013 by personal service, Service WtlS completed on November 24th ,1999 at approximately I :00 p.m. Dated: December ~ ,1999 c' C)Jtd; (}Jc/Ai,' Nadliim AI-Klmlili Certified Legtlllntenl r'~ \ -I' D1SAl3lLlTY LA \V CLINIC 45 N, Pitt 51. Carlisle.I'A 17013 717-243-3696 - . ~ _."1 .'-, ,..1 ." ;)\ p' ::; ('\'" .,..... . ---........... '1' ({ ( /. r, .AI - (.- (- .:.1 ,j) rt" (U~~,'- ,) S' l' \. ~,.,H . ~ i I ~ g i 3. Ar1lcle Addressed to: J r. C l Ll le+l\R 1\'\. om ,-\-\\ ~ .j) ~ I t>OK CIa b \ell fI \171\- I 'lODlp I also wish to receive the following oervlces (for en extra fee): 1. 0 Addressee's Address ~ 2, 0 Restricted Delivery ~ Consult pootmnStor for fee. t 4e. Ar1lcle Number l! 'b i . .CompIllllt:m. 1 ard'or 2"'01 adttitiOnIIlIMcet. .CompIlllitImI3,.... and .b. .p..,.. VOW' MM end add,..t on the rtvenl 01 thlttonn 10 IhIt we can mum thlt _lOyou. .AII"'" 1111I loon 10 tho """ oIlho ....pIoco. .. on tho _"...", doH noI .er.:.il..... RocoIpt RoqlJOllod'on Iho .....pIoco boIow Iho .rtldo_. .The Rllum Rectipt. lIhOW' 10 whOm IhI artidl WlI dlllYered Ind It'll dill doINorod. Ciu3 '" .Ii !I ! 1 !' 5, !; ~ .!l PS Fonn 3811, Decembe 1994 .Q2595-07.nO'79 Dornestle Return Receipt .~~ _,..J 1- .~. 4 n ~(": ~n ,.... c: , r IN TIlE COURT OF CU!\I\lEIH.ANIl COUNTY. PENNSYLVANIA OIH'IIANS' COIJln DIVISION III re: Louella 1'. Smith CIVIL ACTION. ADJUDICATION OF INCOMPETENCY AND APPOINTMENT OF A OUAIWIAN OF TilE PERSON 21.%.975 rONSENT ANI> ,\I'I'ltO"A\. FOIt Al'l'EAltANCE UNI>Elt 1,,,,B.A.lt. 322 I. Jennifer A, Wolbaeh. hereby eonsenttothe nppenranee ofNndhira AI.Khnlili,n Certified Legnllntenl under the supervision of nn nllorney. on my bellnlf in the above-entitled proceeding before the Honorable J. Wesley Oter Jr.nt 1:30 p,m. on Mondny, December 20, 191)9. Date 20 !PC2M-&",-/7'f1 ( As the supervising nllOnley for Nndhira AI-Khnlili, certified under Pn.B.A,R. 322, Inpprove of her nppenrance on behalf of the nbove.nnmed client in the nbove-mulled proceeding. I' J.., "., Date , ;-. (..{. .' I L ,7 I ~/ .. it :. /. '/ c. /~" I i rt::. c. /. -.: ,. h_" ROBERT l~. RAIN'S Supervising AHorney DONALD M, MARRITZ Stnff AHorney DISABILITY Y LA \V CLINIC 45 North Pill Street Carlisle.PA 17013 717.243-2968 .. · PU/nONER'S I EXHIBIT /..);)6 , ) SUPREME COURT OF PENNSYL.VANIA WESTERN DISTRICT ~ J. CERASO, ESOUIRE OEPUTY PROTHONOTARY CANQACE Y. FAY CNIEF CLERK 101 CIlY.COUN1't SUf.OING P1TT1IURGN. PA IU 1I.24U (4111 HI.nla hllP/NNM~.ltIlIPlu' February 11. 1999 REGISTRATION UNDER RULBS 321 , 322 (PENNSYLVANIA BAR ADMISSION RULBS) OP BLIGIBLE LAW STUDBNT Nadhira A1-Khalili 29 W. Ridge Street carlisle. PA 17013 10 THE APPRnvKD SUPERVISING A'M'ORNEYI professor Robert Rains Donald Marritz. Es~ire The Disability Law Clinic The Dickinson School of Law of the pennsylvania State University 45 N. Pitt Street Carlisle. PA 17013 The above-named law student has been approved and certified under Pa. B.A.R. 321 & 322 by: Harvey A. Feldman. Associate Dean The Dlckinson School of Law The pennsylvania State University 150 South College Street Carlisle, PA 17013-2899 as a duly enrolled law student who has completed at least three (3) semesters of legal studies. or the equivalent thereof. is of good character. has been adequately trained and is of competent legal ability to perform as a legal intern as of reb 11. 1999. pursuant to such certification and in accordance with and subiect to the provisions of Pa. B.A.R. 321 & 322. the above stuaent has been registered and you have been approved to perform the dutip-o of supervising attorney. WITNESS '/flY signature and the .eal of thl Court. rLa~ ~ er o. Squlre pr honotary Icyf ~ PETITIONER'S I EXHIBIT 1-) () "'1.lI\ll'~' L "xhlll'hh'f. 1'\11) llih'l"!tlf,';IIHl.lIIll' '\'"''l"l.lh''' .IIZ I:rtllhll~ll.hl ",lInp Ihl1.I'" 171111 171717.12-2'117 Guidance Associates of P A Branch Office .17.11.inll1ln W,lY F.lst L"h.lI11Ill'l'sburg, 1',\ 17201 RES.lJME 1999 rtl~I'IIt' II ~h'dll'f. ~l.r\. lIH'lhl'\II'''Hhlllll~I'1 17\ 1111(1,111 W,1\' I....' t 'h.lIl1l~l'J..bllf~~. 1',\ InOI c7171 :1,l..I\II.:! Eugene II. Stecher, M,A. 473 Lincoln Way East Chambersburg, Pa. 17201 Phone: 717-263-9392 ~ PETITIONER'S i EXHIBIT , ~ IdLyk,a U~ V Education 1965 - A.B., Albright College, Reading, Pa. 1968 - M.Div., United Seminary, Dayton, Ohio. 1983 - M.A., Loyola College, Baltimore, Md. Work History 1968-1973 - Pastoral Ministry. 1973-1980 - Pa Dept. of State, various professional and administrative positions, 1975-1987 - Director, CONT ACT-Chambersburg, 24.Hour Helpline, 1982-1983 - Wilson College, Coordinator of Counseling Services. 1983-1984 - Special Assistant, State Board of Psychology. 1983-1987 - Psychological Associate, Guidance Associates ofPa. 12/3/87 to present - Psychologist in private practice Experience and Contracts. Nol Current Research and Statisties: State Board of Psychology. Evaluations: Scotland School for Veterans' Children. Therapist: Lellerkenny Army Depot Health Clinie, Group Education Programs: FranklinlFulton D/A Council. Mediation/Custody Officer: 39th ludieial District (Pennsylvania). Current Experience and Conlracts. Evaluation Therapy Consultation Self referrals: Families/Couples/Individuals. Fulton County Services for Children. BedfordlFulton Head Start, Knestrick & SIeber: Cornell-Abraxas Youth Programs EAPlManaged Care Contraets: Magellan, United Behavioral Health, and many others. Credentialed by state offices: Medical Assistance [child through age 21], Disability Detennination [child through adult], Voeational Rehabilitation [Adolescent, Adult). Olher Client Sources: Attorneys, Physicians, Guidance Associates ofPa [Camp Hill], Legal Services, Inc., County Base Service Units, Human Services Agencies, Court Custody Offices, Insurance Provider Panels, Secured Positions Employers. Professional Credenlials Pennsylvania Psychologist License (Ps.005074-L). Pennsylvania PsyehDlogical Association (Member). Registered Custody Evaluator, Professional Academy of Custody Evaluators (Diplomate). , . :"\, ~'.:. :',,\,,:><,"~ll'.li ':\~,::~.~. \c.:'''~ '.:.'," ... .... .,~ . '.:t .;:.~:;,':' C~;,t\,\!,...', ....:.l::.T Guidance Associates of P A Branch Office ~l.",h'\' I "'~:hlll'ld~,t. 1',1 P 1 llh'\:ll1r. (;uhl,lIl(l' .\....11(\,111'.. .112 I rhlhll~\,.hl ,',UtiI' 11111. 1':\ 1~t111 (7Ii) ilZ.;.ll;' 47) Unwin Way East Chambl!rsburll. I'A 17201 RESUME t999 11I.~t'lll' II '>h'illl'r, M,\ 11(l'lhl'tll'''\'lhilltl.~I..1 -li'\ I inwln \\,,1\' 1""..1 C-h.111l1""...hur.: PA Ii'ZIII 11171 ~hV'\II~ Eugene II. Stecher. M.A. 473 Lincoln Way East Chambersburg, Pa, 17201 Phone: 717-263-9392 Education 1965 - A.B., Albright College, Reading, Pa. 1968. M,Div., United Seminary, Dayton, Ohio. 1983 - M.A., Loyola College, Baltimore, Md. Work History 1968-1973 - Pastoral Ministry, 1973-1980 _ Pa Dept. of State, various professional and administrative positions, 1975-1987 _ Director, CONTACT-Chambersburg, 24-Hour Helpline. 1982.1983 - Wilson College, Coordinator of Counseling Services. 1983.1984 - Special Assistant, State Board ofPsyehology. 1983-1987 _ PsyehDlogical Associate, Guidanee Associates of Pa. 1213/87 to present - Psyehologist in private praetice Experience and Contracts' Not Current Research and Statistics: State Board ofPsycholDgy. Evaluations: Scotland Sehool for Veterans' Children, Therapist: Letterkenny Anny Depot Health Clime. Group EducatiDn Programs: Frank1inlFulton D/ A Council. Mediation/Custody Officer: 39th Judicial District (pennsylvania), Current Experience and Conlracts' Evaluation Therapy Consultation Self referrals: FamilieslCDuples/lndividuals. Fulton County Services for Children. Bedford/Fulton Head Start. Knestrick & SIeber: Cornell.Abraxas Youth Programs EAPlManaged Care Contraets: Magellan, United Behavioral Health, and many others, Credentialed by state offices: Medical Assistance [child through age 21], Disability Determination [child through adult], V oeatiDnal Rehabilitation [Adolescent, Adult]. -- Other Client Sources: Attorneys, Physicians, Guidance Associates ofPa [Camp Hill], Legal Services, Inc., County Base Service Units, Human Services Agencies, Court Custody Offices, Insurance Provider Panels, Secured Positions Employers, Professional Credentials Pennsylvania Psychologist License (Ps-005074-L), Pennsylvania PsychologiearAssociation (Member). Registered Custody Evaluator, Professional Academy of Custody Evaluators (Diplomate). (-\.:::.~~ ::'L. t'",~'d~tlj"t:t(.,l Tr":lrlt:. :\nt:l.'r \1.l!1.1Ll'!!Wnt . \h.di.1t:,.;. (~;":"lh'. L::l'.:.llh':~ MAIN OffiCE 412 Erford RO.td ump Hili, PA 17011 Stanley E. Schneider. Ed.D. DlrKtor GUIDANCE 1 ASSOCIATES OF ~ PENNSYlVANIA " , \ . I , ." ,.' C~mp Hill: (717) 732.2917 Henhey: (717) 533.4312 Cu\llle: (717) 245.2289 Ch~mbersburg: (717) 2&3.9392 FAX: (717) 732.5375 PSYCHOLOGICAL EVALUATION Client: Louella Smith BID: 10/23/38 Age: 60 Education: Informal Referring Agency: CP MH/MR ~valuation D~."",,- i?P:6J.'P., .:10' ' .'," . .,. ,\;i' ,-,:t~".'z'l:t;ll"(:I". U~~l'''';''''.: . ..... .. _.... t ,,,'I,~t.. ..... j. Ref'en-aI InformatiolL Lotidlabas been n:fblod for "psychological evaluation to provide an update of intellectua1 functioning and level of daily, adapiBtioiL ~ PETITIONER'S I E~IBIT ll}~'V Assessment Tools. Observation and Interview, Impairment was too severe for standardized tasks to be useful. perceptuallmotor ability is \imited to scribbling with a large crayon. Observation. Louella was accompanied by Alice Lesh who has served as her caregiver for the past eight years. Louella presented in a wheel dlair!Jnd had a neat and clean Bppcarance, Weight appeared to be excessive for ~..swurc and build. l.9UelIa was unable to vezbaI1y communicate. She did engage 111 many VOC"'i7J1tiDDS ~echoing of words. During the interview she held a beanie toy, and her hand was in constant motion with it. Louella is an affectionate person who made kiSsing sounds toward the ~miner when it was time to leave. ',.' " "'; ~.'(.~' . Interview. Louella resided atPennhurnlDOst'ofher 1ife, but in 19S5'she moved to a group home, and she has her own room and bath. ~ Jtc two other housemates', Louella's twin sister and her father are both deceased, For years there'was no contact with her mother who is now in her 80's and lives in Blain, Pa. However, the mother has visited in the past year, and she tells Louella, "This is.your mother. I IDve you." ,.....~.. . Louella rises .1ll,.~.;..~h.1I1)As n~ independ~.peno~ careslalls. Sh~ may .run a cloth" over part of her ooafft'lSIle IS ilble to gIVe some he1~1n dressin8 and undresslll8. NonnaIly she eats oatmeal for bre'H'.;.( She can use a spoon ~with a secured ~ whi~~ a lip. Her eating is descn'bed as "neat,. She driI1ks from a reguiar &p but holds it Iil her owiljudque way, She is able to wipe her mouth with a'napkin and to wipe the area where she has juSt"~en. Following breakfast Louella will sit in the living room and listen to musie and play with toys such as the beanie animals, baUs, plastic puzzle pieces. and a number of gadgets that make a variety of sounds. She ....il\ pick things up otft!1e floor. Louella is sufficiently mobile to use a walker as I(\ng as it is b'Uided by an adult or to use a railing. Later in the morning she attends the Alternatives Day ClIfC program and them comes home by 1PM. She then spends time again in th~ living roorn unlillhe cverjng meal III 4PM. Her food is served in puree form. and she usually crinks juic~ In the evening Ihe siatfworks on goals like vocabulary, carr);llg dishes to the sink, Comprehensive psychological Services . Drug and Alcohol Treatment . ..,', picking up dirty clothes, and other activity geared toward independent behavior. Louella does not engage in behavior that is aggressive toward others or a danger to herself. Between 8:00 and 9:00PM Louella has a way of indicating tbat she is ready for bed. Louella speaks the following words with a recognition of their meaning: bed, eat, cup, tea, coffee, no. If while riding along deseriptions ofthe scenery are given or a song is played, Louella is able to repeat words. Receptively, she appears to understand the following terms: stand, sit, slide back, wash the table, step up (to the van), back up, stand still, tife your foot. However, if seeing a doctor, she will not respond to the following phrases: open your mouth, take a deep breath. Except for a very oecasional outburst, Louella does not voealize anger. In addition to the activity already mentioned, for enjoyment Louella likes to hang on to staff and move to country music. Occasionally, she has the opporrunity to attend a concert, and this Fall she will be taking a guided tour to Tennessee to the Grand Ole Opry. She seems to very much enjoy long rides. A basic therapeutic intervention consists of keeping something in Louella's hands constantly so that she does not scratch.up her faee and head. Diagnostic and Clinical Impressions. Range of functioning is most similar to Profound mental retardation (318.2), The evidenee for this conclusion consists of almost total self-management dependency, both in terms of self-care and independent judgment, language limited to the most rudimentary understandings, no basie academie skills. and no production activity capacity except use of a spoon. Community and interpersonal adjustment and awareness is consist with severe rather than profound impairment. Louella is certainly deserving of all county services available to mentally and physically challenged persons. ~, Eu ne H. Stecher, M.A. Psychologist GAPlPsyEvaVLouellaSmith 2126/99 2 IN THE MATTER OF LOUELLA P. SMITH, an allegedly incapacitated person IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION No. 21-96-975 IN RE: PETITION OF JENNIFER A, WOLBACH SUPPORTING ADJUDICATION OF INCAPACITY AND APPOINTMENT OF A GUARDIAN OF THE PERSON OF LOUELLA P. SMITH, AN INCAPACITATED INDIVIDUAL. PURSUANT TO 20 Pa.C.S, CH. 55 BEFORE OLER, J. ORDER OF COURT AND NOW, this 20th day of December, 1999, upon consideration of the Petition of Jennifer A. Wolbach Supporting Adjudication of Incapacity and Appointment of a Guardian of the Person of Louella P. Smith, an Incapacitated Individual, Pursuant to 20 Pa. C,S. Ch. 55, and following a hearing on this date at which the subject of the proceedings was present with her court-appointed counsel, Stephen Hogg, Esquire, and at which the Court received testimony and other evidence in support of the petition, Louella p, Smith is adjudicated an incapacitated person, and Jennifer A. Wolbach is appointed permanent plenary guardian of her person. The guardian is directed to file reports in accordance with the provisions of the Probate, Estates, and Fiduciaries Code respecting incapacitated individuals. Notice is hereby provided to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. Louella p, Smith, a domiciliary of Cumberland County, residing at 1026 Drexel lIills Boulevard, New Cumberland, Cumberland County, Pennsylvania (a community residential facility operated by the Cumberland-Perry Association for Retarded Citizens); Ms. Smith was born on October 23, 1938, and is presently 61 years old. 2. Ms. Smith's nearest next of kin is her mother, Aletha M. Smith, an adult in her 80's, who resides at RD 1, Box 92, Blain, Perry County, Pennsylvania, and who has indicated no objection to the petition for appointment of a plenary guardian of the person and no objection to the appointment proposed of Ms. Wolbach, 3. Petitioner is Jennifer A. Wolbach, residing at 1072-11 Lancaster Boulevard, Mechanicsburg, cumberland County, Pennsylvania. 4. The allegedly incapacitated person has been represented in this proceeding by Stephen Hogg, Esquire, Court-Appointed Counsel. 5. Ms. Smith suffers from profound mental retardation, a condition which has existed since birth. 6. As a result of this condition, Ms. Smith's ability to receive and evaluation information and make and communicate decisions has been impaired to such a significant extent that she is totally unable to meet the essential requirements for her physical health and safety. . 7. The aforesaid condition of profound mental retardation must be said, at the present time, to be of an indefinite duration. 8. The Court finds that Ms. Smith is in need of plenary guardianship services with respect to her person. 9. Pursuant to the statute respecting incapacitation, a permanent plenary guardianship of her person is required in this case. 10. Jennifer A. wolbach is a person qualified to serve as plenary guardian of Ms. Smith's person. 11. The foregoing Findings of Fact are made on the basis of clear and convincing evidence. DISCUSSION The provisions respecting an adjudication of incapacity have recently been amended and are contained in 20 Pa. C,S. Sections 5501 et sea. Petitioner has substantially complied with these provisions, and based upon the foregoing Findings of Fact, the following Order of Court will be entered. ORDER OF COURT AND NOW, this 20th day of December, 1999, upon consideration of the petition of Jennifer A. Wolbach Supporting Adjudication of Incapacity and Appointment of a . " .. Guardian of the Person of Louella P. Smith, an Incapacitated Individual, Pursuant to 20 Pa. C.S, Ch. 55, and following a hearing on this date at which the subject of the proceedings was present with her court-appointed counsel, Stephen Hogg, Esquire, and at which the Court received testimony and other evidence in support of the petition, Louella P. Smith is adjudicated an incapacitated person, and Jennifer A. Wolbach is appointed permanent plenary guardian of her person. The guardian is directed to file reports in accordance with the provisions of the Probate, Estates, and Fiduciaries Code respecting incapacitated individuals. Notice is hereby provided to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. By the Court, Isl J. Weslev Oler. Jr, Nadhira AI-Khalili, Certified Legal Intern Robert E. Rains, Esquire Disability Law Clinic 45 North Pitt Street Carlisle, PA 17013 For the Petitioner Stephen Hogg, Esquire Court-Appointed Counsel for Louella Smith wcy c IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION LOUELLA P. SMITH, An Alleged Incapacitated Person NO. 21-96-975 : INCAPACITATED PERSON IN RE: PETITION FOR APPOINTMENT OF A TEMPORARY GUARDIAN OF THE PERSON PURSUANT TO 20 PA. C.S.A. 5513 BEFORE OLER. J. ORDER OF COURT AND NOW, this 26th day of December, 1996, upon consideration of the petition for Appointment of a Temporary Guardian of the Person Pursuant to 20 Pa. C.S. 5513, and following a hearing held at the Cumberland County Courthouse at which the allegedly incapacitated person was present, Louella P. Smith is adjudicated an incapacitated person, and her mother, Aletha M. Smith, residing at R.D. 1, Box 92, Blain, Perry County, pennsylvania, is appointed temporary partial guardian of her person for the purpose of executing a "2176 waiver" and any other necessary documents to effect her daughter's continued participation in the facility known as Drexel Hills Group Home in New Cumberland, Cumberland County, Pennsylvania. This appointment shall expire following the accomplishment of this function. No bond shall be required of the guardian. Notice is hereby provided in person to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. . .. ~ ...... IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTy, PENNSYLVANIA ORPHANS' COURT DIVISION LOUELLA P. SMITH, An Alleged Incapacitated Person NO. 21-96-975 INCAPACITATED PERSON IN RE: PETITION FOR APPOINTMENT OF A TEMPORARY GUARD I OF THE PERSON PURSUANT TO 20 PA. C.S.A. 5513 BEFORE OLER. J. OPINION ANn ORDER OF COURT oler, J. At issue in the present case is whether Louella P. smith should be adjudicated an incapacitated person and, if so, whether her mother, Aletha M. smith, should be appointed temporary partial guardian of her person. A hearing was held on the matter on Thursday. December 26, 1996, before the undersigned judge. The allegedly incapacitated person was present for the hearing. Based upon the evidence presented at the hearing, the following Findings of Fact, Discussion and Order of Court are made and entered: FINDINGS OF FACT 1. The allegedly incapacitated person is Louella P. smith. a 58-year-old (date of birth october 23, 1938) adult individual residing at Drexel Hills Group Home, 1026 Drexel Hills Boulevard, New cumberland, cumberland County, pennsylvania. 2. petitioner is Robert L. O'Brien, Esquire, . solicitor for the Cumberland/Perry Mental Health/Mental Retardation Office. 3. Ms. Smith, since birth, has been profoundly mentally retarded. 4. As a result of that condition, Ms. smith's ability to receive and evaluate information and make and communicate decisions has been impaired to such a significant extent that she is unable to meet essential requirements for her physical health and safety in the form of deciding whether to execute a "2176 waiver" for purposes of federal funding and other documents necessary for her continued care at a facility known as Drexel Hills Group Home. 5. Guardianship services are necessary for Ms. Smith, notwithstanding the personal assistance which she receives from her family and from services provided by the county. 6. Based on the aforesaid condition of Ms. Smith and her lack of capacity to make and communicate decisions in the regard mentioned, a temporary and partial guardianship with respect to her person is required. 7. The duration of this guardianship shall be until the guardian has executed the necessary "2176 waiver" and secured Ms. Smith's continued participation in the aforesaid program, if the guardian feels that such measures are in the interest of her daughter. 't, ... ......." B. Pursuant to 20 Pa. C.S. Section 5512.1(b), it is found that Ms. Smith is partially incapacitated and in need of temporary partial guardianship services of her person. 9. The mother of Ms. Smith is a person qualified under 20 Pa. C.S. Section 5511(f) to serve as guardian of her person; Louella P. Smith's mother lives at R.D. 1, Box 92, Blain, Perry County, Pennsylvania. 10. It appears that Ms. Smith's condition is of an indefinite nature in terms of duration. 11. The foregoing Findings of Fact are made on the basis of clear and convincing evidence. DISCUSSION The provisions respecting adjudication of incompetency have recently be amended and are contained in 20 Pa. C.S. Sections 5501 et sea. Petitioner has substantially complied with these provisions, and, based upon the foregoing Findings of Fact, the following Order will be entered: ORDER OF COURT AND NOW, this 26th day of DeCember, ].996, upon consideration of the Petition for Appointment of a Temporary Guardian of the Person Pursuant to 20 Pa. C.S. 5513, and following a hearing held at the Cumberland County Courthouse at which the allegedly incapacitated person was present, Louella P. Smith is adjudicated an incapacitated person, and her mother, A1etha M. Smith, residing at R.D. 1, Box 92, Blain, Perry county, Pennsylvania, is appointed temporary partial guardian of her person for the purpose of executing a "2176 waiver" and any other necessary documents to effect her daughter's continued participation in the facility known as Drexel Hills Group Home in New cumberland, Cumberland County, pennsylvania. This appointment shall expire following the accomplishment of this function. No bond shall be required of the guardian. Notice is hereby provided in person to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. By the Court, Isl J. Weslev Oler. Jr. J. Robert L. O'Brien, Esquire Solicitor for Cumberland/perry MH/MR Aletha M. Smith R.D. 1, Box 92 Blain, PA 17006 Louella P. Smith Drexel Hills Group Home 1026 Drexel Hills Boulevard New Cumberland, PA 17070 Cumberland/Perry MH/MR :slr IN RE: LOUELLA 1'. SMITII : IN TIlE COURT OF COMMON PLEAS : CUMBERLAND COUNTY PENNSYLVANIA : ORPIIANS' COURT DIVISION Ol(-fb - 975" PRELII\1INAIW I>ECIU;:E , " . AND NOW, this $ \t, day of.Nol.lc..,\:'c5, \ ~'i'i' ,upon consideration of the ~ : :1 , :1 'I , i PetitiDn for Adjudication of Incapacity And Appointment of a Plenary Guardian ofThe Person of Louella P. Smith, it is hereby ORDERED and DECREED that: I. A citation is awarded, directed to Louella p, Smith, to show cause why she should not be adjudged an incapacitated person and why a plenary guardian of her pcrson should not be appointed; the hearing thereon to be held in Court Room / , Cumberland County Courthouse, Carlisle, Pennsylvania, on 'fi7l1l2 'f ~. ~ 0 , /!l!li, at /: 3t) o'clock, :t.M, 2, Petitioner shall cause to served by personal service the Citation and Pctition, together with an attached Notice pursuant to the provision 01'20 Pa,C,S.A. !j 5511(a) upon Louella Smith, the allegedly incapacitated person, atleasttwcnty days prior to the Court hearing. The contents and tenns of the Citation, Petition and Notice shall be explained to the maximum extent possible in language and tenns the allegedly incapacitated person is most likely to understand in accordance with the provisions 01'20 Pa,C.S,A!j 5511 (a), An allidavit of service containing specific avennents as to the above requirements shall be presented at the beginning of the court hearing. 3. At least twenty days prior notice of the court hearing, together with a copy of the \: 5, Namcs and addrcsscs of othcr scrvicc providcrs: Unitcd l'crchraIPalsy-Altcrnalivc (Day Program) 925 Linda Lanc Cmnpllill,PA 17011 Cumbcrhmdll'crry.MIIIMR (Casc Mauagcmcut) 16 Wcst lIigh Strcct Carlislc,pA 17013 Casc Mauagcr: Nancy Parrish 6, Louclla 1'. Smith's ncxt of kin is hcr mothcr, Alctha M. Smith, an adult in hcr cightics (80's), who residcs at ItD, I, Box 92, l3Iain, Pcrry County, Pcnnsylvania,I7006, Thcrc arc no other presumptive adult heirs to Louclla p. Smith's cstate, Alclha Smith is in agrccmcnt with this petition to determine Louella Smith ineapacitatcd and appoint me as her guardian of her person, 7. Guardianship of the person is being sought because Louella Smith's mcntal retardation impairs her capacity to make and communicatc decisions. This petition is instituted to aid and benefit Louella Smith, and the nature of pctitioner's relationship with her is that of a close personal friend as well as her former Cumberland County MHlMR case manager, 8. Petitioner is not seeking guardianship of the estate because Cop ARC currently handles all of Louella 1', Smith's linancial atlilirs. Pctitioner avers that C-PARC is better equipped to handle those matters than she. 9, Louclla Smith is ineapacitated as defincd in Chapter 55 of the Probate Estates and Fiduciaries Code. Shc is an adult whosc ability to receive and evaluate information etTectively and communicate decisions is impaired to such a signilicant extent that she is totally unable to meet essential requirements for hcr physical hcalth nnd safcty, 10, In n psyehologicnl Evaluntion performed by Eugene H. Stecher, MA of Guidance Associatcs of Pcnnsylvania un Fchruary 26, IlJlJlJ, 1.uuclla Smith's rangc of limctioning was dctcrmincd tu hc "prolillllldly mcntally rctardcd", Shc is almost totally dcpcndcnt lilr scll~ managcmcnt. Shc has no indcpcndcnt pcrsonal carc skills. Shc is unahlc tu vcrhally communicatc. Louclla Smith's community ami intcrpcrsonal adjustmcnt and awarcncss arc consistcnt with scvcrc impairmcnt. II, Louclla Smith uscs a whcelchair lilr mostofhcr mohility, Shc can usc railings to hclp hcr walk, or a walkcr as long as it is guidcd by an adult. Shc is blind and ovcrwcight. 12. Stcps have becn taken to Iind a Icss rcstrictivc ahcnmtivc to this guardianship, C-PARC gives Louclla Smith daily instruction in activitics gcarcd toward indcpcndcntliving, but her impainnent is too scvcrc and shc continucs to nccd guardianship scrviccs, 13, Petitioncr is qualilicd to bc Louella Smith's guardian bccause shc is interested in her welfare and has no intcrests advcrse to hcrs. In addition, Petitioner eamcd a Bachelor of Arts degree in psychology from Elizabethtown Collegc, and is currcntly cmploycd as a care manager at the Cumberland County Omce of Aging. 14, On December 26, 1996, Thc Orpllllll'S Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania, adjudged Louella Smith incapacitatcd lor the purpose of appointing a tcmporary guardian of the person to cxccutc a 2176 waivcr, This guardianship expiTed when the 2176 waiver was cxccutcd on Octobcr 7, 1996. A copy of the pctition and order in that matter, Docket Numbcr 21-96-975, is attachcd, 15, Louclla Smith has no currcnt guardian alrcady appointed. 16, Petitioner, hcreby, givcs hcr writtcn conscnt to bccomc Icgal guardian of Louclla p, Smith lor thc duration of Pctitioncr's lifc or Louclla P. Smith's lifc, whichcvcr shall cnd Iirst. .- IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION LOUELLA P. SMITH, An Alleged Incapacitated Person NO. 21-96-975 INCAPACITATED PERSON IN RE: PETITION FOR APPOINTMENT OF A TEMPORARY GUARDIAN OF THE PERSO~ PURSUANT TO 20 PA. C.S.A. 5513 BEFORE OLER. J. ORDER OF COURT AND NOW, this 26th day of December, 1996, upon consideration of the Petition for Appointment of a Temporary Guardian of the Person Pursuant to 20 Pa. C.S. 5513, and following a hearing held at the cumberland County Courthouse at which the allegedly incapacitated person was present, Louella P. Smith is adjudicated an incapacitated person, and her mother, Aletha M. Smith, residing at R.D. 1, Box 92, Blain, Perry County, Pennsylvania, is appointed temporary partial guardian of her person for the purpose of executing a "2176 waiver" and any other necessary documents to effect her daughter's continued participation in the facility known as Drexel Bills Group Bome in New Cumberland, Cumberland County, Pennsylvania. This appointment shall expire following the accomplishment of this function. No bond shall be required of the guardian. Notice is hereby provided in person to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. . .., -, ~.. ~. IN THE MATTER OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION LOUELLA P. SMITH, An Alleged Incapacitated Person NO. 21-96-975 INCAPACITATED PERSON IN RE: PETITION FOR APPOI~ OF A TEMPORARY GUARDIAN OF THE PERSON PURSUANT TO 20 PA. C.S.A. 5513 BEFORE OLER. J. OPINION AND ORDER OF COURT Oler, J. At issue in the present case is whether Louella P. Smith should be adjudicated an incapacitated person and, if so, whether her mother, Aletha M. Smith, should be appointed temporary partial guardian of her person. A hearing was held on the matter on Thursday, December 26, 1996, before the undersigned judge. The allegedly incapacitated person was present for the hearing. Based upon the evidence presented at the hearing, the following Findings of Fact, Discussion and Order of Court are made and entered: FINDINGS OF FACT 1. The allegedly incapacitated person is Louella P. Smith, a 58-year-old (date of birth October 23, 1938) adult individual residing at Drexel Hills Group Home, 1026 Drexel Hills Boulevard, New cumberland, Cumberland County, Pennsylvania. 2. Petitioner is Robert L. O'Brien, Esquire, . . solicitor for the Cumberland/Perry Mental Uealth/Montlll Retardation Office. 3. Ms. Smith, since birth, hilS boon profoundly mentally retarded. 4. As a result of that condition, Ms. Smith's ability to receive and evaluate information and make Ilnd communicate de<:isions has been impaired to such a oignifioant extent that shll is unable to meet esoential requirOlllonto for her physical health and oafety in the form of deciding whether to execute a "2176 waiver" for purposes of federal funding and other documents necessary for her continued care at a faoility known as Drexel Hills Group Home. 5. Guardianohip serviceD are necessary for Ms. Smith, notwithstanding the personal assiotance which ohe receives from her family and from serviceo provided by the county. 6. Based on the aforesaid condition of Ms. Smith and her lack of capacity to make and communicate decisions in the regard mentioned, a temporary and partial guardianohip with respect to her person is required. 7. The duration of this guardianohip oball be until the guardian has executed the necessary "2176 waiver" and secured Ms. Smith's continued participation in the aforesaid program, if the guardian feels that ouch meaoureo are in the interest of her daughter. 8. Pursuant to 20 Pa. C.S. Section 5512.1(bl, it is found that Ms. Smith is partially incapacitated and in need of temporary partial guardianship services of her person. 9. The mother of Ms. Smith is a person qualified under 20 Pa. C.S. Section 551l(fl to serve as guardian of her person; Louella P. Smith's mother lives at R.D. 1, Box 92, Blain, Perry County, Pennsylvania. 10. It appears that Ms. Smith's condition is of an indefinite nature in terms of duration. 11. The foregoing Findings of Fact are made on the basis of clear and convincing evidence. DISCUSSION , i I The provisions respecting adjudication of incompetency have recently be amended and are contained in 20 Pa. C.S. Sections 5501 et sea. Petitioner has substantially complied with these provisions, and, based upon the foregoing Findings of Fact, the following Order will be entered: ORDER OF COURT AND NOW, this 26th day of December, 1996, upon consideration of the Petition for Appointment of a Temporary Guardian of the Person Pursuant to 20 Pa. C.S. 5513, and following a hearing held at the cumberland County Courthouse at which the allegedly incapacitated person was present, Louella P. Smith is adjudicated an incapacitated person, and her mother, Aletha M. Smith, residing at R.D. 1, Box 92, Blain, Perry County, pennoylvania, io appointed temporary partial guardian of her person for the purpose of executing a "2176 waiver" and any other necessary documents to effect her daughter's continued participation in the facility known as Drexel Hills Group Home in New Cumberland, Cumberland County, Pennsylvania. This appointment shall expire following the accomplishment of this function. No bond shall be required of the guardian. Notice is hereby provided in person to Louella P. Smith of her right to appeal and to petition to modify or terminate the guardianship. By the Court, Isl J. Wesley Oler. Jr. J. Robert L. O'Brien, Esquire Solicitor for cumberland/Perry MH/MR Aletha M. Smith R.D. 1, Box 92 Blain, PA 17006 Louella P. Smith Drexel Bills Group Bome 1026 Drexel Bills Boulevard New cumberland, PA 17070 cumberland/Perry MH/MR :slr ~p I,UI(I,II) COMMOHWtALnt O~ peNNSYLVANIA NOTIFICATION OF MENTAL HEALTH COMMITMENT Tho Unlfonn Fifunno Ad, II PA. eS.ll0S(c)(I)Il*l!Io'lNl.""'be _ ""lIftptt1Ollldjullcalodu 111 """"-lor"""".. bHn WMIlun~_.., 10 I menlll 1n.~lU1lCln "" Inplllenl COli Ind Ir..1mon1 unci., Sodlon 301, 303," 301 01 tile ",..III HIIIIII PIllOId.... Ad 01 Ju~ I, 1171 (P.LI17, HQ 1IlllQ PO""", UN, manutactl.wt. -. ...or.....,.._ ThloMlUldinCNd..djurfClllOnolrapamy..........IIo20PI e.SA.15S01, PUf1u.nllo 11II P.nn,y!vlnil "'"nlllll..1U1 Proc.dur..Ad, B_ '01, _lIOn.".. be _10 11II PIM.ylvlnil SIIII PoIloo by tile Jvd1lI, menlll "'"11II.._ olllc:e'" COIInl'f menlll "'"IV> Ind menlllllllrdluon Id_llnll.. wtINn I!V!Hd'YI of ~I IdjudiCItlOn, c:onvnittMnl OIIrI.tmtnt by ftnl diu mad to Ihl ',nnlylnnl. Stat. POlle., AtttnUon: 'Irunn Unit. UOO I!lm.rton Av,nu., Hlmlburg, PA 17110. NOTe: Thllnvtlop..hlll be n..rII.., .CONF10EHTlAL.. PIICO In .X' on eith.r Involunllty Commitment or Adjudlcal.d Incomp.l.nl INVOLUNTARY COMMITMENT ADJUDICATED INCOMPETENT Dlle or Involunllty Commitment or Adjudicaled Incompelenl . INDIVIDUAL INFORMA T!ON (INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INeOMPETENT) LAST NAME Smith FIRST Louella MIDDLE P . JR., ETC, MAIDEN NAME 10/23/38 ALIAS DATE OF BIRTH soelAL SEeURITY NUMBER 180-5605890 SEX F RACE Whi te HEIGHT 4' q 1/2"WEIGHT 1 ?R HAIR Rrnwn EYES (blind) ADDRESS 1026 Drexel Hill~ Rlvn . N~M ""llmbnrl~Rg, P.~. NOTIFICATION BY (Ple..e print name, address, area code, and phone number of agency or county court.) i eounty Submilllng NolificaUon Ii County Mental Health and Menial R.lardalion AdminlslralQ' eounty Menial Heallh Review Officer Physician Hospital! Facility Providing Treatment! Address Judg. SIGNATURE OF NOTIFYING OFFICIAL OATE Couri C..e Numb.r Dal. of Couri Orda, - "-- 1'....._ 11______ NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS Tho p/1yU:IJn shaD pI1lYid. s;gned _lIOn 0111II dolomliNlicIn 01 !he Iacl< Qf....... mental diubil,l'f following lIle lnitil' eXlmiNlon under Section 301(bl or lIle "'onlll HIIIV> PtllOedIn.Ad Ind puI1U1nl 10 !he Unifotm FIr..rms Ad, Sedion 1111.' (g)(3). HQtice .hllI be lransmlled by lIle phy.iciln to "" Ponn.ylYlnil Stall Pol", 111_" lIle COIInl'f menW h.a1tl'Iancf men~l retardatlon .dmlnisttalOt or mental health review orncer. Name 01 Physician (PI...e print.) Signalure 01 PhysiCian Oal. RECEIPT FOR PAYMENT =================== Cumberland County - orphans Court Hanover and High Street Carlisle, PA 17013 Receipt Date 11/03/1999 Receipt Time 15:23:13 Receipt No. 1013104 SMITH LOUELLA P F 11e Number Remarks 1996-00975 FAMILY LAW CLINIC DO ------------------------ Distribution Of Receipt ------------------------ Payment Amount Payee Name 15.00 CUMBERLAND COUNTY GENERAL FUN 10.00 CUMBERLAND COUNTY GENERAL FUN 2.00 CUMBERLAND COUNTY GENERAL FUN 5.00 BUREAU OF RECEIPTS & CNTR M.D Transaction Description PETITION ADJ INCAP CITATION CERTIFIED COPIES JCP FEE Check# 338 Total Received......... $32.00 $32.00 i , (k; r~l' . r~, Ci I',. ,,J I ';.. >,' '96 :;0'1 27 r 2 :04 ,.., \(', Ck:.: Cur,'. .1.1 FA "...-~'~=:,1':::~:"~:~~":'.,":'-:'-'-'.-' .......;: ::::~T:"~'-:_:::_' ...,_ '_",.......,~_",...:~n._ -"....-..'. '. .. :~[J~! '" . ,~-" , ,~.i:f i{tt~ (~,;:.~ i'jl?,~,/r. ~!:,: r.J,l~~ "':,",,'I'',\\Pl :::\:i';:;tt~1, ~-, ~<("'~-oh i.;,-4tiLii,. .', "~.' "~~,\.t:~lf{\\'i~ ':":";;ll:\"'~\"f '-'. ~;'-'i;'.' >;;;:r"j,.J<~ ~_'- ! ',:' ' ;; J. ".,7'.-'; i .!.':,'!.-\"'l,~(-' Il~~:i~~{E-'~' ~ ,:g~~':r~~,~.~ ~' ., \ '~":"~' ""'(-~~l~ "'P". ........~~ , ..,;'>~"~.i1; '~"\ . '. ., ....'.A~. ~'~:~~~::_:~~;~;~;t;J:"~lV . .. ."....;.,~..~.. 'f ' "~: ~-- >,..,. . ,c - ~. .' {Il... ...',,,. 2:) .,,."'-: . .,', .; '.~ . ',.- ',., -'.,-, III Z ..c 1:1: p. I>: o l'l Z, I.....g;'~ :~.. .0('''': I" :"z .. :0( 9 ~"I ~':' ~ ~ " ~~. .z.:: ~ ~'~ .5':': i S r.J ' .m :: _,en, " Ii: ~::J " 0: " ~. .'~, \ .. -, ,. ~~~''''-'j-:: ~~~,:r,.":_~j:.'-~' ;__1 ~cn:i}~.:;;~~~Ft";~<: ~fIIl'M,,;~, .' N ~"e ~...... ~., ~"-T:;:.:~ii;"'.'l "fJ><" :,},f'-._'........ '" ';riC1f~!;~;~~1~,; ~,;-;,-~: ,f.<j-....~. "'^",.. ~Ji:i~ fir: l~:f;;:.~~'~t :~Ot,t:)-Jl'~.:-_"',\-.-^, r~:c::.O;iel~,,::.'. .~(-:c'i..'......n.::..'.: 1il<0)......~. ". 1;"~'J..,. """.:' "'...... lil' ..... 'Ji) ~"- .';~'J.:1: "l'..~....... i'~fIi>l. ~ -o-;l-':'"'; ~\.o.~, '}/):". f..""'~ ,Ill..',....... ~j:z.".,. '4, -Cldfr.1~.:z:~f;1.~, l.!~t:I..~ 1lQ'"", ff'-oi-. ro..':<, -';:~:: ~U~ ',:-:-,"^",". ~~~f;~'~;I{/_~~~;-:; ~='O,:"..,."" ~~t;f~i':':: z .0 1:I:'1Il .. E'<' .'.1>: ..... :..1lQ 'PI :';1: e:\' p. .'IlQ"<1Il1lQ A .E'<'.':' ClIlQ 'E'<.. '.IlQE'<' ~:" p.,.:(..c '~:.:f~ ~" :1:I:',.":(l2:~ :E'<.,;"1lQ ot, ^ '....0 ... , '. 0 ..c .Z..U <1:'4',.:( z, ... Z o ... III ... > ... \OA OlE'< 011>: .....0 ,0 OU ~ 'ora.' .,.0 '. ~. .~ :~-; ,'-.... "1"-": 'i-', '.r ., '!'.".-' ".;.' :',: '.j -:::} "', , ,,~ . .,:. " IN TilE MA'l"l'ER OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. JJ _q/J-q15 INCAPACITATED PERSON LOUELLA P. SMITH An All eged Incapacitated Person AND NOW, this ORDER OF COURT 21.. tt, day of JU....oJ , __~t'J , 1996, upon review of the attached Petition, a hearing is scheduled in this matter for 7kpUJ d ~ ' the t;?c, ~ day of .tiJV'.A"c7....-YV""~ ~ 1996, at 01.'(1) a.m.Q:..jf., in courtroom>> .5 , cumberland county Courthouse, carlisle, pennsylvania. Personal service of this order and accompanying Notice and petition shall be caused to be made upon the alleged incapacitated person by Petitioner in accordance with the probate, Estates and Fiduciaries Code. Notice shall also be given to all other persons and entities required to be notified under the Code. proof of service shall be furnished at the above-scheduled hearing. BY THE COURT, , , ,; . " IS THE liATTER OF I 13 THE COORT or \:~ PLEAS I , c:otnrrr, A..n.u.~IA I I ORPHAaJ' cauRT DIVISIOJ I IS R! ~. , .. . (.ouo11<1 P. Smi tit AbI ALUGEO !UCCMPEn::rr PE't'I':':ON FOR APPOIDTM!trr 0' A 'l'!HPOMR'l GUi\RDIA8 OF THE PnSON PURSU~vr TO 20 Pe. C.S.A. 5513 ~e Pet1l:ion of Tl"1llpl]n P. Smith , r..p.ct~ul1y :.pr..enes: 1. Your PI'ti tion.r i..I Mrs. Aletha Smith .' , 2. Louella P. Smith is cur:enely ree.ivin~ care at Drexel Hills Group Home 3. Louella P. Smith dOlllicil~ at 1026 Drexel Hills Blvd. New CUmberland, PA 17070/2176 Waiver Conversion 4. Louella P. Smith is 58 y.ars of &9. havinq be.n born on 10/23/1938 .... 5. Louellj'l P. Smith llIUial natna ia sing1.e, never married 6. Tho.. persons, i! any, who are Tntlpl1A P.. !=imi tb nexe-of-kin and their rel&tionshi~ eo sam., of wham yoar Petitioner has knowledge are as foll=ws: Mrs. Aletha Smith, M::>ther ." ....ith a !,rognosis .1S follo....s: [. " I'. , ~ \ \ l l, I .r JI . \ "11\ ( \ , 1\" . \ (It il( /", ,\~. \,,- .. 7 J fl , I I ," If " , , , '\ , '\-_1.)' " I' '. , 2. On the basis of the foregoing history and examination. the affiant is of the opinion that Louella P. Smith , b~cause - .... ..., " of mental deficiency, lacks sufficient capacity to make or communicate responsible decisions concerning his/her choice to receive community-based or institutional servicas for the mentally retarded. 3. Because of the physical,or mental condition of said patient. his/her welfare would/would not be promoted by hiS/her presence in Court. ,I " ___,1./:/;, '{) ::;LC<-C(( t/L~ Sl'101U1 1'0 AND SUI3SClUBED BEF~c.t.DA,{ / OF .;qq(p NOTARIAL SEAL Frances G, Roso, Nolorl Public CerllGlo Boro, Cumberland County My Comlr.l5slr.n [):;"rc:; Nov. 22..1991} __ ...--.........--..- a~~ NOTARY PUBLIC , counr 2 VOUCIlEn o Ol!ilocl JU~1ICO r:J Common Plt!d~ n Appnllilltt n OlhUf - N~ 4315 --------------------.---- - J FORIDJ.CP.API'ELLArEI 4 AT ICllY/STAT() ~ DUDGeT CODE 1',1111' II', 1'/\ "'1_ J'J.. (,'II.():C' 6 III rilE CASE OF r CHAnG[JOH[tj~a: IflU'WO~j CI'AflO~4' " (J PErry OFFE>4SE I n r fl : LOlle II" I'. t"JlII it 11 CI FELQU'f () MlsorMt/lNon . -- 9 pnOCEEOlt~QS IOncflbe bf,llty) 11 V[WJor4 HEflRE50HEO U CIVIL DOCKET >40 InCO;T1pett>ncy II~;, 1'1111.1 1111 , " O.I.""."t Adull 1 " O.',,""A'" Ju,.""lt 110. / l_,/()_rj /1) Appointment of (;'lil rei \ "n 01 till' l 'J AVfll"I,,,, 13 CRIMINAL OOCKFt f,O person represenled . " ApI""I... , 'j IUbOltU P,....O."1lI . " J.4"'I!r,,11'l.,."tn I " PAIl'll". CI'A'Ql!1 W,l" ""01"'0" 10 PEnSON REPRESENTED IFull N.mel . C P'ob.hO...r Chi'''''''' W,Il'l '1'OI.hOn '4 .PPE.LS DOCKE r >40 . :i a'''.f Louella P . Smith 12/9/99 16 NAME OF ArrORNEY/PAYEE AND AIlOI 0..,. MAILING AOO~lSS SteplH~11 J. Ho<)g, Esquire J. .icsley Oler, Jr. 19 c II~nover Slrt~l~l, Ste. 101 -" Carlisle, [>11 17013 NAME OF COMMON PLEAS JUDGE ASSIGNED TO CASE 17( TELEPHO>4E No. 18 'jOCI"'l~[GURI'''''O OAf''''IU 717) 2/,5-26'18 23-252-9152 CLAIM FOR SERVICES OR EXPENSES '9. SERVICE HOUPS DATES ....OUNTS CL.,"'ED a. ArraIgnment Indlor PI.. J-4ull1ply rate PIr hour Ilmeslo'al b Preliminary He.rtno hourt 10 obla'" ~In Court~ Com. penuhon Enter tolal below c. Mollonl and RIQues11 .. el Ball Hllrings 0: :> tt. Senlenc' Hurlngs 0 U t TrIal ; O. ~I"ocatlon HearlnOI h. JU"lnlll Hearinos l APpeals Cour1 '9" TOTAL IN COURT COMPo ~ Clner tSPIClfy on addluonll shelllsl 1.5 -l?/'Jn/qq TOTAL HCU~S. 1.5 ~PERIlOUR -s 67.50 20. a. Interv.ews and conl"lnCII 1.0 J-4Ulllply ratl per hour limes lolal b. Obi II nino and 'hilWtng recordS . 5 hours. Enllr 10111 "Oul 01 Cour14 .... compensation below. 00: c.. Legll 'a"arch and !)flel wllMO I. " ..:> :>0 d. lnvesllgab.... and oltler worK (Speofy on addItIOnal sheets) 20.. TOTAL OUT OF COURT au letters COMPo ./1 TOTAL HOU~5. 3. Ii ~ERHOUR -s 153.00 21. ITEMIZATION OF REIMBURSABLE EXPENSES AMT PER ITEM Miloal'!9 5.25 oor m~o . 0: W :< 2'" TOTAL ITEMIZED EXP. .. 0 -s 22. CERnFlc.nO>4 OF ATTORNEY/PAYEE 23. GR.ND TOTAL CLAIMED Hal campenulton andlor relmburlllmentlor work In this cue pre"loulty been applied for? 0 YES (j NO -s 220.50 II y......,.you p.,d? a YES :tJ NO lIy...by..hO.,......;~~I- Ho..mueh? 24. DEDUCT. PRIOR PYMTS. Has Ih. p...on r.pras.nl.d plld Iny monlY 10 y,~;;rto g;:;, kn~~nYOne ."..In eonneellon ..,Ih lh. mllll' 10' -s ..n,eh you ...,. appolnl.d 10 ",o,'d. 'Ipraslnllllo . ,.... E 0 _A y~~ Q". dolO'" on Id7!1I~'t~ '~:~ I swear or .fIlrm Ihe lruth or conactn_" Y U ., ;7 "2- :; 2~. NET AMOUNT CLAIMED ollhe abo". slatemonts Slgna}lrl 1>' '(~o';;?'P'JI' / . f 0111 -s 220.50 2S4"Pllt,..I:I\ '\. i ti L' '(/~I 27. .MT. APPROVED . '"11 SlQn.lu,.ol . /,11 '-c1. /, f_" .0..'.] I I) ? -s ') , 0 ' ~.-o "......1"11 JuOOI ., 2. c,.. ) -/ ,/ AUTHORITY TO PAY CounT APPOINTED COUNSI:L JAN (I:i 111l1~\ COpy 1 . Mall to Court Administrator at completion of service .JI -<{If' -((7 b Louella P. Smith - Year 2000 Update Enclosed you will find Louella's annual plam; from her residential provider (CPARC), her day program provider (UCP) und her funding source (Cumberland/Perry MRS.) As her guardian of person I have attended her 6mo. and 12mo. treatment team meetings. I have visited Louella three times this year and spoken with either the Program Specialist or the Program Supervisor approximately every other month. One thing that was new this year was Louella tried a couple days at an Eldery Day Program. At her most recent review, however, the team agreed that most of the activities offered at an elderly day program do not meet Louella's needs or abilities. We did discuss the possibility of in the future giving Louella a day maybe every other week where she could stay home and have one-on-one time and individualized activities. She currently attends the UCP Alternatives Program five days per week. Louella's housemates have stayed the same - two younger ladies who have lived with her at least three years. Most of the staff who work with Louella have "turned over." Two exceptions are her current residential supervisor, Kathy Fernbaugh, who has known Louella at least eight years, and her CPARC Advocate, Pam Shenk, who has also known her a long time. Pam contacted me in early December - both residential and day program staff are noticing that Louella is "spitting up" more - Pam clarified that "is not vomiting, it is more like spitting up." Pam asked if I remembered the Doctor who treated Louella's twin sister, Lourene, and I informed her it was Dr. Casal on Front St. in Wormleysburg. I gave her his phone number. I agreed a consult was a good idea, based on the experience we had with Lourene as vomiting increased and her physicaJ,.~ondition really turned for the worse (which eventually led to her death.)'~'1 offered to attend this appointment with Louella and her residential staff - Kathy will be calling with the date and time. Other than that, Louella remains her delightful self - easy to get along with, fun-loving, always ready to laugh. I plan to see Louella and speak with her staff at least as often in 200 I, if not more. . Jennifer A. Wolbach . . ~- ,. '1' .. ;'.1 1"..' Residential Services Plan of Care Name: Louella Smith Address: 1026 Drexel Hills Blvd. New Cumberland, PA 17070 Telephone: (717) 774-0266 Date of Plan: May 5, 2000 Review Dates Program Specialist Signature cc: Individual Louelhl Smith Parent/Guardian Aletha Smith Advocate Pam Shenk - .Jen Wolbach County Case Manager Nancv Parrish Day Service: Other: Office File Alternatives-West . . FllIlIllclllllllrlll'lllllllOIl Source Claim II 185-01-4598 C2 Amoullt Rellrescntative Pavee Exe Director CPARC SSA $636.00 Name of Bank: Keystone Financial/Financial Trust Type of Account: checking Address: Highland Park Office, 433 South 18th Street, Camp Hill, PA 17011 Balance: $843.81 Burial Planninl! Contact Person: Althea Smith (mothcr) 1. Burial Fund Bank: PNC Bank Address: Account #: 89-9563-2933 Amount: $6,489.14 Funcral Home: Nickel Funeral Home; Mr. Jim Nickel, Loysville, PA Ceremony: Viewing, funeral service w/religious representation Cemetery: Blain cemetery; Blain, PA Additional Comments: 2 i I' Ii : i I I i Ii ;: " ii I' ~ i , '~ I Ii 'j Ii ;1 Ii 'I " 1 li ,[ ;; ,I I, , , 3-11.00 Blood illld puss ill stools llltemill hemolToids; prescribed Anusol HC suppository BID and B.lllllc;( ointmcnt PR:-l for reetill irritiltion. 3.23.00 Sores on mouth Impetigo; prescribed Baetroban ointment TID for 3- 5 days. 4.10.00 Cold symptoms Symptoms improving Dr. recommended a few days off from da rogram. Annual Dental Examiniltioll Dentist: Dr. Fredrick Hecht Address: 238 Alexander Spring Rd. Carlisle, P A 17013 Telephone Number: (717) 249.7007 Date of Exam: 4-18-00 Findings: Oral health good TreatmentlRecommendiltions: Return in one year Plan for Dental Hygiene: Staffwill assist Louella with brushing gums daily. See dentist yearly. Optometry Optometrist/Ophthalmologist: Dr. Robert Thompson Address: Medical Arts Building Suite 207, Wilson St, Carlisle, PA 17013 Telephone Number: (717) 243-2331 Date of Exam: 9-14-99 Findings: Stable exam; crusting on lashes. TreatmentlRecommendations: Continue Dacriose eye irrigating solution each eye BID. Return III one year. Other Practitioner: Dr. Westra Address: 4700 Union Deposit Road; Suite 230, Harrisburg, PA 17111 Telephone Number: (717) 545.9811 Date of Exam: 7-21-99 Findings: Increase in vomiting and other stomach problems TreatmentlRecommendations: DIC Pepcid, 20mg 2 tabs QD HS; DIC Dicyclomine, IOmg cap 2 caps TID; Prescribed Prilosec 20mg QD. Follow-up when necessary. 4 "\\'ar~n~ss ur Danl!~r and Sar~l\' I'r~l~anlitlns - ==-.----= --_..-_._- Typc of Danger a. Poisonous matcrials b. Traflic, crossing strccts c. Strangers, threatcning people d. Hot water e. Hot oven or range f. Fire (opcn name) g. WaleI' (Le.: swimming pool) h. Getting lost or scparatcd L Other No A WHI'CIICSS X Adequatc AlVarcn~ss Dcficicnt Awarcncss X X X X x x x SELF-l'RESERV ATION SKILLS ,0' No self-preservation skills :A Must be physically moved 0 Evacuates with physical prompts 0 Evacuates with verbal prompts 0 Responds to alao11, evacuatcs 0 Knows lire cmcrgency independently procedures (i.e.: use phone or call box, meeting place, etc.) Can this individual be lell alone? DYes .0' No [fyes, how long may they be lell alone inthcir home? 0 How long may they be lell alone in the community? 0 Plan for Decreased Supervision: The Treatment Team does not reconll11cnd a plan for dccrcascd supervision, due to Louella's lack of self-preservation skills. 6 RESIDENTIAL SEI{VICES Indi';illual Loudl.l Smith POC ANNUAL ImVIEW Page I Ill' I - Status LRO 1:19 Loudla will participate in community activities based on her likes of music, animals, etc. STG 1:2 Louella will participate in a conullllnily activity Iwice a monlh for 6 months. Dl: 9-\4-99 TD: 4-\-00 EXT: 5-5-00 GA: 5-5-00 Stalus: GA Feb I oul of 1 = 100% Mar2 oulof2 = 100% Apr lout of 1 = \00% May I_Sib 0/0 = 0% did nol work on goal 13 .: l I --_.- -' , -. -. ..-.~ -.... 3 ~ Health Medical Services: Primary Physician: Dr. Nancy Grubb phone: (717)531-8 \ 81 l\ddress: Hershey lvledieal Center 500 University Dr. Hershey, PA 17033 Neurologist: N/A Dentist: Dr. Frederick Hecht phone: (717) 243-8123 Address: Belvedere Medical Center Carlisle, PA 17013 Gynecologist: Dr. Nancy Grubb phone: (717)531-818\ Address: Hershey Medical Center 500 University Dr. Hershey, P A \7033 ophthalmolOgiSt/optometrist: Dr. Robert Thompson phone: (7\7) 243-233 \ Address: Medical Arts Building Carlisle, PA 170\3 phone: Other specialistS: Address: ~ 4 Thernpy Services: Orthopedic Surgeon: Martin Rubin Prescribes lifts for shoes Phone: 761-5530 Address: 3916 Trindle Road Camp Hill, PA 17011 Nutrition: Address: Phone: Music Thernpy: Address: Phone: Speech Thernpy: Eliznbeth Solon-Frantz Phone: 975-2785 Address: 3809 Heathstone Rd. Camp Hill, PA 17011 Contact person: Brenda Yeagley Other Specialized Services: Adaptive Equipment: walker Respite Care Services: CumberlandlPerry Association for Retarded Citizens, Address: 117 N. Hanover Street, Carlisle, PA 17013 Phone: (717)249-2611 Emergency Care Services: Holy Spirit Hospital Address: 503 N. 21st SI. Camp Hill, PA 17011 Medienl Services Phone: (717)763-2100 Psychintric Phone: (717)763-2219 or 763- 7013 ,_ ;;'i(.,"-},.....-<-~.-,......, I. General Health - ;\lcdleallScl1Sory Conccrns A. SUl11mar)' I. Dalc or last physical CUI11: 10106199 I'hyslclan: Dr. Nancy Grubb Wclghl: 1451bs Hclght: approx. 56" 8/1': 110170 Othcr findings: urinalysis - normal; CXR (TB) - normal; flu shot RccolllmcndatlonslTrcalmcnt: Return in one ycar. Return ,,1511 duc: 10100 or PRN 2. DenIal - Lasl exam: 411SI00 Dentist: Dr. Hccht Findings/RecommendatlDnslTrcatmcnt: Oral hcalth good. Rctum in one year. Brush daily Return "isit duc: 4/0 I Frcquency: Annual 3. Specially ExamInations: a. GyneeDIDgleal: Dr. Nancy Grubb 5/27/99 - Routine breast exam/mammogram- results normal Return ,'lslt due: 5101 b. Neurological: c. I'odiatry -last \'isit: Physician: Procedures: Results: Reco III III enda tlo nsn' rea tm en t: Routine \'isit due: Frcqueney: d. OphthalmDlogleal-lasl \'isll: 9/14/99 Physician: Dr. Robert Thompson Proeedurcs: Annual exam Results: stable exam; crusting on lashes Reeommcndatlons: Continue Dacriose eye irrigating solulion each eye BID. Return in one year. Did examination include: \'islDn screenIng: no sercening ror patholDgles or the eyc: no Return \'isll dnc: 9100 Frcqneney: Annually c. Audlologle:ll- last \'lslI: 10106199 Physician: Dr. Nancy Grubb Procedures: No hearing problems per hcr physical Results: No hearing problems per her physical RecommendatlonslTrealment:Testing done at annual physical. Return \'lslI duc: 10100 5 . f. Olher: None "h)'slclull: NA Lust visit: Gellerlll eXlIl11hllltloll: 6 .t. Describe proecdure for shurlng medleul reports within the teum. Pcrtinentmcdicul infomlation is shared with TrcDtment Team members at monthly meetings. Medication and medical infonnation documentcd by residcntial staff on monthly progress reports. 5. Summary Comments: Mechanical soft diet (purced). A void dairy products Type & Dosage 6. Medications: ReaSDII Reviewing Physician Calcium Carbo 500mg 2 labs once daily calcium supp\. Dr. Grubb Carbamide Peroxide, 6.5% Otic solution once weekly in each ear wax build up Dr. Grubb . 1 , i , II , I Doeusale Sodium, 100mg 2 caps once daily bowels Dr. Grubb Eye wash (both eyes) Twice daily cleanse eyes Dr. Grubb i ., , I , I I ,\ I i Dr. Westra prilosee, 20mg Once daily acid reflux Multi-vitamin. I tab once daily supp\. Dr. Grubb Bran. 2 tbsp Once daily bowel regularity Dr. Grubb MelOclopramide. 10mg Three times daily digestinn Dr. Grubb Balmex ointment. I'RN skin rash Dr. Grubb Nystatin Cream, PRN irritation under Dr. Grubb breasts Last Review Frequency 7. AlIcrgies/Precautions: No known allergies. pureed diet, avoid dairy products' f\D IOf1~1.- I\H.eM'(j ~ 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually 10/06/99 Annually J 0/06/99 Annually 10106/99 Annually - "jt\ : " - ~,...". ..-. -. -"..,.-..." , - " 7 8. IIcpntitls n scrccnlng: Ycs X No Results: 10/06/99 . Hepntitis B surface antibody positive. Surface antigen negative. Immune and cannottrnnsmit Hepntitis B. n. Goals: Ms. Smith will havc an annual physical scheduled 10/00. She will be seen in the interim as her medical situation warrants. Ms. Smith will have and annual dental exam 04/01. Ms. Smith will have an annual gynecological exam 05/00. Ms, Smith will have an annual eye exam 09/00. Methods: CLA staff will be responsible for scheduling all necessary medical appointments and transporting Ms.Smith to those appointments. Evnluation aud Responsibility: CLA will implement these goals under the supervision of Heather Wagner, Program Specialist. Documentation will be made in daily logs, monthly progress and TPP/Quarterly Reviews. 8 mental relardation. Louella faccs major delicits in thc areas of gross mOlar ambulation as well as expressive and reeepllve eommUlllcatllln. Louella has made remarkable progress wllh her ambulalion skills. Her staff have encouraged her to walk IIldependenlly aboul the house with the help of hand rails. Where hand rails arc nol available mlhe house, Louella responds by following the staff member's vOIce. She uses a roiling walker for any longer distances. Walking goals arc also worked on at the Altematlvcs day program. Louella has also Jdvaneed in the area of speech. Group home staff have worked infomlally with her 10 repeat and leam new words. Louella IS now able to place two or three words together at times. Louella continues to express her sense of humor through laughter. she seems to realize when she or others arc being funny! Louella is currently working with Brenda Yeagley, a communication therapist, in order to incrcase her communication skills. Brenda is currently helping Louella with tactile communication exercises and is in the process of obtaining a communication device that is appropriate for Louella's nccds. B, Goal CLA staff work daily with Louella to improve Motor/Communication skills. They have set up a coding system for the doors in the house (ie: one has bells, one has a sachet, etc.) so that Louclla can tell which door leads to the bathroum, which to her bedroom. etc. Louella continues with physical therapy exercises, daily walks, and walking throughout both home and Altematives with some assistance. Infonnally, CLA staff continue speech recognition activities such as naming and pointing to various body parts, \'ocabulary expansion activities through repetition and listening to tapes or music. The Altematives program also continues this work. Brenda Yeagley will work with Louella twice per month to increase her communication skills. She is currently working on tactile communication exercises during which Louella is given an object to identify and then she repeats the name of the object. Louella is given a choice betwcen two objects which she must identify and repeat the name of the object she chooses. Louella's choices currently include toys, music, bed, bath and bathroom. Louella is doing very well with these exercises. Brenda is also in the process of obtaining a communication de\'iee which is appropriate for Louella's needs. C. Methods: The CLA staff will work with Ms. Smith on the above mentioned activities for at least 15 minutes a day. Brenda Yeagley will continue to VIsit with Louella twice per month and implement new exercises as appropriate. D. Evuluation and Responsibilil)': CLA staffwill implement activities rccommended by the speech and occupational and physical therapy e\'aluations. Pro!,'1'ess will be documented m datil' logs, monthly progress reports and IPP/Quanerly ReVIews as well as monthly Treatment Team meetings. 10 3. Community AWllrcncss: II. AWllrcncss of DlIngcr Ycs No I. Fire X 2. Trllfne X 3. 1I0t Sll)\'c X 4. 1I0t Watcr X 5. Othcr No awareness of cleaning supplies danger Commcnts b. Knows name Knows addrcss Knows phone number x X X c. usc of pcrsonalldcntilication: Has PA non-drivers card. Docs not have functional knowledge of use for ill purposes. d. Use of telephone: No skills. e. Use of public transportation: Ycs_ No X Availability of transportation: Public_Private X Public: Not able to use. Private: CLA has a van for all consumer needs. f. Ordering in rcstaurants: No skills. g. Shopping, purchasing: No skills. h. Traveling about ncighborhood: Dependent on staff Will walk witb staff assistance. i. Other: 4. Educational Skills:: No formal skills in this area. No records of education. 5. Summarize progrcss on gO:lls from last plan: Ms. Smith has gained more indcpendence in motor and communication areas. Her only maladaptive behavior is inappropriate verbal outbursts. These outbursts have decrcased but occasionally surface when she gets upset or desires attention. Goal Review: 12 IV. VocationallEducntionnl Skills: A. Summary: Ms. Smith attcnds the Altematives program of United Cerebral Palsy five dnys a week. Staff are working on appropriate use of functional words, walking daily with assistance, verbalizing needs. and recreational activities such as crafts and musical instruments. Ms. Smith has been very cooperative with staff and appears to enjoy the activities. Her only maladaptive behavior is inappropriate verbal outbursts. There have been very few outbursts over the past year. B. Goals: Ms. Smith will: 1. continue to increase communication skills 2. continue to develop functional daily living skills 3. will identify descriptive term named by picking up object independently 4. complete line motor tasks 5. walk independently with least amount of assistance 6. identify objects by smell or by touch (ex: warm/cold, rough/smooth) 7. will operate recreational devices with one verbal prompt (ie: play the keyboard. tape player. radio and use head phones, Connect Four, Trouble, art: Crayon drawings) Methods: Alternatives staff will work with Ms. Smith on achieving these goals on a daily basis. Progress will be logged daily. Louella has changed program rooms for increased sensory stimulation and exposure to female staff to whom she is known to respond. Evaluation and Responsibility: Alternatives staff will work under the direction of Barry Claypool (Program Director). Progress will be logged in monthly progress reports and IPp/Quarterly Reviews. Summary of Token Goal Plan for Louella Smith: N/A ." ", ...... United Cerebral Palsy of the Capital Area ' 925 Linda Lane Camp Hill, Pennsylvania 17011 , I ALTERNATIVES Individual Program' Plan-IPP Cover Sheet INDIVIDUAL NAl\;IE:: Louella Phyllis Smith DOB: 10-23-38 SSN: 180-56-5890 BSU: 50200603 CURRENT ADDRESS: 1026 Drexel Hills Blvd. New Cumberland, PA 17070 PHO",'E: 774-0266 DATE OF ADMISSION: April 9. 1985 CASE MAl"lAGER: Nancy Parrish ADDRESS: Cumberland-Perry MH/MR , Human Services Bldg. Rm.301 - 16 West High Street, Carlisle. PA 17013 PHO",'E: 697-0371 EXT.6325 PERSONS RESPONSIBLE FOR IMPLEMEl\TATIO>l: N.A..ME/TITLE: Kathy Seiderer, Program Manager N.A,,\;IEiTITLE: Diane Robison, Program Supervisor DATE OF IPP REVIEW/REWRlTE: 5/5/00 RESIDENTIAL PROGR.A,,\;t N.A,,\1E: CPARC Residential Program ADDRESS: 117 N. Hanover St., Carlisle, PA 170i3 PHOl\'E: 697-8343 FUNDING SOURCE:Cumberland'Perry MH/~IR REVIEW DATES 8/00 11100 2/01 . . ,~ ,. I,.. ..'. "'.", United Cerebral Palay of tho Capital Area 925 Linda Lane Camp Hill, Pennaylvania 17011 ALTERNATIVES MEDICATION RECORD Page 2 NAME: ~O!..l. dk.. 0.-r..d-1t , 1_ fi../J. nf,' ." I~ lC/rYati II SDe "y", ....,... ~ I. '"'\. \ Pro:..c/s,1 101'.':, ~n~cnclh+E. Ilwr'~ct,. -1.. - f(.J JStr€:' :;.k'./J';',IY,t/.. r , . v E'Cl b,'-Iu.~1 ~ lJfY1 4t1h.1u~$ M1Sv(!1. Jydro(odol.t!1fP4 C.:J..!-frak 00D .buriu';:' 6ClC.t t-r CL C.i 11 ~ '1 . ~ ....U~.LI~<..I/I Scic.i-b"acJ(\ sro t.. ()1 ';y~ Oi"~ Arnbl~r1 Olwd.e.r(r1 - . , .:c j'fj:: .,~ ~~-'J;r... 't ,;~'!j L'l).t>...( "b " DOSAGE I TIME S I PHYSICI';''' I START I STOP I PURPOSE ld~4. 'Z1C~'/l' I " ,I Hi- t! A/v I V/w- rlCIr.L .1J /1/ ,'.. . ,..(. rut' -", t""W. -, ... J.'.~.. I O'~"?I /9!:S/:;! ..'~ '. " . " i.Jf. I;....~__' ./ 1/.... .... 13p. J~" "r .J ~'_.", ,....~ - _.~ - ." 2ft, QID I vr. J-Ia. rold I q! 1"/9'-1 dk d.. 2-13p. 'fldtL'i DI,P~/ 1/ /J~/'1<I Il/flr 7 Uo..,,-,Jlf-. 1mb C~'t.PI I Dr h'orh.1 1'!:,1q5' ~ Po..J.'/I . bltU/7 4 0 1.1& '9~ {clio r bv .=....;...~ D t. ;-':..!.L;/ t;/s/qo- ~-(ac Ou/clu.rr; Ih..b i7 ;,,~ ....t" i "i(l " it'l'ln \.I~JD. ~, I I SOorr:. Sib iJr. t-iarkf, .r'30. e; let r- I,'h'~,b.:ll b:> ri ^ an ... Cl.Ppi'f+O B,b lJl. Ha (to ( )',jo-qc ~~ I~cb'<.!,., to ;, !,t-o" \." "r,~ , 'r I U lrlo-q.r & -Z9.Q ~ ~- (/~' (/ {:.,q.qS- Iqq(p 1t 'z.q..qS- d/r:!..- t:-ZQ-9.!:J- IZ-/~4~ tZl-qS- ,0-/1.:, In,5C)m ,] I~ .:xYR. M .uX"'chrf.!a~ (4,~, ~ / "'"J lj 1/ vQrrJ.tb'7R v 7 /-,," ,.','.\ _ ,iol',"''- ~".'~ Vt hr. bEi:\',c, I)" ~01 ts of' 1..l."1 'n , I '., ,.,i; .........l;;! ., U1r~'-:....... 1... I' -' '--r ,;)IO:JV I J, :: .,',~' ','.0- 10/:" ,~~- A ~"J:t.\./ ' : ," oJ " . .. "'- ' .' I ,. Unil~d C~tPbtal r.l.y of lh. CApil.1 ^tea 925 Linda I,ftne CAmp Hill, rpnnnylvanla 17011 ALTERNA'rlVES 'age "t:J lAM E: Lou. t.11 t4 ..srx.i:ttJ /:!EDJJ:A'U OIL.F,F;J:'Q~!> ;EDICATJON_ --POSAGl; A2p(J id 7U./if ~ '-::/",; r'.. , "'t ~( C/:t(!~:.A.... IbfJ .J...Jy.EJ~ -EHYS1CJ.b}L__ _~TART Ji.5 -11,yr. Vr. h;)l:.e/s7c:J/") II/ZZ/q!:.- Q1 - 80t1.,.:;'~,.L~'(l IIZ'- . I ' POl - 1ft ~,,~ ,.JJ"'J IJr r:;~7i.:.i.J,7.i1 I//! Z ':1 -I' 1,-j"", ' ft. STOP PURPOSE :e!t.J)/((-J.. re/(CJ.f di&J!d.v~ () fit tuJd , ~rH. p:""IOf:- .., , ..-....: t)., .'foe VI2.slc,- J.P;:firt! J.;J .1.;1' O/I~ ('y ztrp, .:.-"/~1./ - {:!.:II,~ \ i:" ~ Ir ~ 'n." '.-r ..(.n.. ./~ l It n'-l;f, - 4L!.1rt'~\1..I i/l2~- &CLpt/ ~,,11 eo, JbJ+-...(~I,i , ~tmdL'1 '" f[I-J- . :;'')..&t:r'Cf i!J.. (J "'i' 'L1 ,./..., nl , ' ...JV '..l{U/H (, ~I~. ha /~ 'it ~ S:Of'6 ' [Jr. h.1l:e !!.f~f) 1/1/10 It.!/'j Iis,- I Z./zl/vr' Izjz'/hr bo< it.. Cl-.WU_Hn..:a!lI~l <: /'1 r- ~ c.f. a b 111.1 V(1 ! v 'f,dr-v _" I ., l.! j) ;/1 t.!9/.p (!c)dJ.5/Jre 1. "'/ If) , ( ~I f Nic 6rd ~riJa(i 1]/[) IO/Je/,," P...c )~jd ... IJr lV<.siT:.... S / l:.lf '{") (i?f!u...: dtj, C:/l.,y- 10(0) drY/) v - r Pro Ju./0i d ZOfl.t:J /tJ.., ..:1', /) I ' B ko/n 7, / rj.~J f,?;_ . , )5 . eat l.,(~b:,. BQr.1 0/. &.'u.. " /1/11?1 IIJ../~iwr. \ ,z:..,W;VI.:.!: I t-icra./z % er{Ci 1 ~P:y.-b co r/ , 'Or. Gru..bb I\/'~/(y:t- 1/::/98 rash l.1.I1d..1.f Ilr,'OJ-is.. B i,1. . (' r....'..-, 1(' ^ if /JjqS v/n/9S l!c..yin/i;cJ .(1"~(15(~11~". {,('hil ~CO r(~ ' COri. t ( Cd ad i/l{;1 'O:......r,1. 1- ..u,),IJ n:. ~b(uY .5' 'J'j; d I..;,~ iJ, [.r:Lbb u IO/li}:;;; P(~j i..1~ i.."'-\"\r' o"l,lo'14{ II' ".2:..(a....1 I ~ v.....l.l ,.4 ..:.~...' 4n10Y I'c.i lIin ~ :J x c&. III~*, 12./2./15 Sinu.5/rWch'6Y1 ...... .. " 'I . United Cerebral Palsy of the Capital Area 925 Linda Lane ~--. ClU:lp Hill, Pennsylvania 17011 , , ALTERNATIVES Page f NAME ~rl..i:L17 . dH~ MEDICATION RECORD MEDICATION ~._-'" ~7 PHYSICIAN ,,~ 'E J . ..,'7..... ~~ &rubb ....... Alternatives Louella Smith Louella is currently unable 10 be without direct supert'ision, Comments: Due to Louella's visual impairment, need for assistance to walk, display of minimal SIB and low communication and safety and self preservation skills, Louella requires constant staff supervision. Louella does remain in the bathroom by herself for privacy once she is seated on the toilet and with frequent checks (and something for her hands). \' , . " ........ Louella Smith Allematives Social, Emotional, Environmental Needs and Supports Louella is not currently taking medication for maladaptive behavior. Louella does exhibit maladaptive behaviors. The specific behaviors are: raking thumb nail across head and nose, picking loose skin from fingers, rocking vigorously, scream/swear, and push chair from table. Social WantslNeeds: Redirect Louella to more appropriate use of her hands. Provide Louella with objects for tactile stimulation (even when using the toilet). Emotional WantslNeeds: Speak softly and gently to Louella to interrupt her screaming/swearing. Redirect her to a topic that is pleasant to her. [fredirection of this manner is unsuccessful, offer Louella a drink, take her for a walk, or have another staff talk with her. Singing softly in her ear, rubbing her head/running fingers through her hair may help calm her. Environmental Needs: Loud repetitive talking from others seems to irritate Louella; she may tell that person to "shut up" and begin other yelling. Staff should be aware of individuals who seem to bother Louella. (MW, KL, SA, JS, JZ) Yelling may also be an indication that Louella needs something, ie: to go to the bathroom. Check that all basic comfort needs are met. It is important that Louella be taken to the restroom on a regular schedule, a minimum of once every two hours, or more often if needed. [fit is felt that Louella may be experiencing pain due to arthritis, call CPARC on-call to request administration ofTylenoI. Behavior Plan Implemented at Alternath'es? No Allcmalivcs -....... Allcmatives Louella Smith ComrilUnication #5 Continued 5. Louella will respond to Bobbic'slCindy's grecting by activating Me'isage Mate with hand-over-hand assistance. Date Achieved: 1/31/98 6. Louella will respond to Bobbie's/Cindy's greeting by acti\'ating Message Mate with physical prompts. Date Discontinued: 2/24/98. Move to step #9. 7. Louella will respond to Bobbie's/Cindy's greeting by activating Message Mate with verbal prompts. Date AchievedlDiscontinued: 8. Louella will respond to Bobbie's/Cindy's greeling by activating Message Mate independently. Date AchievedlDiscontinued: 9. Louella will respond to Joe's greeting by activating Message Mate with hand-over-hand assistance. Date Achieved: 3/16/98 10. Louella will respond to Joe's greeting by activating Message Mate with physical prompts. Date Achieved: 5/18/98 11. Louella will respond to Joe's greeting by activating 1",lessage Mate with verbal prompts. Date Achieved: 6/12/98 12. Louella will respond to Joc's greeting by activ'ating Message Mate independently. Date Achicved: 7/30/98 13. Louella will greet Jonah by activating the Message Mate with hand-oyer-hand assistance. Achieved: 2/25/99 14. Louella will greet Jonah by activating the Message Mate with physical prompts. Achieved: 5/17/99 15. Louella will greet Jonah by activating the Message Matc with verbal prompts. Date AchievedJDiscontinucd: 2/1/00 ..,...... AL TER.'1A TIVES GOAL PLANS INDIVIDUAL: Louella Smith Area: Communication Skill: Vocabulary words Current Skill LeveVStrengths: Louella has been repeating a lot of new words lately and so the team would like to begin introducing new words on a weekly basis .Louella is most interested in and motivated by things relating to food. so we will relate the vocabulary words to the weekly cooking project. Short Term Goal: Louella willleam a new word each week. Criteria: A new word will be introduced each Monday during the cooking project and work on all week. Target Date:5/01 Goal MetlUnmet/Explain: Goal to begin next quarter Steps: NA . ' -....'"- Alternatives lndil'idual-Assessment . , Louella Smith l'i eeds continued . Toileting schedule: minimum of once e\'ery two hours, or more onen if needed. Sensory stimulation activities Sometimes needs prompts to put hands on table to pick spoon, etc. LIKES: One-to-one staff anention Eat Manipulate preferred objects, rake objects along table top Dance, jump, hug, kisses, laughing Clap hands with staff, imitation games Having head rubbed/fingers run through her hair. Country music, other music Teasing, "rough housing", giving back rubs, tickling Coloring Going for walks Going Outdoors Swinging Stories being read Sit in bean bags Swimmino '" Water play Roller coaster ride, water ride Stirring with spoon in mixing bowl Helping bake muffins, cakes Folding paper Spin art painting DISLIKES Some loud noises, individuals who talk loudly/vocalize loudly - high pitch. Crowded environments Cranberry juice Revised with IPP of 5/5/00 . ' ....... . " (i I '1 :i I :1 :1 II " 'I I i , . .. . . - .. .__._-....~" --.. . - Plan of Care. Services Provided 1. Residential Services. Frequency: 7 days/week Provider: CP ARC Address: 117 N, Hanover Street, Carlisle, PA 17013 Phone: 249-2611 Primary staff contacts and phone number: Heather Wagncr/Program Specialist/249-26 1 1 The ResldentlallHP addresses the followin service areas. SERVICE AREA YES/NO/N/A A. Primary Health yes B. Primary Dental Care yes C. Vision yes D. Audiology N/A E. Podiatry yes (as needed) F. Psychiatry N/A G. Neurology N/A H. Gynecology ycs I. Motor Skills/Ambulation yes J. Speech and Language yes K. Financial Profile yes L. Contingency in Event of Death yes M. Socialization/Recreation yes A copy of the ResidentiallHP is attached OTHER: Burial Fund - PNC Bank - Aletha Smith I Funding Source Waiver Eligible Waiver Ineligible MNMedicare A&B MNMedicare A&B MNMedicare A&B N/A MNMedicare A&B N/A N/A MNMedicare A&B PT Routine with staff ass!. Waiver Eligible CPARC CPARC/Aletha Smith yes , , t I . 2. 011)' Progrllm . Frequene)': 5 days/week; 9:00 a.l11. _ 2:45 p.l11. Provider: VCP (Alternatives) Funding Source 2 Waiver Eligible Address: 925 Linda Lane, Camp Hill, P A 17011 Phone: 717-737-3477 Primar)' staff contacts IIl1d phone number: Diane Robison/Program Supervisor1737_3477 Julia ShultZ/Program Instructor1737-3477 Docs the Day Program Plan address the training needs of the client? YES-L NO - If 110, see Casemanager/Coordination Goals. A copy of the Oa)' Program's Individual Program Plan is attached? YES-L NO - 3. Transportation Services Provider: NI A - Included in Residential Contract Address: Phone: Primary staff contacts and phone number: Transportation is provided in relation to the fOllowing services with the following frequencies. 1. 2. 3. -'~"''''''''H.r,y.....'"".,-,.V ,...,....>.. ,.~ Cllcnt 1.0111'//0 p, Smith Page 6 Plan of Carc Casemllnllgcl1lcnt/Coordlnlltion GUllIs Dllte 05 Mav 2000 Goal Number Gual: Louella will be visited monthly and monitored quarterly at her home, visited a minimum of CI'Cry four wceks and monitorcd quartcrly at hcr day program and monitored quarterly at a place agreeable to her. Method: Conversations with Louclla (and CLAlUCP staffwhcn applicable), waiver fonns, progress notes, and mcdication logs. Documcntationrrimc Framcs/Rcvicw: Residential fonns quarterly, case notcs on filc atthc MR office. Pcrson(s) Responsiblc: Nancy Parrish, Case Managcr 2 Goal: The case manager will attcnd monthly trcalmentleam mcetings. Method: Rcview goals, Dr. appts, discuss tcam and clicnt concerns. Documcntalionrrimc Framcs/Review: Case notcs on file atthc MR office. Pcrson(s) Responsible: Nancy Parrish, Casc Manager Goal: Method: Documcntationrrimc Frames/Review: Person(s) Responsible: . . . Client: Louella P. Smilh Plan of Care Meeting . 115 J\'f.~l' 2000 . The following individuals CO) have participate in the development and review of this Plan of Care. '\ Signature ~'JJ Title Vvv' ~ ~ \(~ Self Vv, ,,(,~) 'f:t P 111"' t::;/.., C.., M'"',,, 3. G' C=.~ ~~~ 4. \ K~\u" ~~ pr".9 \"rU,1 a..j,~tJvr 5. ~;C~ ;.j \ I :,})\f:\;( '~1:;C(lfl\ ~~~::,lLQ '. Date 1. sf s / 00 q/c/ <TO r -5'~7000 .r;-I /") ("ff~ ............ i::::) ( .... '- 2. 6. 7. 8. 9. 10. Approval County Administrator/Designee: Date Reviewed: *Each client shall have a PianoI' Care dcveloped in conjunction with an Interdisciplinary Team consisting of at a minimum. the client or his/her representative, the County Cascmanager, and major service prll\'illers i.e. Residential staff and Day Program staff. C/l( ... q I { G -~ Louella P. Smith - Year 2001 Update Enclosed you will find Louella's annual reviews from her residential provider, the Cumberland/Perry Association for Retarded Citizens (CPARC.) As her guardian I have attended her six month and twelve month treatment team meetings. I visited with Louella twice this year and have had various phone calls with her staff, approximately every other month. At her meetings we discussed whether Louella wants to "slow down" as she gets older. Presently, she still wakes up early, on her own, and other than small cat naps which have been a constant in her life, she shows no signs of a need to slow down. However, we have agreed as a team to keep reviewing and looking for signs. Another constant in her life is the presence of vomiting after meals, periodically. 2001 was no different for Louella and she was seen by Dr. Burkhart (GP, January 2001) and Dr. Casal (Gastroenterologist, August 2001) and had some testing at Hershey Medical Center. Enclosed you will find the test results commentary. Louella still attends UCP's Alternatives program in Camp Hill, where the goal is a sensory stimulation program. William LaCour has returned to CPARC residential services and is now Louella's house supervisor. He knows her from the last time he worked with her, about five years ago. Kathy Fernbaugh continues to provide residential services and be a constant in Louella's life. Kathy is instrumental in getting Louella to see her mother (they meet in Perry Co. for lunch about once a month) and for other activities like pairing up with another lady from a group home and going to the movies or to the mall. Being short on staff remains an issue at Louella's residential and day programs, as it is in all of human services. My plan as medical guardian is to continue attending treatment team 6mo/12mo. meetings, keep reviewing the medication changes, quarterly reviews and incident reports sent to me and in the next year I plan to monitor Louella at Alternatives, to see if they are following her recommended feeding plan (becauslc}l~~e seems to vomit more frequently at UCP.) ',~1 Jennifer Wolbach Bowes 1072-11 Lancaster Blvd. Mechanicsburg, PA 17055 {}~: L IE ::lID 10. H _'.JOlj -- ..# ~. ~.. ~. A;'il'llJAL ASSZSSi'rfE........r ClIECKUSr Source ,1. Medical history or docll1JlCnbtion of al1cmJlt.~ to lllJuin (Disability, medic:a1 Iimibtioos, IInd level of functioning) Mt::OjCAl-. I~ i ':;>it>.e t..J N ""eR.AlI Vi:. / S'-I2~~~':>, ,vEE:Df N MLA rr"'F- :C"i-/'T'ELESI -::r:NV~ 2. Strengths/needs 3. Personal interests (likes, disJikes, ~d recreational activities) 4. Level of personal and sociaJ adjustment (ADL's, social activities) 'S'12E.rJ5-n-. / N€.€:~ ~ I S~eNJt:. / N E.EJ) 5 ( 5. Financial skills 6. Need for supervision (self-preservation skills, ability to recognize heat/poisonous materials) t-JN!J2.A Ti'\JE: 7. Progress towards self-administration of medication or a stalaDent that it is unforeseeable N ",tt.t.A Tl'J e.. ~. Areas or personal wants, training, programming, and services A~~'t ~lJ,'-IIA~ i-/.~,C'i Dale ((:) . c;,) crrJ elE-vtCWa) u.l / (~ -r:JJ, en W.\,... '-1 ~. c. \ Date \5".-~ -OJ Dale :c Individual LOu~L-A S M i'T'-l Parent/Goardian Mr.5. 'S^,-,ro. Advocate 'Va,,,,,, Si-/GJI< S,-k...C.Ly 6E.~ 'J ~ N...J Wert "RkSlJ ~1'C.C. ~ A l-lerC){l.h vf.S vVr,St- County Case Manager Otber(s) LOUELLA SI\IITII Mt:IHCAL IIISTOIW FOR ANNUAL ASSESSMENT Dale: Anril 3, 211111 Medical Medical Hislory 10 date (childhood diseases, immunizalions, chronological summary of medical problems, include major illnesses or injuries, hislory ofhospilalizalions, hislory of physicians ulilized, family hislory regarding disease, physical restriclions). During childhood, Louella experienced frequent upper respiratory infections. She had all the normal childhood diseases including chicken pox. Louella had her teeth removed in early childhood after a hislory of biting. Louella's records stated a history of seizures in 1973 but she has been seizure free since then. Louella's immunizations are up-Io-date. She was inoculated for all general childhood diseases including polio, diphtheria, tetanus, small pox, measles, typhoid, saloin, and Asian Flu. Louella's most recent immunizations are: diphtheria boosler, July 21,1993, and a tetanus booster, July 21,1993. Louella receives flu shots every year. J Louella's current ongoing medical problems are blindness due to traumatic cataracts (first reported in 1965), microcephaly (a diagnoses after a chromosome analysis done in 1984), kyphosis (reported in 1982), irritable bowel syndrome, chronic conslipation, arthritis of the right knee (diagnosed after an exam in 1991), and bursitis of the left shoulder due 10 a separalion on February 8, 1962. Louella tested posilive for Hepatitis B and for Tuberculosis. She has been exposed to both diseases and developed immunity, bUI she is not contagious. Louella will at times vomit after ealing. By doctor's recommendations, Louella should eat with a small spoon, swallow each bite before taking another, and not lay down until four hours after ealing. Louella had a barium swallow and chest x-ray done on August 24, 1995; results were a large hiatal hernia with gross reflux and intermittent aspiration. Louella broke her collarbone on January 5, 1995. Louella spent Ihe first four months at Pennhurst in 1942, in the infirmary with an upper respiratory tract infection. Since her move to CPARC's Residential Program (May 1985), Louella has been in good health. She was taken to the emergency room in March of 1993 as ordered by Dr. Herrold for possible blood in her stool. Results were negative. On February 2,2000, Dr. Grubb prescribed Vioxx for pain in muscles and joints. On February 17, 2000, Louella was seen by Dr. Ann Bero at Hershey Family Practice for having a bloody bowel movement. Dr. Bero performed an anoscopy, which showed internal hemorroids. Dr. Bero prescribed Milk of Magnesia 30cc PO today, Colace two POC HS and Anusol HC suppository 2 times per day for 2 weeks. Dr. Bero discontinued the Vioxx, due to it possibly causing the internal hemorroids. On March 11,2000, Louella again had blood and pus in her stool, as well as pain. Louella again was Annual AU.umenl Louelll Smith PIRe 2 .' diagnosed with intemal hemorroids and a fissure. Anusol HC suppositories and Balmcx ointment was prescribed. On 12/28/00 Louella was seen by Dr. Cassal, gastroenterologist, for frequent vomiting. Dr. Cassal recommended: I.) Complete supervision of all meals to make certain that food is swallowed before her next spoonful. 2.) Do not allow Louella to lay down within 4 hours after a meal. 3.) Have a speech evaluation regarding swallowing food. On 1/4/0 I Louella received a swallowing evaluation. The speech therapist recommended to closely monitor Louella when she is eating, give Louella smaller portions, try giving Louella small sips of a drink between bites, and continue to monitor Louella's Vomiting on a chart. If incidents do not decrease or increase, the speech therapist will consult with Dr. Cassal, Gastroenterologist, to discuss a modified barium swallow study. On 2/15/01 Louella had a wart removed from between her breasts. Louella is ambulatory with physical assistance or by use ofa wheelchair or walker. Louella is able to toilet appropriately. She wears adult briefs both day and night due to her incontinence. , , Louella's family history for disease includes a reflux disorder that seems inherited. Her twin sister passed away because of complications experienced after placement of a jejunostomy feeding tube. This was required because her reflux disease was so severe she was aspirating stomach content into her lungs. Her father had a similar disorder. She has a positive family history for mental retardation. History of Physicians Utilized (pre 1985, Pennhurst Institution physicians) 1985 - 08/18/95 Drs. POller, Herold, and Harker West Shore Family Practice Center 804 Popular Church Road, Suite I Camp HilI, PA 17011 Family physician I: 11/15/95 - present Hershey Family & Community Practice 845 Fishburn Road Hershey, PA 17033; (717) 531.8181 Family physician Apple-A-Day 6230 Carlisle Pike Mechanicsburg, P A 17055 Family physician Dr. Frederick Hecht 238 Alexander Spring Road Carlisle, PA 17013 Dental 1997 - Present I I 1 I 1 Annual A.....m.1I1 loudla SlIIlIh rlK' J Dr. Mortin Rubin 120 South Filbert Street Mechanicsburg.I'A 17055 Orthopedic Surgeon Dr. Robert Thompson Medical Arts Building. Suite 207 Carlisle. PA 17013 Ophthalmology Dr. Rolando Casal 532 North Front Street Wormleysburg, P A 17043 Susquehanna Surgeons Hershey Family & Community Practice Gynecologist Dr. Westra 4700 Union Deposit Road Suite 230 Harrisburg. P A 17111 Gastroenterology Clinical DiagnosislLevel of Mental Retardation from Professional Evaluations A psychological evaluation was performed by Eugene Stecher of Guidance Associates on February 26,1999. Louella's range of functioning is most sirnilar to profound mental retardation (318.2). History of Medieations Used. Colace Docusate Sodium Keflex Neosporin Opth Lavoptic Eye Wash Garamycin Opth Diazepam Pepcid Hydrocodone Tums Multi-vitamin Dulcolax Polymox Dicyc10rnine Dacriose Eye Wash Phenergan Duricef Cephalexin Benzonatate Immodium AD Fleet Enema Emetroll Neosporin Caltrate 600 Bacitracin Robitussin Ativan Propulsid CeRin Tri-tannate Rynatuss Amoxicillin Dimetapp Carbamide Peroxide Oysco Bran Lodine Hydrocortizone Nizoral Cream 2% Nystatin Cream Claritin Prilosec Zithromax Augmentin Vioxx Propulsid Milk of Magnesia Anusol HC Balmex Ointment Bactroban 2% Ointment Acetaminophen A1legra-D I i I I I I I I i i , : Annuul A"e..menl Louella Smllh Page 4 Dental Dental history to date (all dental work completed, Iisl of previously used dentists and/or specialist). Dr. Frederick Hecht; 238 Alexander Spring Road, Carlisle, PA 17013. Louella is without teeth, dentures, or a panial plate. She sees Dr. Hecht on an annual basis to assure healthy gums. Louella has seen Dr. Hecht annually since 1985 and has had no oral problems to date. On April 17, 200 I, Louella had her annual dental check-up. There were no problems and she is to return in one year. A. Personal Profile i I I , i , I I I r'i i I I ,; I! I Louella is a gentle, pleasant, 62-year -old blind woman. She resides at 1026 Drexel Hills Boulevard, New Cumberland, P A. Louella is unable to read or write and cannot fonn or develop sentences. Those who are close to Louella are able to understand and communicate with her and can therefore satisfY Louella's wants and needs. When in a foul mood, Louella will repeat 1-2 syllable words that she hears. Occasionally she will put 2-3 words together at a time. Louella enjoys clapping her hands, stomping her feet, laughing loudly, giving hugs and kisses, and dancing. She will indicate to staff, either in her home or at her day program, when she is hungry, when she has to go to the bathroom, when she wants affection or just company to spend time and have fun with. When Louella is not in a good mood, she will often scream loudly, say or yell obscenities, and rock backwards and forwards. Occasionally she will also rake her hands through her hair, usually resulting in hair-loss and/or scratches on the forehead, face and nose that mayor may not bleed. The causes of Louella's anger could be a soiled diaper, the need to use the bathroom, feeling ill, running a fever, loud noises, fatigue or the need for attention. Staff can cheer Louella by talking to her and resolving the problem quickly. Louella enjoys spending time with familiar people and being outside when the weather is wann. She likes singing, having her hair brushed, her back massaged and scratched, hands held, listening to country music and Broadway musicals. Louella enjoys drinking teas, fruit juices, coffee, milk, and sodas. She enjoys eating puddings, jello's, applesauce, anything sweet, mashed potatoes, chicken, meat and vegetables and just about everything else. Louella requires all of her meals to be pureed or mechanical soft. She will feed herself with a spoon after the food is served and she is guided to her spoon and plate. Louella's meals need to be monitored so that she does not eat too much or too fast. If she does have too much to eat or eats too fast, she may vomit. Louella has a favorite chair that she sits in during the days and evenings at home. She has two plastic tubs filled with different textured items that make sounds or feel soft or hard, large " Annunl A'I!enml'nt IAlurlla Smith l)aRf (, F. Supportive Services Louella attends Allernatives-West (UCI'), 925 Linda Lane, Camp Hill, PA 17011. She attends Monday through Thursday, 9:00 a.m. to 3:00 p,m. and Friday's 9:00 a.m, to 2:00 p.m. The contact person for Louella is DiDne Robinson. At Alternatives-West, Louella docs various arts and crafts, goes on outings, cats snacks and lunch, sits in a chair and listens to music. In 2000, Louella toured the Elderly Day Activities program in an attempt to possibly switch day programs. The end result was the EDA was unable to meet Louella's needs, so she will remain at Alternatives-West until another opportunity arises for a day program that will best suit Louella's needs. The Treatment Team will review the possibility of Louella retiring each quarter. At this time, Louella shows no sign of slowing. G. Vocational Prolile Louella has not worked on any vocational skills in the last year. There are no current Treatment Team recommendations at this time to address this area. H. Residential Prolile - Life Management Skills 1. Self-Care _ Louella needs assistance with getting in and out of the bathroom and shower. She needs her hair washed and help with rinsing the shampoo and soap offof her body. If given a soapy washcloth, Louella will scrub herself in the shower. Louella is incontinent but she will occasionally let staff know when she needs to go the bathroom. She needs staff assistance in wiping and changing her diapers. Staff take Louella to the bathroom every two hours. Louella will place dirty laundry in her hamper, to be laundered by staff. Staff pick out outfits for Louella on a daily basis and take her to buy new clothing as needed. Staff schedule all of Louella's medical appointments and provide transportation to and from them. Staff also administer all of Louella's medications according to dose and schedule. The Treatment Team has deemed Louella inappropriate for testing of the Self-Medication Oral Review. 2. Household _ Louella has minimal skills in this area. Staff prepare all meals, however Louella can help stir or mix food in a bowl. Staff do the dishes, Louella can help place her dirty dishes in the sink and scrub them offwith staff assistance. Louella can also help dust, wipe and sweep with staff assistance. Staff then make sure the areas that Louella helps out with are refinished thoroughly and completely. Louella will pick up her toys around her chair independently. 3. Financial- The Executive Director ofCPARC is Louella's representative payee for her SSA benefits. Staff take Louella to make purchases on her behalf, then log all transactions with receipts in her accessible cash account. The Residential Supervisor, Program Specialist, or Associate Director are responsible for paying her monthly bills, as well as helping Louella make large purchases. -... Likes and Preferences (c::ntinuedl ( '1 t)\1 rr.cney: ~ood paYing jcb rr.cvles (videosl: f><J -/-0.. 'l ~ oJ ^' r>J~ ( 1 t'/,I resconSlble iO ~m;:lele lhlr.~S restaurams. cut :0 d3t: f"",1J ,^uln~iC ftl~ ( 1 rr.cv,rg ~ut freely on tne ;Ob (')(J nding in vehic:es: ('A rr.usic: ('~ [..,.I^r~ 16f MlIS;<' ( 1 sewir,g ( ] r.cr:crir.g woO< (~ sr.cppir.g ar.d t:1J'firg thir~s ( ] or::ering thir:gs thr::u911 catalogs ( ] singir.g ( ] or::erllnesS ( ] outs:ce woO< M peeple: c!ose frier:cs ~P!l:" F'A.........c.( ( 1 sl<alir.g {)!!Y- -.,.A-a..; [x'l sleeping [ 1 SOo'cl<ir.g [~ peeple: ac.,--cair:tarces ~ scdaliing with peeple Y~t-€. (P A~L;r:> [ 1 pla'fir.g s;:crts [ 1 [)() [ 1 (xi pr.otcgraphy praise rakirq and/or bagging leaves rec::c;nition & attention ' S'Himmir,g S'Heej:irig Kl ( 1 , -= Getting to Know individuals: And the Survey Says ... Activity #4: P3ge .4. Dislikes and Aversions ( animals: ( ] keeping UP (nOI) ".' [ I lone'ines~ [ I Icsing [Xl loud and neisy envircnmer.:s [ ] manual deXlerrty (jecs that re~uireJ [ I assemcly line :ype werk " [ ] ordered with no ex;:lanatien (I:eing) [ I cad< seal et the car WI pain (being in) [ ] calning [ ] past (thinking et me) l}(J txlred (being) [ ] pacple (cenain): [ ] cnang e ( ] cnar.ging clethes [ ] C:-:crcil ( ] c::ld (being) ( ] c::r.:lic:s ( ] pnysically del1'.anding jees ~] c:r:tusk:n ( 1 pid<ed on (being) (y[ cmic:sm ( 1 pressure situatIons (XJ c:::wcs ( 1 put on the Spcl (being) "') ( ] demands [ 1 repelrticus jcbs ." " ..... f><] dieting D<] scared (feelir.g) [ ] disl1es (deir.g) [ ] sharing ( ] diso:;anizaticn [ ] sitting fer :Cr,g ;:er'.cCs ef lime [ ] dec:ors [ ] s-.ar.cir,g lOO :Cng , ] elevators ( ] ticXled (beir.g) L [ ] teel (beir.g en) [ ] told no (beir.~) [ ] getting up in the l1'.cmir.g [ 1 lold what to do (beir.g) [ ] gccd ;ob (r.ct navir.g a) ( 1 unemploymem [ ] guns ( ] ,unwanted (feelir.g) ( 1 heigr.ts [Xl waitlnQ ( ] housework ( 1 wimer ( ] iCentitied as 'M. R: (l:~ing) [ 1 wcr1<sl1cp (being in a) [ ] jobs (certain): Additional activities may be identified on the back of this form. Getting to Know Individ11.:1ls: And the Survey Says ... Activity #4: Page . 6 . Individnal Lol1~ II" <)~,~t, . STIlE:'I(;TII/NEE/lS I'fUlFll.E SlrclIll.l1u Abililic~, c.ll"lhiliIlC~. Irllcrc,1> ,11111 Irllcrl-ilc<l Pcrlon3 NI't.'113 I'llsilive <I1'Scriplilln of Individual Needs. 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SafclY in CommuDity ~t c...-wln\l."",~' k-r),e\\a. I~'\\ ~~ '\ \ tL " ')\-"" ~vferlilS IMv 0..1\ -k'0\f S i VI .f;t.... Cl'Y1'l11/1'U"';,'k . \ J.... 0:,1 '" \ \\ \ Carli ofPersoDal BcloDgi.o~ r-w..e Co.. ~ rlWS ~,o r ,.. ~JPr+i 'S ~ h."l\ ClSS I.",.t ~-\ C. 'k_ h(l...,..) l-e <; 1\1\ 4-0 \/,~..",:el\o.- . \>, i,^MI.\o.:\I-1'~ . b (L box ~"\ ~ l.~\ as e-.I-o. hll..r bedrOt:-lv<.. <4". b J D.e:r,CfV\C\.\ ~e\t'1^"':"-vS T J -.l 2 ludividuul ~ot.,~ IL, ')\n','\-'\, I \ Pcrsuual Kno~k"(h:c/nc:IIlIY OricOl111 liou . h.i:>u.e\ <J. .I<",-.w<, lor ~vu: Jr- ("?'7"'~ . hGl.lI.!./ a.. <'''"'1'''+ rr'~~., :sl-.~ VO, <K<; lW-.~ i h,t; t,..-\' r-.(~~ -h\<'$' of- ~ ,Ye~ tiJ..,JI-. F" J ') , 0( ~t~ OO(J i . Fuod Preparlllion/McaJ PlllnniDg . -h,.\A.e.\ \" ~ s~,.- ~ " )h...+f ,,;', t\ h.... r("f'~'~lt\.. I'\l,v <=ceil ':,~ ~ b&t0\ <1:.v-a .1;.,.. """I n!.....,,;"'l oCPj\""J.;...,1 'i:::> f J. It , I .2p.-.e>tJ r....,) p.\r;~<x. AJ.L ~~ ,,',11 kptl..ee~ . . '- Shopping . ( Ll'h.lf\\l\- ~ J;:N-;jeJyS ~'/~) ~ lY\l WI-e d\ ~. ~L.LS A......-IJ ~.jJ~ k.u:eit.".'s ~\'\"",,',C\..~ ~S<l.c\..~,,~ . ~ I l&\. '),; 1~/'o. V;l\ a.cc.~ -sk--.(i:: ke\\~ ~S ~ <;~l<; . \ Use ofTeJephone .1e\epke.~t ).k~ u.:.1I M.D>..\I:.-e W R.e.c.c.;\J~ c...lls (.".. ~u.el\a... h L~.L-ell,,- A~c; ~o~ r--ec..d o-r lllr~~ . ReadingIWriting 'S~~ t;{\ ('€$H?-.u o.~ ;,cc.......ell\-I-s- 1.'::\% lnuel\" ~ Q.....~ l oC\ Ie (tie (t r e~i tU) l\:tL1 C.'~f. kP\\CL k.s ~D s ki\\s I'" (II1W>\\ers (~r Ii Me. Numbers and Time (7~, .- J ~E..U..A . --c:...0 c.~ ~. , SrAf:P ~ P=.r...p ~K b -~__:fi~~, : --. .- ;. . J , Individual ~l>e\\a.... '5M ~,"'- ~ .Use IlCCllrnlllnnilv Rc:\llurccs LI\~...e\\o... .~V\~t;>'1S be\~ j" 'k'P\\~.'l~ r>N "- L...'1C-- tow.,"t."11~ l;;f.I\.,.. o;\.. . _ .(;,r """"'"l<>. C''1O'\~, l:l; A (~{>'H( .", ' ~\.-(+ u:,1I ,"a~e <;LCre 1"",1'\\" (jl'~' ('<,Ii iJ. ~1,((\'f1I~I~, ML't!icaUSclC-qlrC .' , \;.ou€\\... be~"",~\)r'(b..\ bIer,!;] S~~ t:...tl ~""\;\<;\erkuel"",, ;\~:\-~~~~:~- '~;:\~::;~;"~~~" ~ .....~a:!~ V'-e€~ec SIlt iYlIW(f. \ II . 1\ InlcrpersonaUSocial Languagc _ \ II L \.-Ov..el\C\.. v..."-1\ f'eper&- ul~o<; St:;..~ w,\\ n~~L -k. ~\.u. kc..rs ~~) ;,,~ .....""'1 ~r ~\\a s,1,,'c;!.,'<>~ SC1v\.e. wr-.-bs l.o e><pcesS N~, b'( ~)~W;""" \""r ~\-S lI..V'il t>\ee}s . \ b ~ . _ '\ Communication ko.e\'-"'. ,>-,\\ ~e. %i'eo 'iv..'t'Shellll; L6t€\\.... 'Co..Jl.-O uSe. ~~ S\-c-.# do lMU 16LutI~ re"'~N~ Me>R.F Co.tt,ttv:.]ic.A:i7'M L ~ 1A1~ ~l.j-€';" ~"~o". (:.cUc:uA <;1::' t'u.....3 O/='-e-.N (IV'-iT.6(r€.5 ~O~ SR:s~~ '6'-1 01V<-Gtt.S. Rclationships With Others _ \ . b ~ k, '5\-..f~ .."S c...e-o'\~\'\.U!! "'" !; r-e *' ~ 'il~e- \..-...e\\n.... ,.\-4 I:> E lJIH' S 0.,,-) ~ fc.OM.b I-u.:,,- \.0 4f'ku,.',L., 'i-- ~PJel'f--:- . s\.u:w lI.~c\....,), R"l.th"~\\:f~ ~~, ~w._~ e:m..&..~ , _,\ . I. Self.Esteem and Scxual Awarcness ~ .... ~I\ns I<>e,ks.; F<;#)) . . 1" 'S~__-fk " l-e\~ ,,,.Jc~ S~ _0-\\\ LC'I'\~~ c....}) ",f- (l'\~V\~<; t ~1-9 . ~r rtMc;e ~l\a..., 4 . Trcatmcnt/Rccolllmcndations: Rcturn in onc vear Plan for Dcntal Hygiene: Stair will assist Louella with brushing hcr gums daily. Shc will have annual visits with the dentist. .' Optometry Optometrist/Ophthalmologist: Dr. Robert Thompson Address: Medical Arts Building Suite 207, Wilson St, Carlisle, PA 17013 Telephone Number: (717) 243-2331 Date of Exam: 9-6-00 Findings: Crust on eyes. TreatmentlRecommendations: The doctor prescribed Ciloxan 0.3% ointment for 7 days and to clean eyes thoroughly. Return in one year. Health South - Language Pathology Practitioner: Dawn Irwin - Groleau Address: 840 North Front Street, Wormlysburg, PA Telephone Number: (717) 975-3337 Date of Exam: 1/4/01 Proceduresffests: SWallowing'evaluation due to frequent vomiting as requested by Dr. Cassal. TreatmentlRecommendations: A modified barium swallowing study may be ordered pending discussion by Dr. Cassal if problems remains persistent. Recommends: smaller portions, single bites oHood, small sips of liquid between bites and closely monitor eating. Susquehanna Surgeons Practitioner: Dr. Cassal Address: 532 North Front Street, Wormleysburg, PA Telephone Number: (717) 761-4141 Date of Exam: By appointment. TreatmentlRecommendations: Dr. Cassal recommended that: I) complete supervision of meats to make sure that food is swallowed before taking the next spoonful. 2) Not allow Louella to lay down within 4 hours after a meal. 3). Swallowing evaluation with speech therapist. 4 Medicntions Mediclllion 1II00d And l'url'Dsel nevicwiug Frequency Levels DoslIge Ilillgnosis I'hysicilln or neview Necessllry Bran, 2 Tbsp, Am Bowel Grubb Annually No regularity Docusale Sod, 100 mg 2 Bowels Grubb Annually No caps al bedtimc Ear drops 6,5% oncc Wax build up Grubb Annually No wceklyal 8pm in ears Eyc wash/irrigating Cleanse eyes Grubb Annually No solution swab both eyes and lashes 2 limes daily Johnson's baby com starch Rash Grubb Annually No apply topically to affected area twice daily Metoclopramide tablet Digestion Grubb Annually No once daily Multi-vitamin tablet I daily Dietary Grubb Annually No supplement Oyst-CaI 500 tablet 2 tabs Calcium Grubb Annually No once daily supplement Prilosec 40mg cap once Stomach Gmbb Annually No daily reflux Allegra-D SA every 12 Cold Grubb Annually No hours PRN symptoms BalmllX ointment PRN Skin rash Grubb Annually No Nystatin cream PRN Skin irritation Grubb Annually No How will medications be administered? (Check appropriate spaces) Completely independent with self-administration. (No staff involvement) Independent with sclf-administration by filling daily or weekly (circle one) pillbox. Slaff monitoring or no monitoring (circle one). Self-administers by recognizing hislher medication. Self-administers by picking out correct amount. Self-adminislers by knowing when to take hislher medications (not necessary 10 know correct time). --X. Completely administered by staff. 5 Which best describes the met bod used for mobility? o walks independently o walks with support of another person (for stairs, etc.) Zwalks with an Dssistive device: 0 cane Zwalker iJ braces 0 other ,B'uses a wheelchair: -ff manual 0 electric 0 other ;;3'transfer skills: 0 independentZminimal assistance 0 total assistance. Residential support provided in the area of mobility: Louella uses a walker with staff assistance in the home and at her day program. She also uses a wheelchair outside the home for appointments, activities, etc. Staff transport Louella to all her appointments, day program and activities, etc. Which best describes the method(s) of communication used? Receptive Expressive "ffVerbal )3 Verbal: 0 Proficient ZLimited o Gesture Z Gesture o Sign _ Basic Words 0 Sign - Basic words o Sign _ Fluent 0 Sign - Fluent /-fEnglish %English o Spanish 0 Spanish o Other Language 0 Other Language o Use assistive technology Which best describes level of communication? o can make needs/ideas known to the general public and understand responses ).1' can make some needslideas known to familiar persons and understand responses o need support of other(s) to express/interpret needslideas Residential support provided in area of communication: Staffwill continue to infonnally encourage Louella to expand her vocabulary by repeating words with her. 7 , ", ~ ~," \ , Dav Service~ o Employed Employer: Address: ;t Unemployed Day Program Provider: Alternative - UCP (West) Address: 925 Linda lane, Camp Hill, P A 170 II ~ _ Competitive Employment _ Sheltered Workshop _ Transitional Training Program (TTP) _ Supported Employment _ Supportive Employment --X- Adult Development Training _ Elderly Day Activities Volunteer School Partial Hospitalization Other: I i ! \ \ \ \ Contact Person: Diane Robinson Telephone Number: (717) 737-3477 Comments: Louella currently attends Monday through Thursday 9am - 3 pm and Friday 9am - 2pm. 8 " \ LIlIII! 1~lIl1l!r Ohjl'rtivr Namc: Louclla Smith Implcmcntlltion Datc: 10/12/00 Dcscribc Prcscnt StrclIlJths: Louella is ablc to undcrstand short rcqucsts. Shc is also ablc to walk short distanccs using a handrail. Long Rangc Objcctivc: #22 Louella willlcam to walk from thc kitchcn to hcr bathroom and back indepcndcntly using the handrail. Target Dates Steps Toward Objective Projected Actual Procedure Scc specific short tenn step. ST #2 Louella will walk from the kitchen to hcr bathroom and back, 6/1/0 I using the handrail with unlimited verbal prompts and staff assistance by placing staffs hand on Louella' s back. . ST #3 Louella will walk from the kitchen to her bathroom and back 9-1-01 using the handrail and unlimitcd verbal prompts. ST #4 Louella will walk from the kitchcn to hcr bathroom and back 12/1/01 using the handrail and 10 or Icss verbal prompts. 10 RESIDENTIAL St:ltVICES Individual Louella Smith POC ANNlJAL HEVIEW Pnge I of I Stntus LRO 1122 Louella willleam to walk from the kitchen to her bathroom and back indepcndently by using the handrail, ST 112 Louella will walk from the kitchen to her bathroom and back using the MT handrail and unlimited verbal prompts and stalfassistance by placing stairs hand on Louella's back 01: 1/23/01 TD: 6-1-01 Status: March: 9/9 April: 17/17 May: 6/6 . 13 The team a 'rees tis, l~ C '}o Ilains se~ices :Ind activities 10 meet the needs and wants of POC Interdiscinlinarv Team l'articinanls: . f.c..-.),"i'..J'fP l..OUr.LL~'\ ;lu...:'t~C"f"--""J..jf.;;tlut 3;1-01 S,Z~\ Individual 'Date Parent/Guardian Date ~ ,,~- ';:.:,..~-~ Advocate ~-:: -c,\ Date JUtt, liW:c Case Manager _ ~~ hJ~/~ Prolp'am ,1;dvisor 5- J--Q I Date 5-7...-0J Date Program Advisor Date pr07/t:-- R~ntiaJ Supervisor Date 02-0( Date T'~'~ ~. Program Specialist D~~~fl~ Day Services Representative Date C;-. "2 ' ~ Date ~ -&- -0/ Date e'-f740r-t,.,-~ Oth J' [' ~i;W1 iJ/~- M?LL-1LLCt. dlftL~ 1+s::L'i.":.i/Je. j) ( ec./rt'" () 2- j1f ay ;)00 I Date ( I .:f',..0" -0 f Date R_ . : 1 f,- {- 0 I h.f1L-1 ,1~LLl.f r/ 2:! Finnlldnllnforllllltillll $658.00 Representative Payee Exe Director CP ARC SSA Claim # 185-01-4598 C2 Amount Source Name of Bank : Keystone Financial Type of Account: Checking Address: Highland Park Office, 433 South 18'" Street, Camp Hill, PA 17011 Balance: $500.66 Burial Planning Contact Person: Althea Smith (mother) 1. Burial Fund Bank: PNC Bank Address: P.O. Box 535230, Pittsburgh, PA 15253 Account #: 89-9563-2933 Amount: $6,489.14 Funeral Horne: Nickel Funeral Horne; Mr. Jim Nickel, Loysville, P A Ceremony: Viewing, funeral service w/religious representation Cemetery: Blain cemetery; Blain, P A Additional Comments: 2 He:l1th Annual physical Examination General physician: Dr. Nancy Grubb 1 Dr. Christina Burkhart Address: Hershey Family Practice, 845 Fishburn Rd. Hershey, PA 17033 Telephone Number: (717) 531-8181 Date of Exam: 10-24-01 Height: 4' 11 Vi' Weight: 1491bs. BIP: i 18170 Laboratory TestsIX-rayslOther: Urinalysis - CXR Findings: Urinalysis - normal; CXR - clear; no hearing problems noted. TreatmentlRecommendations: Return annually or as needed. General Physician Visits Date Reason for Visit Re ort of Visit 5/16/01 Follow up to ER visit (5/6/0 I}. Staple removal. 6/26/01 Annual mammogram. Normal; return in one year. 8/2/01 Vomiting, diarrhea and low grade fever. No treatment but suggested using soymilk when preparing meals. 12110/01 Excessive coughing. Prescribed Zithromax 250mg 2 tabs today; 1 tab daily for 4 days. 1/29/02 possible urinary tract infection. Bloodwork and urinalysis results pending. 1131/02 Verbal confirmation. Bloodwork normal. Urine culture shows UTI. Dr. prescribed Bactrim 1 tab twice daily for 7 days. 217102 Repeat urinalysis. Attempt unsuccessful. Will try at next appointment. 2/26/02 Urine sample. UTI cleared up will recheck in 3 months. Next a ointment 5/30/02. 3 AnnulIl Dentlll EXlIminlltion Dentist: Dr. Fredrick Hecht Address: 238 Alexander Spring Rd. Carlisle, P A 17013 Telephone Number: (717) 249-7007 Date of Exam: 4-18-02 Findings: Oral health good - gums look good. TreatmentlRecommendations: Return in one year Plan for Dental Hygiene: StalTwill assist Louella with brushing her gums daily. She will have annual visits with the dentist. General Dental Visits Date Reason for Visit 4/17/01 Annual exam. Re ort of Visit All OK; recheck one vear. " Optometry Optometrist/Ophthalmologist: Dr. Robert Thompson Address: Medical Arts Building Suite 207, Wilson St, Carlisle, PA 17013 Telephone Number: (717) 243-2331 Date of Exam: 9-26-01 Findings: Eyes are healthy. TreatmentlRecommendations: Medications (eye stream solution 8am and 8pm, swab both eyes) stay the same. Return in one year. 4 Emergency Room Practitioner: Hershey Medical Center ER Address: 500 University Drive, Hershey, PA 17033 Telephone Number: (717) 531-8333 Date of Exam: 5/6/01 ProcedureslTests: Louella fell and had an injury to her head. Findings: Required 10 staples to top of head. TreatmentlRecommendations: Follow up with family doctor for staple removal in 10 days. Susquehanna Surgeons Practitioner: Dr. Cassal Address: 532 North Front Street, Wonnleysburg, PA . Telephone Number: (717) 761-4141 General Visits Date 8/23/01 Re ort of Visit Ordered an upper Gl series and lower intestinal x- rays. Dr. Cassal also stated that all of Louella's meals should be monitored as per speech evaluation done by Dawn Groleau. Reason for Visit Evaluate frequent vomiting. 10/9/01 Results of upper GI series and small bowel follow up. No presence of a para-esophageal hernia. Instead there is a large sliding hiatal hernia with gastroesophegeal reflux. It should be treated by monitoring meals, smaller portions, and lactose free. If vomitin ersists then surlZe will be an 0 tion. 5 Medications Medication Ulood And Purposel Reviewing Frequeney Levels Dosage Diagnosis physician of Review Necessary Bran, 2 Tbsp. am Bowel Grubb Annually No regularity Docusate Sod. 100 mg 2 Bowels Grubb Annually No caps at bedtime Ear drops 6.5% once Wax build up Grubb Annually No weekly at 8pm in ears Eye wash/irrigating Cleanse eyes Grubb Annually No solution swab both eyes and lashes 8am 8pm Metoclopromide 10mg 4 Digestion Grubb Annually No tabs daily Multi-vitamin I tab daily Dietary Grubb Annually No supplement Oyst-Cal 500 tablet 2 tabs Calcium Grubb Annually No once daily supplement Prilosec 40mg cap once Stomach Grubb Annually No daily reflux AIIegra-D SA every 12 Cold Grubb Annually No hours PRN symptoms Balma.x ointment PRN Skin rash Grubb Annually No Nystatin cream PRN Skin irritation Grubb Annually No How will medications be administered? (Check appropriate spaces) Completely independent with self-administration. (No staff involvement) Independent with self-administration by filling daily or weekly (circle one) pillbox. Staff monitoring or no monitoring (circle one). Self-administers by recognizing hislher medication. Self-administers by picking out correct amount. Self-administers by knowing when to take hislher medications (not necessary to know correct time). --1L Completely administered by staff. 6 Awnreness of Danl!.er and Snfetv \'recll\ltions Type of Danger a. Poisonous materials b. Trame, crossing streets c. Strangers, threatening people d. Hot water e. Hot oven or range f. Fire (open tlame) g. Water (i.e.: swimming pool) h. Gelling lost or separated i. Other No Awareness Adequate Awareness Delicient Awareness x x X X X X X X SELF-PRESERVATION SKILLS J! No self-preservation skills x[ Must be physically moved 0 Evacuates with physical prompts C Evacuates with verbal prompts 0 Responds to alarm, evacuates [j Knows fire emergency independently procedures (i.e.: use phone or call box, meeting place, etc.) Can this individual be left alone? [j Yes fi No If yes, how long may they be left alone in their home? 0 hours How long may they be left alone in the community? 0 hours Plan for Decreased Supervision: There is no plan to decrease the anlount of supervision Louella receives. 7 Which best describes the method used for mobility? o walks independently o walks with support of another person (for stairs, etc.) Zwalks with an assistive device: 0 cane 2"walker 0 braces 0 other J5 uses a wheelchair: Z manual 0 electric [j other ,ffiransfer skills: 0 independentZ minimal assistance 0 total assistance. Residential support provided in the area of mobility: Staff assist Louella with the use of her walker and encourage Louella to use her walker when walking short distances or when not suing the handrails in the home. Staft'transport Louella to all activities and appointments. A wheelchair is used for longer distances. Which best describes the method(s) of communication used? Receotive .zv erba\ o G,esture o Sign - Basic Words o Sign - Fluent ZEnglish o Spanish o Other Language Expressive ,ZVerbal: 0 Proficient ZLimited B"Gesture o Sign - Basic words o Sign - Fluent ,2'English o Spanish o Other Language o Use assistive technology Which best describes level of communication? o can make needslideas known to the general public and understand responses Zf can make some needslideas known to familiar persons and understand responses o need support of other(s) to expresslinterpret needslideas Residential support provided in area of communication: Staffwill continue to informally encourage Louella to expand her vocabulary by repeating words with her. 8 Plan for Individul1lized I'articination in Community Life Integration in community nctivities with peen without disabilities and residential plan of SUI1Jlort for Jlllrticillation and Interaction.) StalTwill assist Louella in making arrangements to take trips ofinterest to her, Louella will continue to engage in community activities and resources such as restaurants, parks, malls, theaters, etc. Staff will also assist Louella in visiting her mother on a monthly basis. Stall'will inform Louella of events and activities and assist her in choosing those she would like to allend. Louella will also continue to have her hair and nails done as she chooses. '. Growth and Develooment Long Tenn Goal to be Addressed Implementation Date Target Date L rG #23 Louella will increase her participation in activities of interest to her. 3/12/02 3/I2I03 10 ~ ~ -~"'-'-_'.~h~"".~'.'. .1-"''';..';.;3''''''..'''.~~.'k.''...''...''^ long T~r:n Go~1 (continued) Criterion t\lr Compl~cion: 1l!lJr/b /mll ,.;'C!/t'f'{y ""Nt, SIc'/J /".I),t'i'1 , .:; :;, .) r,( i ;~ k,' .:)yn,;.z."nA' Or 1;'-'7<:; f~?;-- ,:; n->..>n In ~ Datc(s) co be rC'liewed for pos3ible rc':ision: ('it (,JVk .'(" I I:.:)kd ;::"11-<' //.;; '" r C?n-l4'-/,.- .~ ) ( f-/-'~ !ndi'lidual's Signature ~;{,', 1J~ Supcr/isor's Signature /fk.(f toil) Y?:,.-tk-..-rtr ,;.../ }:..;:y S -';;-0)", Dat~ -z ).~ ()2.. Dat~ _./" ~ 4' . 7/7C/"'--_ "",...___4.10- Program ccialisc's Signature .... / i ASSOClat. ~ -d -() ") Dact: UL a/A/OJ-; Date , , , .. ..... " l8 " Long Teml Goal II Monthly Datn 12 RESIDENTIAL SERVICES Individual Louella Smith I'OC ANNUAL REVIEW Page I of I St:lIUS L rG #22 Louella will learn to walk from the kitchcn to her bathroom and back independently by using the handrail. SrG #7 Louella will walk trom the kitchen to her bathroom and back using the GA handrail and 4 or less verbal prompts, 01: 1/18/02 TD: 3/30/02 GA: 3/12/02 Status: Fcbruary: 15 times March: 6 times LrG #23: Louella will increase her participation in activities of interest to her. MT SrG # I: Louella will participate in an activity of interest twice a month, ID: 3/12/02 TD: 6/12102 Status: March: 2 times April: 5 times 14 have attended the annual Individual Program Plan meeting for the above named individual and approve the ,Ian as discussed pending review of the final copy. If I do oat agree \\ith the final copy, I ....ill request a team :1eeting in writing to the Progrc:.m Director v.ithin five (5) days of receipt.. ,~\.6P . .:.~ -- 0. 6-/).-D:f. ndividual, Date Alternatives Director 1!Z:,\' C ltc'iliNit',,- 5 ~ 2. -0 L _~ ;a\ 0 f ko giJ hdV\ :ase Manager Date Alternatives Supervisor ;.~-+; . ';;'~~' .. ..,' " :; . ...~... ....... .~..;:. .:.-:.~~ .:. ',' ',. ~'. .; UNITED CEREBRAL PALSY OF THE CAPITAL AREA 925 LINDA LANE CAMPBILL,PA 17011 ALTERNATIVES 'ype of Review: Initial Development oflPP -L Annual IPP'ReviewiRewrite LOll. e. QtJ~ S 11\'\ ~{h_ :1dividual's Name: ~r-.. ~ Advocate , Date S'.2-0L Date Family Member $-'l..-01- Date Alternatives InstrUctor 7a;'~ ~ Other (Specify) I'':~ s~. Invited, did not/could not attend: S -:2- 0 J.. Date IPP was review~d ....ith LOu. 0 ~i ti - Individual bYJ);QI,Lt ~~ISo\CL- Staff Date .. 5 Jd-./o/J- . , Date S\7.\C"\L. Date Date Date ~hJoz- D te' s/~/Od- Date NOTE: At least three members of the interdisciplin2J)' team must be present at the Annual IPP. . I d\aJtv<cIIIl)'Pcm.lCw.fr:n.doc / .. AltcnHuivcs Louclla Smith I'rol1lc ! , I Louclla is a 64 ycar old woman functioning in thc profound n1nge of mental rctardation, Louclla ambulatcs with an unslcady gnit nnd rcquires assislancc/wnlker to wnlk nboutthc program building, and n whcclchnir opcrnlcd by slaff for distanccs, Louclla is blind nnd has vcry limitcd communication skills. Louclla is scrvcd by CI'ARC's rcsidcntial progfllm, and livcs in New Cumberland. i ,i " Ii Louclla allcnds Altcmativcs 5 days a wcck. It had bccn considcrcd that Louclla allcnd a scnior program onc or two days a wcck so that shc can spcnd somc timc wilh pccrs closcr to hcr own agc and broadcn her social contacts. Scvcraltrials wcrc allcmptcd with Louclla , but it did not work out and at this point Louclla will continuc to allcnd Altcmntivcs fivc days a wcck. Thc team did discuss the possibility of Louclla casing into rctircmcnt by starting to cut back onc or t\\'o days a wcck , this will not bc donc unlilthc tcam fells that Louclla nccds it and wc will rcvicw thc possibility at hcr trcatmcnttcam mcctings and her annual. Shc currcntly sccms to enjoy thc timc that shc is hcrc at Altcmativcs and shows no signs of cxccssivc tircdncss. i ! Sue Kissingcr is Louclla's advocate. Medical Louella has a diagnosis of profound mcntal rctardation, microccphaly (abnonnal smallness ofthc head), blindness with traumatic cataracts of both cycs, Kyphosis (cxaggcration ofnorrnal posteriorcurvc of the spinc), and GERD, Past mcdical records also Iistcd: unsteady gait, chronic constipation, hiatal hcmia with gross rcflux, ostcoporosis,), arthritis ofthc right knce, bursitis in hcr Icft shouldcr, irritablc bowcl syndromc and conjunctivitis. Louclla had onc seizure in 1973, but has becn scizurc frcc since that time and is on no anti-convulsion medications. See allachcd Medication Rccord for mcdications. Louclla takes Mctocloprmidc onc half hour I)e~ie lunch whilc shc is at Altcmativcs, ..~ Louclla uscs a lili in hcr Icft shoc. Louella uses an Atlas walkcr at homc and at Altcrnativcs. Louclla is cdcntulous and rcccivcs a purccd dict.. Food should bc moist. Avoid orangc juice and dairy products.. Louclla continucd to havc a problcm with vomiting at almost cvcry mcal over thc past ycar , thc rccommcndation was givcn thnt Louclla should cat onc small bitc of food and thcn take a drink bctwcen cach bitc for thc duration ofthc mcal ,this hclpcd a lilllc with the vomiting, but it wasn't untilthcy PUI Louclla on a lactosc rcstrictcd dictthat wc really began to see a big improvcment. Louclla vcry rarely vomits at mcals now. '~"_.'-----''''''''''''"'''''''' '~.';,-;'.J ."'^,.',,"'~. _y~_ ,'_ _, .. Louclla Smith Ahcmalivcs Soclnl, Elllotlonnl, Envlronlllcntnl Nccds nnd SUJlPorts Louclla is not currcntly taking medication for maladaplivc hchavior. Louclla docs cxhibit lIIalad.lptive bchaviors, Thc spcclfic bcbnviors arc: raking thumb nail across hcad and nosc, picking loosc skin from fingcrs, rocking vigorously, scrcam/swcar, and push chair from tablc. Soclnl Wants/Nccds: Redircct Louella to more appropriatc usc of hcr hands, Providc Louclla with objccts for tactilc stimulation (cvcn whcn using thc toilet). Emotional Wants/Nceds: Spcak sonly and gcntly to Louclla to intcrrupt hcr scrcaming/swcaring, Rcdirccl her to a topic that is pleasant to hcr. Ifrcdircction of this manncr is unsucccssful, offcr Louclla a drink, takc hcr for a walk, or have anothcr staff talk with hcr. Singing sofily in hcr car, rubbing hcr head/running fingers through hcr hair may help calm hcr. Environmcntal Necds: Loud repetitive talking from others seems to irritate Louclla; she may tell that person to "shut up" and begin other yelling, Staff should be aware of individuals who seem to bother Louella. Yelling may also be an indication that Louella nceds something, ie: to go to the bathroom. Check th.! all basic comfort nceds are mcl. It is important that Louella bc taken to the restroom on a regullflloschedule, a minimum of once evcry two hours, or more onen ifneedcd. Ifit is felt that Louella may be expcriencing pain due to arthritis, call CP ARC on-call to reque~t administration of Tylenol. Bchavior Plan Implemcntcd at Altcrnativcs'! No f ; , !. ... i 1\ hcmal i vcs Louclla Smith ,\I'cn: Communication Skill: Mcssagc Matc Currcnt Skill Levcl/Strcngths: Louclla somctimcs rcpcats words, and somctimcs initiatcs spccch. although thcsc arc usually words from a Iimitcd rcpertoirc. Louclla has favoritc toys, talles and tasks that shc enjoys, the team would Iikc to sec if Louclla could leamto usc the mcssagc matc to choosc onc of her favorite activities, Short Tcrm Goal: #5 High Louclla will indepcndcntly usc thc Mcssagc Matc makc choiccs, Critcrla: Once daily for 18/20 consccutivc scssions, Target Dale: 5/03 Goall\let/Unmct/Explnin: Louclla has mct onc stcp of this goal and still sccms to havc nn intercst in it . continuc goal. Steps: J. With physical prompts, Louella will choosc bctwccn two activitics. Date Achieved: 5/02 2. With vcrbal prompts, Louclla will choosc bctwccn two activitics, Date Achievcd: 3, Louella will choosc bctwecn two activitics indcpcndcntly. . ~~e Achicved: .' ,"), 4, Louclla will choose betwccnthrce activitics indcpcndcntly. Date Achicvcd: 5 Louella will choosc bctwccn four activitics indcpcndcntly, Datc Achicved: Allematives Louella Smith Asscssors Comments Louella can piek up, hold and manipulate objects, She can take objects in and out of a container. Louella uses a walker to gel around the program with staff assistance, Louclla does rcspond to hcr namc and rccognizes familiar pcrsons. Reviewcd with IPP of 5/2/02 . no changes, , .l: ..",",\ Ll...J 11)2..0:X.CQ) \'!~ f(" fJ, ,>1 UH:!WCIl-. J .,(A)2)'J\\..tf:'.2D'''-' Clllllhcrlllud/I'cl'r~' I\IclltllllIcnllh/Mclltlll Retllrdutlllll Prll~raJl1 1'llIn IIfCllrc 2176 Wlllnr I'.'II\:rllll1 Cllcnt Nalllc: Louclla Smith Dutc of l'lnn: 05102102 Cllcnt Address: 1026 Drcxcll-lills Blvd Snpports COllrdlulltor: Mcrj Haunstein Ncw Cumhcrlal1ll, P A 17070 IISUII: 50200603 phone: (717) 774-0266 Date cntcrcd Walvcr Prll\:rllm: 01/01/97 Datc of IIlrth: 10123138 Date Level of Carc Certll1clltlolllllst complctcd: 09/06/01 MR Diagnosis: Profound MH Diagnosis: Nonc Other Diagnosis/Medical Conccrns: Microcephaly (abnOmlal smallness of the head); lactose intolerance; lBS; chronic constipation; arthritis of thc right knce; bursitis in left shoulder; GERD; conjunctivitis; hiatal hernia with reOuX; blindness with traumatic cataracts in both eycs; unsteady gait; osteoporosis; kyphosis; allergies/precautions-allergic to TB (Tine and Mantoux) test, receivcs a pureed diet Social Seeurit)' #: 180-56-5890 Medlcallnsuruncc: ACCESS Mcdicare A&B Medical Insurance #'s: 600760002637070091 4 185-01-4598-C2 Income and Source: SSA - $658,OO/mo, Payee: CPARC Executive Director PAt 62 Liability: -0- Parents/Guardian Name: Mrs, Aletha Smith (Mothcr) Address: RD #1. Box 92, Blain, PA 17006 phone: 717-536-3255 Emergenc)' Cootaets/Rcllltionshipll'hone: Nicole FriedmanllProgram Specialistl249-2611 Jenny WolhachlMedical Guardian/240-6578 William ~Cour/Rcsidcntial supervisorl774-0266 Suc Kissinger/Advocate/249-2611 Alctha Smlth/MothcrI536-3255 Bill Morton/Pennhurst Advocatc/61 0-270-1134 1 l'lnn of Curc - Scr\'lccs l'ro\'ldcd Fundin~ Source 1. Rcshlcntlnl Scn'lccs . 1;I'equcucy: 7 days/wcck Waivcr Eligible & Waiver Ineligible I'rovldcr: CPARC Addrcss: 117 K Hanover Street, Carlisle, P A 17013 phone: (717) 249-2611 Prlmnr)' staff eontncts nnd phone number: Nicole FriedmanVProgram Specialistl249-2611 William LaCourlResidential supervisor/774-0266 The Residential HIP nddresses the followln!! service areas, SERVICE AREA YES/NO/N/A A. Primal')' Henlth Yes MAlMedicare A&B B. primaf)' Dentnl Care Yes MNMedicare A&B C. Vision Yes MANedicare A&B D, Audiology N/A N/A E. podiatry Yes (as needed) MNMedicare A&B F. psychiatry N/A N/A G. Neurology N/A N/A H. Gynecology Yes :\1NMedicare A&B I. Motor Sldlls/Ambulation Yes PT Routine with staff asst, J. Speech and Language Yes Waiver Eligible K. Financial Profile Yes CPARC 1. Contingency in Event of Death Yes CPARC/Aletha Smith J\t, Socialization/Recreation Yes Yes , A COP) of the Residenllnl IHr IS nttached OTHER: Burial Fund - PNC Bank - Alctha Smith 3 4. Soclnllzntlon/Rccreatioll . Frcqucnc~': As dcsired Fundla~ Source I'rovider: CP ARC Residcntial Sclf Addrcss: 1026 Drexcl Hills Blvd, New Cumberland, I' ^ 17070 phone: (717) 774-0266 Primary staff contacts nnd phone number: Nicole Friedman/Program Specialist/249-2611 William LaCour/program Spccialist/774-0266 Is the clicnt's SoclaUzution/Recreation Program(s) described In another Program PIan'! YES2- NO - If IlO, describe in CnsemaDngemeDl/CoordlDutlon Goals. If yes, specif~': Residentiall.P.P. 5, Speeiallzcd Serviccs, Therapies and Other Services. Service Plan(s) attached? A. Behnvioral Managcment - Frcquencr: Provider: N/A Address: 8, Frequency: I i i i I I I . I , I i I I ! Phone: prlmnl1' staff contncts and phone numbcr: Provider: Address: Phone: Prlmnr~' stnfr contacts nnd phonc number: Client: LC.'L-0 \CA ~ (V'LJ -\ 11 S-2.61. l'lun of Care Meeting The following individuals (..) have participate In the dcvclopmcnt and rcvicw of tbis Plan of Cure, Signature Approl'ul County AdministnltorlDesignee: Date Reviewed: Title Date "Each clicnt shall hUl'e u Plan of Care developed in conjunction with an Intcrdisciplinary Team consisting of ut a minimnm, the client or his/her I'cpreseotutil'c, the County Cusemunager. and mujor scn'ice pro\'iders i,c. Residcntial staff and Duy Program stuff. Client Cascmanager 0,2,0"<:' \\.~c...G=>.. rJ'CCI;,m.:ff\ OJ:\IJ) &;,(' ~'(~Ao\\j~ S ' "2-' o'Z...- ,- -, ~ .', ....~ .'':- -..1(; f.-, '5 -~ -Od. /'rtlf/.?'-' 5:(X('/~;;JI- S~.J.-oJ. 1!~"Je&.U ~u~~ s-:: z...-O'Z.- '", W =-t'r"8l"'-V\ S~\'lill.i\ Mt~ r ro nrwrn- aa ItISdIf' /r,-e,.,.j7 / b-V'O"'...l\ CO>-f" .s-- z..-O;l. S - ~ -1}1.- 5-z..-0'2.- c. ;;; \ -I{lv _C( 15 LOUELLA P. SMITH - YEAR 2003 Enclosed you will find Louella's annual reviews from her residential provider (CPARC) and day program provider (UCP,) Louella continues to visit her mother who resides in Blain, PA. One staff member recently purchased a home in Blain so she has been taking Louella on the trips, Usually they have lunch together, at Mrs. Smith's home, As guardian of person I have attended her annual review (in April) and have seen her at home and at day program, She appears to be aging gracefully. Occasionally she may have some arthritis pain, it is hard to tell (she does have a PRN arthritis medication.) There is no plan to stop her from attending UCP's program five times per week, she is still an active participant. Medically, the vomiting instances continue to be monitored by residential and day program staff, Both staff continue to implement the one drink, one bite approach, using a teaspoon. Louella is gradually adding dairy products back into her diet; nothing unusual has been noted thus far. Late this year a doctor appointment revealed that Louella may have some blood in her stool. I accompanied her to Hershey Medical Center on 12/17 for an anesthesiology consult, on 12/30 we will return to Hershey for GI tests to explore this possibility. Louella has adjusted well to moving to a new home on Virginia Road in Mechanicsburg. The home is all one level, it is well-lit, each resident has a private room, Louella again has a private bathroom. The rooms are large and open, so there is plenty of space for her to ambulate with her special walker. There are also handrails that I have seen "Lou" use with staff monitoring her. It is my hope that Louella will remain in a CPARC group home as long as possible. The staff truly provide personalized, caring support, They assist her with everything from meals to using the bathroom to trips to listening to her favorite country music, I cannot currently imagine a better setting for Louella's care. Respectfully submitted, ( . -?~'-~' tJi-k c.d- JY-[(.!l/.)- J~~er wJbach Bo'~ 1072-11 Lancaster Blvd, Mechanicsburg, PA 17055 Enclosures Finnnrinllnformntion Source SSA !:;laim# 185-01-4598 C2 hmounl $686,00 ~resentativc p~ Exccutivc Director CP ARC Name of Bank: M&T Bank Address: 1 West High Street, Carlisle, PA 17013 Balance: $1090.40 Typc of Account: Chccking J3urial Planning Contact Person: A1etha Smith (mother) I. Burial Fund Bank: PNC Bank Address: P.O. Box 535230, Pittsburgh, PA 15253 Account #: 89-9563-2933 Amount: $6,489.14 Funeral Home: Nickel Funeral Home; Mr, run Nickel, LoysviUe, P A Ceremony: Viewing, funeral service w/religious representation Cemetery: Blain cemetery; Blain, P A Additional Comments: H enlth Annual Physical Examination General Physician: Dr. Christina Burkhart Address: Hershey Family Practice, 845 Fishburn Rd, Hershey, P A 17033 TelephoneNumber: (717) 531-8181 Date of Exam: 10/31/02 Height: 4' 9 v. " Weight: 134 lbs, BIP: 160/88 Laboratory TestsIX-rayslOther: Pap Smear Findings: Blood prcssure high; pap smear results reportcd 12/9/02 - normal TreatmentlRecommendations: Schedule to have blood pressurc checkcd once a month for ne>.'! two months, Follow-up with Dr. Burkhart in three months. Blood work and urinalysis ordered. 2 General Physician Visits Reason for Visit 5/30/02 Date Mild uppcr respiratory infection, abrasions on buttocks Renort of Visit Prescribed Allegra D, 1 tab cvery 12 hours as needed and Bacitracin Zinc ointment, apply to open arcas on buttocks BID until hcaled, Ordered urinalysis, 6/1/02 Results from urinalysis Diagnosed UTI. Prescribed Sulfamethoxazolc, 1 tab every day for 7 days, 6/26/02 Annual mammorgram 8/1/02 Urinalysis 8/2/02 Drop off urine sample 9/10/02 Urinalysis, follow up to UTI 10/24/02 Pain in right knce, blood in urine Results received 7/2/02 - no abnormalities noted. Unsuccessful allempl. Will attempt at home. Urinalysis results reported 8/5/02, UTI diagnosed, Prcscribed Bactroban, 1 tab BID for 7 days. Results received 9/12/02 - UTI. Prcscribed Cipro 250 mg BID for 7 days. Urinalysis and x-ray of right knee, Results pending. Prcscribed Bactrim DS, 1 tab every 12 hours for 7 days, Celcbrcx 100 mg once daily, and up to every 12 hours PRN, and Annusol HC suppositorics, I suppository BID for 7 days, 10/29/02 Results from x-ray and Urinalysis normal; no signs of arthritis in right knee. urinalysis of 10/24/02 11/7/02 Blood drawn and urinalysis (ordcred 10/31/02) 11/26/02 Blood pressure check 12120/02 Verbal confirmation 1/8/03 Regular check-up Results for urinalysis reported 11/13/02. Urine still not clear. Prescribed Amoxicillin 250 mg, 1 cap TlD. Blood in stool, prescribed Anucort suppositories, Blood work results reported 11/26/02 - normal. Blood pressure 144/80 - normal Louella unable to put pressurc on right leg. Prescribcd Celebrex 100 mg I time daily for 2 weeks and then PRN, mood pressure normal, lungs clear, no signs of a cold, 3 3/11/03 Verbal confirmation Dr, Burkhart prescribed Thick-It, ) tbsp with drinks at mealtimes due to cou hin while drinkin fluids. Annual Dental Examination Dentist: Dr. Fredrick Hecht Address: 238 Alexander Spring Rd. Carlisle, P A 17013 Telephone Number: (7I7) 249-7007 Date ofExan1: 4-) 8-02 Findings: Oral health good - gums look good. Treatment/Recommendations: Return in one year Plan for Dental Hygiene: Staffwill assist Louella with brushing her gums daily. Louella will visit the dentist annually. Optometry Optometrist/Ophthalmologist: Dr. Robert Thompson Address: Medical Arts Building Suite 207, WlIson St, Carlisle, PA ) 7013 Telephone Number: (717) 243-233 I Date ofExan1: 9/26/02 Findings: Good ocular health. Treatment/Recommendations: Continue to wash and irrigate eyes on a daily basis, Return in one year. Medications Medication And Dosage Bran, 2 Tbsp, QD am Thick-It, 1 tbsp with meals Debrox ) 5 ml, once Blood Purpose! Re\'iewing Frequency Levels Diagnosis Physician of Review Necessary Bowel regularity Burkhart Annually No Prevent coughing Burkhart Annually No at meals Wax build up in Burkhart Annually No 4 weekly at 8am cars Eye wash solution, BID Cleanse eyes Burkhart Annually No Thera 1 tab QD am Dietary Burkhart Annually No supplement Os-CaI 500 mg tablet 2 Calcium Burkhart Annually No tabs QD am supplement Prilosec 40mg, QD am GERD Burkhart Annually No AIIegra-D SA PRN Cold symptoms Burkhart Annually No Balmex ointment PRN Skin irritation Burkhart Annually No Colace 100 mg, 2 caps Stool softener Burkhart Annually No QDHS Reglan 10 mg, 1 tab 'h Digestion Burkhart Annually No hour prior to meals and QDHS Celebrex 100 mg, PRN Joint pain Burkhart Annually No Nystatin 100000 u/grn, Skin irritation Burkhart Annually No PRN How will medications be administered? (Check appropriate spaces) Completely independent with self-administration. (No staff involvement) Independent with self-administration by filling daily or weekly (circle one) pillbox. Staff monitoring or no monitoring (circle one). Self-administers by recognizing hislher medication, Self-administers by picking out correct amount. Self-administers by knowing when to take hislher medications (not necessary to know correct time). -X... Completely administered by staff. Plan of Behavioral SUllnort Is medication prescribed to treat a maladaptive behavior or psychiatric diagnosis? 0 Yes ~ No Medication DiallJlosis Ifmaladaptive behaviors are present, please list plan of support (formal and informal): 5 Does the Behavior Support Program utilizc rcstrictivc proccdurcs? If yes, please describe: o Ycs I~O Dates ofTRC Review: Initial Review: Six-Month Rcview: Annual Rcview: Attach Behavior Support Progranl. Awareness of Danl!er and Safety Precautions Type of Danger a, Poisonous materials b. Traffic, crossing streets c. Strangers, threatening people d, Hot water e, Hot oven or range f. Fire (open flame) g, Water (i.e.: swimming pool) h. Getting lost or separated i. Other No Awareness X Adequate Awareness Delicient Awareness X X X X X X X SELF-PRESERVATION SKILLS ~ No self-preservation skills -xi Must be physically moved 0 Evacuates with physical prompts 0 Evacuates with verbal prompts 0 Responds to alarm, evacuates 0 Knows fire emergency independently procedures (i.e,: use phone or call box, meeting place, etc,) 6 o Ycs r1--No Can this individual bc left alunc? If yes, how long may they be Icft alonc in their home? How long may they bc left alone in thc community? Plan for Decrcased Supervision: o hours o hours There is no plan to decrease thc aII10unt of supcrvision Louclla reccives due to her lack of self- preservation skills, Which best describes tbc method used for mobility? o walks independently \iI. walks with support of another person (for stairs, etc.) ~ walks with an assistive device: 0 cane ~a1ker 0 braces 0 other ~ uses a wheelchair: ~manual 0 electric 0 other ~ transfer skills: 0 independent ~minim~1 assistance 0 total assistance. Residential support provided in the area of mobility: Louella is dependent upon assistance from staff. Staff encourage Louella to use the handrails in the home and her walker when necessary. Staff transport Louella to all her appointments and activities. A wheelchair is used for these occasions, Which best describes the metbod(s) of communication used? Receptive Elqlressive i Verbal fii-Verbal: 0 Proficient (J,Limited o Gesture ~ Gesture o Sign _ Basic Words 0 Sign - Basic words o Sign _ Fluent 0 Sign - Fluent tlllEnglish ~nglish o Spanish 0 Spanish o Other Language 0 Other Language Which best describes level of communication? o can make needslideas known to the general public and understand responses ~ean make some needslideas known to familiar persons and understand responses o need support ofother(s) to express/interpret needslideas Residential support provided in area of communication: Staffwill continue to encourage Louella to expand her vocabulary skills. Louella will usually repeat words she has heard. 7 rlunemployed Dav Servicc~ Day Program Provider: Alternatives - UCP (West) Address: 925 Linda Lane, Camp HilI,l'A 17011 ~ _ Competitive Employment _ Sheltered Workshop _ Transitional Training Probrram (TTP) _ Supported Employment _ Supportive Employment --1L Adult Development Training _ Elderly Day Activities _ Volunteer _ School _ partial Hospita1ization _ Other: Contact Person: Diane Robinson Telephone Number: (717)737-3477 Comments: Louella currently attends Monday through Thursday 9am - 3 pm & Friday 9am - 2pm. 8 I ,UII\! Trrlll GUill II 2~ Name: Louella Smith Implementatiol1l>lllC: 4/11/03 Dcscribc Prescnt Strem:t!JJ;: Louella is ablc to walk short distanccs with stalT assistancc, She is able 10 stand up and dancc with staff assistance, Long Term Goal: #24 Louclla will bccomc more independent with mobility in her home. Target Dlltc.~ Short Term Goal Projected Actual Procedure STG # 1: Louella will use her 7/11/03 Staff will guide Louella to the handrails independently one time handrails and walker, Staffwill a day. monitor Louella while shc is using thc handrails and walker STG #2: Louella will use her to ensure her safety. walker for short distances within 10/11/03 her home 3 times a week as well as use her handrails one time a day, STG #3: Louella will use her walker for short distances within 1/11/04 her home 5 times a week as well as use her handrails three times a week. STG #4: Louella will use her walker for short distances within her home live times a week, as 4/11/04 well as use the handrails two times a day. 12 Long Term Goal (continucd) Critcrion for Completion: 6,Tfr.J1., q 0 -Jum/O' .S 16 II /) l.o.x!QJ.M e,(.dJ.IYI\ i..o I .J I' "fI :>. :> U< -k,;;").,J Si&--d ,,/ lPtJ.P.h'l (PO jun:U /v'f'l 'l'0:?' Date(s) to bc reviewed for possible rcvision: ~ ~t-->'ld (Dl...~.h fjou-.U-fJ G\ 0" q/II/o~ Date t.J \I'} t03 ~ ti/Il/0 3 Date 41(I(o~ f Date 18 Additional activities and scrvices provldcd to address nccd areas and ''wants'' expressed by Individual. Louella will continue to eat a bite offood, then take a drink per Dr, Cassa! to address tbe problems associated with her GERD diagnosis. Louella will continue with a lactose free diet. Treatment Team will review Louella's need or desire to retire from Alternatives on a quarterly basis, Louella will visit her mother on a regular basis. 13 RESIJ>ENTIAL SElWICES Individual Louella Smith PDC ANNUAL m:vmw I'nge I of I StlltllS LTG 1124: Louella will increase hcr participation in manual activities. STG 113: Louella ....ill participatc in n manual activity four times a month. GA lD: 1/15/03 TD: 4/15/03 GA: 3/3/03 Status February: 4 times March: 3 times STG #4: Louella will participatc in a manual activity six times a month, 10: 3/4/03 TD: 6/4/03 MT Status March: 5 times April: 5 times 14 .' " Th~ rc~ t \' , i' ~JJ1D3 '1-11- 2..003 Da(~ (ndividu~1 ~'.-.L-. f) ll./,.L- Parent/, U~dii I ' ~'",...,.~\..,,,,,~ ~\f~. Case Manager ,;, '-\\,,\ C"l~ , D2.~~ 4/11/07;; Dat: Program Advisor Dat: L 1j -/I-eJj Date -=1-11.",-'3 Date Residential Sup: isor Treat em ~~t ~03 Date Date " . 'Ms1P,t.,. l(/t(/~3 Dat: J-/!ft /03 Date - 1f/1 / /03 . l- (rp;k4:'~- ~ ,o::."'Ic:a... i\j........o. ._..u . ... :.J_..... l Date S/b/03 Da:e Re'.~ewed vl::.NI::.RAL ~[EDrCAL EXAlVUNATrON - R.ES=~ENT[AL SER VrCES I Page l c, :2 I ., Name: i ~({~ 'f Sm~ /(J-c93-3a Address:' /({5IC, breKe{J ~ Blvd, New turnterlDrd\ Pf\ /7)10 Rev, 0 I/O I 'Sirthdate: Date of exam: /O-3{-C)'d, Telephone: ,. . I :(711) '~~.q'~oitP,G~'~' ~ ,:./' _ .' - . . 6_ . ~... ..I .... . :urrent 1\: ~ldications: :Lsee ~~) Jlergiesli :ontra-indicated 'fedicatic : Regimen: '. T B Stm 4e.9-l- I .,w".; '~<rl,,;o~ fu"''''~ty "D''', Sp"'" ""'[th M,;.re""" N,,"" 01 p& _ \ rpUV'~ bl~' . tlmtrw~ ()yrd ; ~kuflf~n ~ LY1f6llerctvt+- l1~~~'?J1~.u L)1. (1{d)cJJ fl ; ~l~ wi o.mqJ;;Z;;;~'W n::sn V..tctDj) - ~ ~ <J .' ~fMedicl! History: Ar-+hr',tis !~ tKlQQ.. \6~.~l+1S Ubf 'i)h~lu-- m\t1rD~ : Q.Q~c.-~ ' , , , , I i i i: " " Completed By: 73S fC/SlkJa (Staff initials and'date) '-./ ~1w.. v ~. [n tbe ~bs,ence or~ny otber ~ppolnted decisioo m~ker or willing next orkio, the/odlity director become> lhe decision mnke,r punu.nt to tbe Menbl He~ltb ~od Meobl Ret.rd~tlon Act 0(1966. Section 417(c) ortbe MH/MR Act.pcclll., lbntthe r~clllty director m~y .utborw. eleetivc surgery, but tbe r.elllty director's .utborlty .ba encomp.sses tbe ,."nge orbe~ltb c~re optioos tb~t buve becomc .v~i1~ble sloce the MH/MR Act "'os possed. ~F.clUty Director" me~os the odmiolstr:ltlve be:ld or~ !:IcUlty. Nnme:rFeCmly. ~ urY\.~Ij}y\~!\~ ~(\ FacllltyDln:ClDrorthelrD..ilPl=: J\J'Y\ ~\! rrer\ DaytimePbone: (l \~-,;)C! ((" - , Evenlngphone:.f.::l1.=::U IC ~LD - '3Lo'SS P~: ~ JL (.:J.l4 ') ~y ~ (1\.\ 'Lr Cell PhOlle: Form COOlplelcd By: ~ ~^ 1 ~ 0 J'-- . Tille: \,<J '?n 0JJJI+1!J. ~ k{1 'f\(l~ Date: The information contained in this' form was taken from the Office of Mental Retardation Bulletin, subject: "Procedures for SlIbstitute Health Care Decision Making," #00-98-08, issued on 11130/98, effective date 11/30/98, .- Type of Review: UCP Central P A 925 Linda Lane Camp Hill, P A 17011 ALTERNATIVES Initial Development oflPP AnnuallPP ReviewlRewrite ~ ()~\ () DQ& ~m~+\rt v-:: - , h'" "t"dol th' .,,,,mll,,,,,,,,,,1 P,,_ Plm ",,,ti,, ,,, tl" "",,,,,,,,d m""d"'" "'" ,pp"" th' pi"" " ""~,,d ""di"" wim' ofth' fiml <0'" 1fl do ""t "," ,,,th th, fi,,1 <0'" I ,ill ",,""t ,""" .' meeting in writing to the Program Director within five (5) days of receipt. NOTE: At least three members of the interdisciplinary team must be present at the AnnuallPP, Individual's Name: Individual ~ f1(l~v/L ~,~ t'nv Case Manager ~ rp,I{,,,L- P ,entlG ardian ( ~ ?t. !~g~ ' esidentfal Pro am ..P~\o.~~ 0\L~~tf\ Residential r gram ' . ,'~ ~...... . ~ .. . Other (Specify) ~~i&J ~r; I ..rl , . """ ' ,<./1 It!t:...,.' no :rtd not attend: IPP was reviewed with Date Altematives Director I.Y\1 k').3 ~ j j)J\J~ J "70' j llbOV\ Date Altematives Supervisor Cf ~J03 ~ 'i!ftlo3 Date Date ~ Date Date ~ \). ,. __ 'S1\.. ~ Advocate \r L\\\~n~ Date Date Family Member L\h\\O?J Date Alternatives Instructor Date Date Date Other (Specify) '0:1t/3 Y-II-D5 L"oJ ~ an. Individual by UIO\{ ~ ~bSol.lL-_ Staff r 4 .n.._ _.~I" "",...." cn:...-,I A h.........';V..I~;I'".t1(r , L '. i ! i ; I I I i I I LOUELLA SMITH'S MEDICATIONS Bran Docusate Sodium 10Dmg Ear Drops 6.2% Eye WashlIrrigating Soln Metoclopramide IOmg Multi vitamin Oyst-CaI-50D Prilosec 40mg Celebrex IDD mg 2 tablespoons with breakfast' 2 caps orally at bedtime 8pm As directed every week at 8arn As directed I tab by mouth four times daily I tab by mouth once daily 8am 2 tabs by mouth one daily 8am I cap by mouth every morning Allegra D Tablet SA I cap by mouth once daily and I cap by mouth twice daily as needed for increased knee pain I tab by mouth every I2 hours PRN Balmex Ointment Apply topically to rectum area With dia~er change as needed Apply topically to affected area 3 times daily as needed. Mystatin 1 DDDDOU/GM Cream Thick It Original Use 1 tablespoonful with meals and snacks. "OII\~"LA SMITH MEUlCA" IIISTOln' FOIt AlIi~t'AL ASSESSMENT I>utc: Murch 20113 Medicol Mcdical History to datc (childhood discllscs, immuni711lions, chronological summary of mcdicul problems, include major iIInesscs or injurics, history ofhospitaliZlllions, history of physicians utilized, family history regarding diseasc, physical rcstrictions), During childhood. Louella cxpcricnced frcqucnt uPller rcspiratory infections, She had all the normal childhood diseascs including chickcn pox. Louclla had her tccth rcmovcd in carly childhood aftcr a history of biting, Louella's rccords statcd a history of scizurcs in 1973 but shc has bcen scizure free since thcn. Louella's immunizations are up-to-datc, She was inoculatcd for all general childhood diseases including polio, diphtheria, tctanus, small pox, measles, typhoid, saloin, and Asian Flu, Louella's most rccent immunizations are: diphtheria booster, July 21, 1993, and a tctanus booster, July 21, 1993. Louella receives flu shots every year. Louella's current ongoing medical problems are blindness due to traumatic cataracts (first reported in 1965), microcephaly (a diagnoses after a chromosome analysis done in 1984), kyphosis (reported in 1982), irritable bowel syndrome, chronic constipation, arthritis of thc right knee (diagnosed after an exam in 1991), and bursitis of the left shoulder due to a separation on February 8, 1962, Louella tested positive for Hepatitis B and for Tuberculosis, She has been exposed to both diseases and developed immunity, but she is not contagious. Louella will at times vomit after eating, By doctor's recommendations, Louella should take one bite of food followed by one sip of a drink. Louella will feed herself, however stalT must sit by her to ensure this recommendation is followed. Staff may gently touch Louella's hand after a bite of food in order for her to put her hand down. StalTmust them hand Louella her cup for her to take a sip. Louella had a barium swallow and chest x-ray done on August 24, 1995; results were a large hiatal hernia with gross reflux and intermittent aspiration, Louella brokc her collarbone on January 5, 1995. Louella spent the first four months at Pennhurst in 1942, in the infirnmry with an upper respiratory tract infection. Since her move to CP ARC's Rcsidential Program (May 1985), Louclla has been in good hcalth. Shc was taken to the emergency room in March of 1993 as ordered by Dr. Hcrrold for possible blood in her stool. Rcsults were negativc, On February 2, 2000, Dr. Grubb prescribed Vioxx for pain in muscles and joints. On February 17, 2000, Louclla was seen by Dr. Ann Bero at Hershey Family Practicc for ha\~ng a bloody bowel movcment. Dr. Bero perlormcd an anoscopy, which showed intcmal hemorrhoids, Dr. Bero prescribed Milk of Magnesia 30cc PO today, Colacc two pac HS and Anusol HC suppository 2 times per day for 2 wccks, Dr, Bcro discontinued the Vioxx, duc to it possibly causing the internal hemorrhoids, AnnulIl A"e"menl IAllIe1l1l Smith PuJ,tl'2 On Murch 11,2000, Louclluugain had blood and pus in ber stool. us well as pain, LOllcllaagain was dilllmoscd with imernal hemorrhoids and a fissure, AnllsolllC suppositories und Balmex ointmcnt was prcscribcd. On 12/28/00 Louella was secn by Dr Cassal. gastroenterologist, for frequent vomiting, Dr. Cassal recommended: I.) Completc supervision of all meals to makc certain that food is swallowed before her ncxt spoonful. 2,) Do not allow Louella tolay down within 4 hours after a meal. 3,) Have a speech cvalUnlion regarding swallowing food, On 1/4/01 Louella rcceivcd a swullowing evuluation, The speech therapist recommended to closely monitor Louella when she is eating. givc Louella smaller portions, try giving Louella small sips of a drink between bites, and continue to monitor Louella's vomiting on a chart. If incidents do not decrease or increasc, the speech therapist will consult with Dr. Cassal, Gastroenterologist, to discuss a modified barium swallow study, On 2/15/01 Louella had a wart rcmovcd from between hcr brcasts. On 5/6/01 Louella was seen in Hershey Medical Ccnter Emergency Room due to a wound on the back of her head as a result ofa fall. Four staples wcre put in and the wound was c1caned. Louella was prescribed Tylenol500mg 1-2 caps PRN every 4-6 hours for pain, She had a follow up with her family doctor in 10 days for staplc removal. On 8/23/0 I, Dr, Cassal ordered an upper GI series and lower intestinal x-rays, The rcsults showed no presence of a para-esophageal hernia. Instead there is a large sliding hiatal hernia with gastroesophegeal reflux. Meals should be monitored, given in smaller ponions and lactose free. If vomiting persists thcn surgery could be an option, At Louella's aMual physical on 10/31/02 it was discovered that her blood pressure was borderline high at 160/88. Louella's blood pressure was chccked monthly forthc following three months, Her blood pressure is currently within normal range, Louella was diagnoscd with UTls on 8/5/02, 9/12/02, and 11/13/02. She was prcscribcd Bactroban, Cipro, and Amoxicillin, On 10/24/02 Louella was cxpericncing pain in hcr right leg and was unable to bear weight on it. Her knce was x-rayed with normal rcsults. Dr. Burkhart prescribed Celebrex 100mg, once daily for two weeks, On 12/20/02, Louclla was again expcriencing pain in hcr right leg, She was prescribcd Celcbrcx 100mg, once daily for 2 weeks, then PRN, On 3/11/03, Dr, Burkhart prescribcd Thick-It for Louella to usc in her drinks to help prcvcnt coughing aftcr taking drinks, Louella is ambulatory with physical assistance or by usc ofa whcelchair or walkcr. Louella is ablc to AIIIIUIII Am,..mrlll IAlllr1l1l Smllh I'II~r3 toilct appropriatcly, Shc wcars lIdult briefs both day and night due to hcr incontinence, Louella's family history for disease includes a reflux disorder that seems inherited, Her twin sister passed lIway because of complications experienced after placement of a jejunostomy feeding tube. This was requircd because hcr rcflux discasc was so severe she was lIspiruting stomach content into hcr lungs. Hcr father had a similar disorder. Shc has a positivc family history for mental rctardation, Historv of Physicians Utilizcd (pre 1985, Pennhurstlnstitution physicians) 1985 - 08/18/95 Drs, Potier, Herrold, and Harkcr Wcst Shore Family Practice Ccnter 804 Popular Church Road, Suite 1 CampHi\l,PA 17011 Family physician 11/15/95 - prescnt Hcrshey Family & Community Practice 845 Fishburn Road Hcrshcy, PA 17033; (717) 531-8181 Family physician Apple-A-Day 6230 Carlisle Pike Mechanicsburg, P A 17055 Family physician Dr. Frederick Hecht 238 Alexander Spring Road Carlisle, P A 17013 Dental Dr. Morton Rubin 120 South Filbert Street Mechanicsburg. PA 17055 Orthopedic Surgeon Dr, Robert Thompson Medical Arts Building, Suite 207 Carlisle, PA 17013 Ophthalmology Dr. Rolando Cassal 532 North Front Strcet Wormleysburg, PA 17043 Susquehanna Surgeons Hcrshey Family & Community Practice Gynecologist 1997 - Present Dr, Westra 4700 Union Deposit Road Gastrocntcrology __1- ~~~ - - Annucl A.....m.nl IAIIIOIIII SmUh I'"~. 4 Suitc 230 Harrisburg, I'A 17111 Clinicall)jagnosis/Levclllf Mcntlllltetartllltilln from I'rofessioJllll Evaluations A psychologicnl evaluation was pcrformcd by Eugcnc Stcchcr of Guidance Associatcs on Fcbruary 26, 1999. Louclla's range of functioning is most similar to profound mental rctardation (318.2), History of Medications Used Colace Docusate Sodium Keflex Neosporin Opth Lavoptic Eye Wash Gararnycin Opth Diazepam Pepcid Hydrocodone Tums Multi-vitamin Dulcolax Polymox Dicyclomine Dacriosc Eye Wash Phenergan Duricef Cephalexin Benzonatate Immodium AD Fleet Encma Emctroll Neosporin Caltratc 600 Bacitracin Robitussin Ativan Propulsid Ccftin Tri-tannate R ynatuss Amoxicillin Dimetapp Carbamide Pcroxide Oysco Bran Lodine Hydrocortizone Nizoral Cream 2% Nystatin Cream Claritin Prilosec Zithromax Augmentin Vioxx Propulsid Milk of Magncsia Anusol HC Bnlmcx Ointment Bactroban 2% Ointment Acetaminophen A1legra-D Metoc1opromide Lotrimin AF powder Ciloxin ointment Sulfamethoxazole Guaibid LA Celebrex Cipro Dental Dental history to date (all dental work completed, list of previously used dentists and/or specialist). Dr. Frederick Hecht; 238 Alexander Spring Road, Carlisle, PA 17013. Louella is without teeth, dentures, or a partial plate. She sces Dr, Hecht on an annual basis to assure healthy gums. Louella has seen Dr, Hecht annually since 1985 and has had no oral problems to date, Louella had her annual dental checkup on 4/18/02, There were no problems noted. She is to return in onc year, A. Personal Prolile Louella is a 64-year-old woman who has a vcry gcntle and kind personality. Louclla AnnUMI Aue..ment IAlUellM Smith I'Ml\e5 exprcsscs hcr happincss by laughing, chIpping, and dancing with stalT, Louella is also n vcry aficctionatc womnn, She will blow kisscs nnd give hugs 10 those who arc c10sc to her. Louella Iikcs having her hands held, Louella is blind. She is unable to rcad or write. Louella is unnble to foml or devclop sentenccs, She will rcpeat one or two syllable words that she hears, Louella is capable of communicating her wants and needs 10 stalT and those who arc close to hcr, She can indicate to stalTwhen she is hungry, necds to go to the bathroom, is tircd, or does not feel well. When Louella is upset or not in a good mood, she will scream loudly and rock back and forth. She will also scratch her face, causing bleeding at times, and rake hcr fingers through her hair, somctimes causing hair loss, These could be signs ofa soiled diaper, hunger, not feeling well, or an attempt to gain attention. Talking to Louella in a soothing manner may calm her down as wcll as find the source of her agitation. Louella enjoys eating, She cspecially likes tea, colTee. milk, fruit juices, puddings, and mashed potatoes. All of Louella's meals must be pureed or mechanically softened. Louella follows a lactose free diet. Louclla will feed herselfwith a spoon, She must first be !,ruided to her plate and spoon. Louella needs to be monitored while she is eating so that she does not eat too much or too fast. She may vomit. Staff continue to encourage Louella to sip a drink between bites of her meal. Louella began using Thick-It in her drinks this past year to help prevent coughing after taking drinks. Louella enjoys the warmth. She sits in her favorite massage recliner chair by the windows during the day and evening. She enjoys listening to her country music favorites. Louella enjoys touching and feeling many dilTerent textures, especially fuzzy stuffed animals. Louella has been working on her manual skills by using Play-Dough, finger paints, sand, and puzzles. Louella continues to enjoy visiting hcr mother on a regular basis. Louella moved into her new home at 4811 Virginia Road, Mechanicsburg, P A, 17050 on February 22, 2003. At first, Louella raked her hair and rocked back and forth repeatedly. However, she quickly adjusted to her new home and appears to be quite content and happy. There are no further changes or progress in this area. 1 I, B. Speech and Hearing Summary Louella can answer simple questions with a yes or no, She will repeat words that she hears that are usually 1-2 syllables, Louella is not able to form or speak in sentences, Her wants, likes, dislikes and needs are best understood by those that know her well and are close to her. She will yell to indicate the need to be changed, the need to go to the bathroom or if she is feeling ill, annoyed or even hungry. At the end of 1999 and beginning 2000, Louella saw Brenda Yeagley, a speech therapist, to determine if Louella could indeed, through the use of an electronic device, communicate more clTectively. Louella did try several communication devices, but all were unsuccessful, therefore, Brenda discontinucd seeing Louella. Annual A.....m.nl [Alu.lI. SmUh ItllJ.t~6 Louella has no apparent hcaring loss or problcm thai has bcen nOlcd, Thcrc has hccn no significant changcs obscrvcd in thc past ycar, C. Family/Signilicllnt Others Louclla continucs to visit hcrmothcr on holidays and birthdays, Stalfprovidc transportation and accompanimcnt for Louclla on thcsc visits, Mrs, Smith Iivcs at Rd III, Box 67, Blain, I'a, 17006. Louclla's father passed away May 26, 1995. Louclla's twin sister passcd away September 10, 1995. On Dcccmber 20, 1999, Jenny Wolbach was appointed Medical Guardian for Louella, Jenny's work address is Cumbcrland County Officc of Aging, 16 West High Street, Carlisle, Pa 17013, Her homc address is 1072-11 Lancastcr Boulcvard. Mechanicsburg, Pa 17055. Sue Kissinger, a CP ARC advocate, currcntly servcs Louclla as well, Therc have been no changes in this area during the past year. D. Recreational Prolile Louella enjoys being in the community, She likes going to malls, parks, movie theatcrs, picnics, restaurants, and visiting family and fricnds. While in her home, Louella cnjoys listening to music, dancing, manipulating objects, clapping, singing, and physical contact with friends and staff. Louella attends Eagle Springs Camp for weekends and weeklong summer sessions, Thcre have becn no changes in this arca during the past year. E. Educational Prolile Louella has not had any educational instruction in the last year. There are no Treatment Tcam recommendations to address this arca, F. Supportive Services Louella attends Altcrnativcs-West (UCP), 925 Linda Lane, Camp Hill, PA 17011. She attends Monday through Thursday, 9:00 a.m, to 3:00 p.m, and Friday's 9:00 a,m. to 2:00 p.m. The contact pcrson for Louclla is Dianc Robinson. At Alternatives-West, Louella completes various arts and crafts, listens to music, and goes on outings, In 2000, Louella toured the Eldcrly Day Activities program in an attempt to possibly switch day programs, EDA felt unable to mect Louclla's needs, thercforc shc will rcmain at Altematives-Wcst for the time bcing, The Treatment Team will revicw thc possibility and need for Louella to retire each quartcr. At this time, Louella shows no sign of limiting or tiring of her daily activity, Therc are no changes in this area in the past ycar. G, Vocationall'rolile Louclla has not worked on any vocational skills in thc last ycar, Thcrc arc no Treatmcnt Annu.\ A.....m.nl I~,udlo Smll" 1'01\.7 Tcam rccommcndations at this time to address this arca, H. Residenlillll'rolile - Life Mllnllgemenl Skills 1. Self-CaL!< _ Louella nccds assistllncc with gclling in and out ofthc showcr. StalTwill wash and rinsc Louclla's hair. Ifgivcn a soapy washcloth, Louella will wash hersclfin the shower; however, she may rcquirc one or two prompts to do so. Louella is incontincnt, but at timcs willlct stalT know when shc needs to use the bathroom. She requircs stalT assistance with wiping and changing her diaper. Staff take Louella to the bathroom cvery two hours. Staff choose outfits for Louella to wear on a daily basis and assist her with buying new clothing as needed. Louella will help with dressing herselfby raising her arms to put her shirts on and by lifting her legs to put her pants, socks, and shoes on. Staff schedule all medical appointments and provide transportation and accompaniment. StalTadministers all of Louella's medications according to dose and schedule, Treatment Team has deemed Louella inappropriate for the Self-Medication Oral Review. Louella is dependent upon staff to assist her with mobility (getting to handrails, in wheelchair, positioning walker, etc). There are no changes or progress in this area during the past year. 2. Household _ Louella has minimal skills in this area. Staffprcpare all meals. However, Louella can help stir or mix food in a bow\. Louella can place dirty dishes into the sink and then staffwill wash them. Louella can wipe her plaee at the table if given a dishcloth. Louella will pick up her toys around her chair independently. There have been no changes or progress noted in this area during the past year. 3. Financial _ Louella reeeives monthly SSA benefits, The Executive Director of CPARe is her Representative Payee. Louella is unable to sign checks, The Residential Supervisor and Program Specialist make sure all bills are paid in a timely manner. Staff assist Louella with making purchases for herself, The Residential Supervisor assists Louella with budgeting for large purchases such as furniture and trips. There have been no changes in this area during the past year. 4. Need for Supervision - Louella requires supervision when in the home and in the community, Louella is unable to dilTerentiate between hazardous, poisonous, and non-hazardous materials. All medications, cleaning supplies, toiletries, and chemicals are kept locked. The Treatment Team, however, has agreed to leave liquid hand soap in the bathrooms and kitchen because Louella is always accompanied, monitored, and assisted by staff when using the bathroom, bathing, and washing her hands due to her visual impairment. The Treatment Team has deemed Louella inappropriate for the Immediate Action Test. Louella requires physical assistance to evacuate the home Annual A...llmen. LoueUo Smith 1'II\:e6 Louclla has no apparcnt hcaring loss or problcm that has bccn notcd. Thcrc has bccn no significant changcs obscrvcd in thc past ycar, C. Famlly/Signilicant Others Louclla continues to visit hcr mothcr on holidays and birthdays, StalT provide transportation and accompaniment for Louella on thesc visits, Mrs, Smith Iivcs at Rd II I, Box 67, Blain, Pa, 17006. Louclla's father passed away May 26, 1995. Louella's twin sister passed away September 10, 1995, On December 20, 1999, Jenny Wolbach was appointed Medical Guardian for Louella, Jenny's work addrcss is Cumberland County Officc of Aging, 16 West High Strcct, Carlisle, Pa 17013, Hcr home addrcss is 1072-11 Lancaster Boulevard. Mechanicsburg, Po 17055. Sue Kissinger, a CP ARC advocate, currently scrvcs Louclla as well. Therc have been no changes in this arca during the past ycar. D. Recreational Prolile Louella cnjoys being in the community, Shc Iikcs going to malls, parks, movie theaters, picnics, restaurants, and visiting family and friends, While in her home, Louella enjoys listening to music, dancing, manipulating objects, clapping, singing, and physical contact with friends and stalT, Louella attends Eagle Springs Camp for weekends and weeklong summer sessions. There have been no changes in this area during the past year. E. Educational Prolile Louella has not had any educational instruction in the last year. There are no Trcatment Team recommendations to address this area. F. Supportive Services Louella attends Alternatives-West (UCP), 925 Linda Lane, Camp Hill, PA 17011. She attends Monday through Thursday, 9:00 a,m. to 3:00 p,m, and Friday's 9:00 a,01. to 2:00 p.m, The contact pcrson for Louclla is Diane Robinson, At Alternatives-West, Louella completes various arts and crafts, listens to music, and goes on outings. In 2000, Louella tourcd the Eldcrly Day Activities program in an attempt to possibly switch day programs. EDA felt unable to mcet Louella's needs, thereforc shc will remain at Altcrnatives-West for the time being. The Treatmcnt Team will review the possibility and need for Louella to retire each quarter. At this time, Louella shows no sign oflimiting or tiring of her daily activity. There are no changes in this arca in the past ycar. G, Vocational Prolile Louella has not worked on any vocational skills in the last year, Thcre arc no Treatmcnt '_0' lrllli\'iduai O-~~'\ 10. enh {'-hI STRENGTIIINEEI>S I'IWFILE Nccds Positive description of Individual Needs, SuIT recommendations and Requests for Support, . ~ d.} (,', Imlepcllde.nt .Fulleti,(Hli_n~ '., '/ Be ,IPji'( h:i'(l/fCtI7t(f 'j.'0{J/let') .' Eatlllg jr:c /II'/A: " h, I ~tllS I' w'lIz-\\n \'-, (\,htr ~-C) ,",,01 5-l.H I J ct.~<:,..,,-l.pd .~ .u A,\\M.i) ri ,\ V I hid I(Y-'rvir 1~thJ- _;- ~o..{J:... {.r', +0 10 0.._ IN ~\l -;-.,..\,(.,\+ C'tL)<', ;-:')-\,(1 \I)~ ,~dui.f ~,,(J ,'-h'\Q n 0.... '10 C-, helll \ h1' r L-'~ IIf' d Dr; rJ L Lj 1'\1 1\ 0, b~.\.e 6f S rx>o n I- oup at ~{> LoCDt.J-e . -tOad (J-\> r D 11: C u S:J o. L . , Toilcting LoJp I j /", / A.)\ II (I ,I.....t:... _ kOJPU 0, ri 0 ~j6 of) ~ C\~ --\n Ue;/-- (hld l)), lL ~-'\fl ,.,.( C.lJ.c,s,\ cJ-t, \rJr'! ;;- ~ld'(ll~Y-?,ht..p\1'r' (",c:, ~ Ii) Cl.J11c1 .~, rn -tolkL e0\ Q ,-., rA (\(\ P , L. t... \(~Mt1:1 , Y loJ.Q.y'lQ Q, n L{S-f5, : . DrcssingfUndrcssingut 11 CX:OI '.J- OlQptr. V )\1 P v\ lDvp LI '^ 15 LnMI Lr..\ n-f'(l d c; :J::L ~ ~J ~~ 0. (S\~~ n~.t... ~ jd)JfJLa' JoWL ()" or Cl~pt- +r) 'J\H-'f/.) ~-f. . \ - cl'l i-f,sS i 1..Q. r J;:... (k.ctf1f,''\"1 Care of clotbino Ol" O)\- .c{-' I \~;~t~~~~~ I~/l~~. ~~b~CU p" ~pOI~ri-L---D- Q~I)D(' \ ~ );lvv) ~ U; d t1 11f'l..t _ lAI \ ~_ \'\dl (: II {l ,\["' J;IvD\1\ L:,.\W- (2.dol.~\11 n 1 SlrclI!!ths Abilities, Capabilities, Inleresls and Interested Persons n .MobilimTra\'cl ~ Lo,Je.D.fl :U L.,p<, ~ ' I -fIt IPI I () d (\.pC-,n t-- --L..- ~~'~~~J~)~~ 0\\fiH~c~ )61,pJH~ \, Pin, h \\('1:...- S I'1.P U~ ~1Mh\'1SI-:'l1Li'\lf,t \ '\ '(' v oi (\('\ OYH''YjP~ ~rJ ~')J) 0c-ti mn'\Ll 11. I 'l-tf luwu..Il~) 0--\10. Silt j:::, cU '0C'\\c\CQl-i- 0 II ~.q-} ~ '\ {oXIS port \"-t> '(' , C'. '4rl IlIdi\'idll:llk~(l r'')fY) \ ' D- - ~ Money Management b ~() ~ Wl'lp i 10 (\i ~ +- l.ove.-\ la.. W ~ '(\r1ot,WJl1 I f) \ i\i~ Q:ll~~ ~ " Safety in H~ . L.., 'd- ~ r-. . "~ 0 \,€ I -t:J- ~.(\~"~~~ :q,,~~nO~l7Y> ~ _ $W f ",,,cd-! ~~~ \J.;~~\ . 8 tIel m\-~~ i r-J y(). \Nl ' Safety in Community ~\ -\\ Y\O.kW ~ \ ~ ~() l-O~Q\,}. . - >>- y')\Io\ () ~ s l'~ ~ ~ q ~ ~N'\1\1J\O(l Cb 11Im' \ vi \~ ~~ cJ..} o...~\ M (\'\-e.S e,~\\? itlC{\\j) (1)'('\\~ Care of Personal BelO~&. \ 0 ~ \ n. f:"SC"S.T .1J.- j ~~~e.';, %Q \,; ~~ . - -, ~~ d s 2 Individual 1.;"'0(:' A ~ 0... 5\'.~:tJ" I'e,,;on:ll KnowledgcfHealily Orienl:lliuu .-,..... 1--',,\PUn IdH\-!~{/E"" !J'\,J'\\Q C'cH$~-y- fb -de., ~ hd t-j -\'(-{Yln~'\ 17 {J C-JV1.Q -.\. ern p ~~f~~k}~:~' ~~~ ~';f' C^,\ H-'-{t~~v- or '\ ~ \ J ene. \,l\H1U'l . Food I'repnratiOll/Mcall'l:llllliog . \ '" l..o 12 i1R-- -Q C1't~ 1:\,\ i}c lc::. ~ft-((, L-J. (J, \ '."\!2 ...!...L- ~-\--'\- r '\-bed ~ ~'\ (\ \~i\0 7 ~cil;c.;, H.Q.. ,thy- 0\'\0 S peon j~~?;\~~0 O~tld $ !€.rOJCCL-\--\0 (J Shopping c I d I. ;.../ 1...(~.\1.0. 01A~ 0r\0'R-t- (e\ ll\,~f U U (lrul" '0 ~'~'D~()cr- Q1.! )-0U'21~ --0,rY'1f1C.(,iG.1 C\1r\lQ (~ \'fD.n:;o I ," \Aill (10r::0[\\rnl'\~ Qto~~ '. Use ofTelephooe \ Y: ~ 5l:cL~.1 I .,j \ \ 1yY\ -" '-" 0)'1\.1>0(\1.(11,fj 0f:{l ~ ~" l0\Jp Un I ()\ 1:1 Url \\0::, f'-( () \f2\Bn\'\~ 'cl.6: \ \~ \ RC'.ldinglWriting D J (;'\\pl$) [~ 1'\6+ ~__;-\:-t"r'4 I '.J~ \1 0.\0 0 1\-0 VQ/)A r:\xY-C.\J~.Q.1 ,), ~JL.q((l\()1Q:()-/C; ~'t~/ 5 irtJc/1'Obf lJfub I ""101(; q v>1 I I~ T/lbl,'r(/~ ~~d\Pld A (9-7} ~~ ' w~ Q.e:5fd-P . Numbers nod Time " lJ2l./p ~:1() hell ~ NO LC)$c:>\$<L 00 \\cc-, ~ --4"\' fl'IQ ("\ f ~19...iY\ ~l S 0 (I ~.A,(\ .Q{ '-\t) ~ y.; \'\ S ~ln (> $ '.i-'\'().c ~ 0+ \;~O ~i'H \\0 I , '\I 3 Indi\'idu:l1 L",,-'('A ~C\. :)(.~W , . l'e~()n:11 Knllwled(\c1Heality Orientation ~ !--0uo-L]lJldrNt{Ir?/J U\"l?\ '0- CO ($~-Y- r (-Ie., ~ h.c\ \.1 _ -\'(-('t1nll 17 R C-J'V\Q ~~\ I () P \'-A"~f'li;;'j)~ ~~~' ~':;~ ~h,f' CA,' \-+{k'0\f'" (')\'""" ~ \ \'\/ ene \\Y\h{~H) Food I'rcparation/Meall'l:lnllillg .. \ " ~ J /2.UR---Q('U~ C\'\~ ~ ~.+({,..c...L (,j, \, "4Q, ~ :::~~- r '\bed: I~ ~'\ r.. \~i\0 7 ~Dtl~1 H-Q.. %)y- 01'\0 S peon ~~~J~?;\~~~C1 o,ntj r) <<:. \B...I.'D:\-\ () n Sbopping c I ..Jif. ~I 1...r~J~ ()IC\.~ ~'~(I~'\.l,~(O:U U (I'r\116 0 ~'5."Dr0-~('v/-- OJ-l )..(\\j2\\0J~ J),rYlnC.(ict( Cbf\.W ('S \"t\J'\5:) I .", \J11l () 0C:0l\'\rn1\~ 0~~ '. Use ofTelepbone "1-... S-\D*~ U,)\ \\ II')') Y-" --::y- Of\\,1>oei-Q1 i2 (1) \ ~ ~~ Lf\\/p I in I (:\\ P \irl \'0 S ['-( () \{2\E'(J\'\~ 'dCA'dS Rc-.IdingIWriling D J C'~1\() 6 \')1\+ /-,~~'~ tlj~ \\ OBn To VQ~A (:\0( ~ \~ ~~,~(XlI()1Qf)-/<) 'h)r~ /C LC/VLd/{).. I'Sin.}o'fc;bf L' :It I I " If! ~'ci.. .' hit- 1&.;,'r~ii~J:;t'P") /J J 1'iumbers aDd Time """ L~",IP ~\() hcu:) NO J.()$P\\~- po \ \(''S ~ ~ 1",( NlQ .lY\bol~ O(l'f-,~~ '-to '?-V --i \\ S -V'-ll P 0 --1.'10 C:( (\-t- ""\, -: ~\ 0 J:i:H '\;\0 r- 3 Illtlivitlll:l' LoJeJ(G\. .S~ Use oC Co IIIIlIUnity 1~9'!r5,J'> ' " I cnl(:'t\O p,,*'-ISl:RC(\f'1 ~rjMtVJA'.l1tIT(rL~LL ~ \..fun ~ k 0>>Jl1lU. 6. t "1l t>, If> . I ('l (il1'ifl'\\'Y$ I N\ \ { " ......~~. _I.. --- ~1" <.;\-o..tt- Aehlih!5:~l(11/((~:sI-jol{<<(Aa~ , S1tJt ()C .~mpa.HA~_=du~u{- -L011ella. MedieaVSelC-Carc r-..... L... ,)0 \ \ (} '+l. (l ('.orr- n ') ,\ (\.Ir aLl ~ ~'..+ U)'- II m &....t", --6)- ~ ~ ~'~~ l ~ 4117 SU~~ ~\, {> 'I~ ~9~ \0 H\ '.,. -t Of SeeV"\\~C::IY\QDv, ~I ("It'"" 1l!U1...+- (j'~ {> ~_.L~ \ , )ill-i.,~m l"l'tlplr.lll1'1 ~ ~.\\ o..Of"Y)\ (\.;,lor VN:<:k. IlItcrpcrsonaVSocial Lang~ft;''\ to d.o~ l-scJ"edo1e. ~~l\n.. dr.?~ ~~,p.Par ,~~ ~~.r.p~4 ~ SOffiD \ ~)n~S '----l'Vl.cu- sh _ ~ I Yuo-6 OLV\ r-l w:\l ~ ~~~~~~Trt ~~()~ ~~ ~('y\ 0 \ Jr)~ J '{-~I'-P'S~ . Q; \, ,0 {) \'\Q. (~ ~ , '" Communication " \.0~ (\ 0. ~\'oAq\ LP'::s\1 Dt'.S b-t ~ "' l-oJello (1[1 '(\ U~ II .-U.... ~.lP \\C'. \ ~ ,,\. ~\M'l, \ \'-1 0.fiY\f\'\ul\ico j (t\(\ S~ ~ no\ -llA~ II I' I, II C'1 U .lJt II I) $) I. n Cl.. ':1'S !('IV IdO Jll}.: \.1.'1,\ \ ~ {-i(l"V , {)1'~~' Lo0e.\\~ ~<k('\ , ' \ Mi cuLt'::. WOf ~ .:Sp'JlLon ~'J..j o'i'l'Q6 ":>'N!~ bQ,..({\I1 Lll1 Rclationships With Othcrs , l.n~Q.\\o I, ),\\ hl..lq fs\rnv ~t-rA...H~ UJI II f'()"\ti(\lA o~ 'I '.(;~17'3 (\ Irq) r 6tt,rLp ho (' '112-9iJP Lo,p Ltc! fu ~~ ~.t\!O\;~ =lnS\"," o~~~~~~'t~ C\~cA-ib(\ Ov'(\c\ 0 -\'-.Q)(6, b . SclfEstccm and SClual Awarcness _ ~ \.\C'\. '-0_\'1 )-\..{ "'l b~',.I'"Y.j- S+o.- ~ ~\ \1 ...J.L- r (7~ '\ ':>e.~ 'n"" "'::)-\-Q..C4 ~ .- bp; "leA ~ ~I 0pY\1( 0." 1\~ ().{' ~J~a - ~\c~r\S 0 (\d -\11 VV\;\~ 4 hlllivillllllJ LoJfl Un.. S~ I have revi~wed this prolil~ ~nd agree / disagree _ with ilS COlli elliS, ~::;~~:~ S~:~y~0I~~Pi~~;~ftA~~iJJ1 Q Assessment Method '\.Q. '(,,::;-O(J aJ oloSo I(\{ (hl-1/\ f'I D~le 3/'f1.n7j 3/tf TJ D!3 I . D~te SlrcngthINccds Prolile Status: A, Will be ~ddressed in POC as a goal. B. Will be ~ddressed in POC in a beh~vior or staff ~ction pl~n. C, Will be addressed informally, D, Will be completed or assisted by residenti~1 staff. E. Addressed through support service, F. No formal action to be taken at this time. -, 5 tx'1 'ac::mplis:1mcnr (s~nsc el) P(1 aC::lonies at ac:::en [XI a"'''1als: , dOIj3.. -, ',-1- ... [ J bcwlir.\: [ J creaks [ J c:1allor.~ir.; ac:ivrtias [ J eM::ren anCler baclas C)Q c!eanir.~ t,X l. c:lleC::in" rhines: ~. ~,rm1S 04 c:~~r.::-I :t,;:ir:~S: i1 CraJtS!. hanciworl<: ~ Likes and Preferences Li.')Ue.ll~ s-n.~", P!!r:i~n's Nama . ~ car.cing ~ c:rawing ( J lis,~lr.g 2\ J tcod inc!ucing: 5 f)'f'). LI 11'0iSllrY1r\ UoWs n~ rY rrI fOt.~ [ ] ~ames: [ ] hares (werl<in~ wrth) [ ] helping pecple ~ ir.ceper.cer.ce .Dd' :Cckir.g nice ( J ma;a:::nes (!cckir.~ ::-:r::.:;:-::: ~ ~ ~rf) [ ] making tI1ir.c;;s: ~ "",eees of transportaticn: .ltJnJ.&L 9h Getting to Know Individu.:1l.s: Acd the Survey Says ... Activity .:4: P:1g~ .3- ...... . Likes and Preferences (C::ntinued) -... ( oJ Ir.cr.ey: ~CCCl paYIng jco (v( Ir.CVles (vic:eosl: ~~~O') ( ] ras;:cnSlcle [0 c:mClele 1~ln~s ~ oert~o~~o dal: ~ PI r \"-P ~ d ( ] J\1 Of v;i~7"" Ir.cvir.g a.t:cut freely on :ne ;co ~us~: (\,)\l~ [ ] r.cr.:cr.:-.g wer\< [ ] cr::enng things tt:r::ugn ca:alegs [ ] q.r::eriiness [ ] outsice wcr\< 1>( pec:le: e!ese tlier.c:s , 11,.....I'I"'Io-.lf 5 .~~itYJS [ ] sewir.~ .1<1 st'.cppir.g anc Cuyir.g lhir.gs 2\f sir.\:iir.g t><f: pecele: ac.,-:.:air:tar.ces ~I ~Y'~Il:h\I~~ ~ ~ OriY1"u.Ylu.r.s [ ] skatir.g .:f>{ s:eepirq [ ] so:-.ckir.c; J>r SX:aJiz:r.c; wnh peep/e [ ] playir,g s;:cr:s [ ] pr.ctc~~11y ;Kj praise [ ] rakiroli ar.c:Jcr bagging leaves U rec::91ition & anenticn q-u S"....immirq ( ] S"....~ing Getting to Know Individuals: A::d the SUI"Iey Says .., . " ". P .....ctlVlty,....: :lge. 4 . TUE [NTEREST [NVENTOIlY( [[) "hilt is it? An overview The II is a. collection ot activities/events tha.t most people experience, This tool is predicated on the tact that having a variety ot experiences is a tundamental part ot developing an adaptive environmental awareness. This awareness, along with the opportunity to experience these activities, provides the basis tor increasing a persons quality ot lire and motivating them to expand their capaci~ies, The lIs usetul Iness is based on the tact that learning/training is enhanced when the learner is motivated, Of equal importance is the instructor's ability to develop a positive relationship wif8 the individual being taught'. One way to both motivate and but a relationship is. to tocus interactions on activities the individual finds enjoyable. Developing relationships can also be expedited when the trainer, at least initially, avoids those activities the individual tinds unenjoyable. The II is designed to have the individual or significant others provide subjective impressions of how much or how little an individual enjoys an activity. This information forms the foundation for understandiQg the individual's frame of reference. These ratings also catalog the exposure to a variety of activities. In all 323 items can be rated. It is understanding what a person values that provides the insight necessary to design a training program that will help the individual grow and expa~d his/her quality of life. Interpreting the resul ts of the II recognizes that "ski lis" are often best assessed unobtrusively. when obserVing a person complete an actiVity they enjoy under natural circumstances performance can be dramatically different than information gathered with formal assessements. This type of evaluation provides valuable clinical information about the persons true potential. Likewise people orten display skills when involved in enjoyable activities that they otherwise do not demonstrate. People tend to be more attentive, motivated and ultimately productive when completing activities that are of interest, These phenomena are evident with grade school children, Children this age often tind mathematics abstract and have difficulty attending to directions. Eowever, when cartoon characters or pets, things children often find enjoyable, are used to apply the math concepts, skills orten improve dramatically. Teaching the developmentally disabled fine motor skil Is, attending and self- initiation of activities often challenge program designers. Progress in these areas can be slow or non-existent. However, when training incorporates a known area of interest, soda for ,example, and provides a functional routine in which to demostrate the ski lis, tasks such as independently accessing vending machines, selecting and inserting coins into the machine are quickly learned, Both of these examples are illustrations of interest(consumer) driven skill training. The II provides a guide to focus the teacher's abilities on relevant subject matter that will facilitate the student's learning. Page - l ln~ul coc~ the T T co., u. IL CULIllog5 inLercsL5, likcs and dl:;likcf., as obscrvcd by family, sLaff and 5ignificllnL oLhers, b, IL'servc5 a5 a mean5 to fuciliLaLe the oUilding of rapport. c . It provide5 a means to bui Id motivation into a training ta5k. d. IL provide5 a means to build in .succes5" for both trainer and trainee. e., It organizes 5ubjective "euL" feeline5. .f. It provides a data base for clinical inLui tion. g, It provides a means to choose cffective reinforcers. h: It details the degree of exposure an individual has had to -normal- life . experiences, i. It provides a curriculum to focus program p'lan design. j, It provides a source of individual ized client centered wants and needs vs system/stand~rd/curriculum centered de,!Dands, -'-." Instructions for usin~ the II: 1, Raters place a check under the category that represents . how much, in the rater's opinion, the rated individual enjoys an activity. , 2. Any number of knowledgeable raters can complete the Interest Inventory checklist. Parents, teachers, programmers 'and advocates should all complete the tool. A minimum of four raters should rate' the inventory-two direct care and two program staff. 3, Use only one rater per checklist. This eliminates the inter-rater bias. 4. Raters complete QDl1 items with which they have had personal experience obserVing the individual's level of enjoyment. 5. Compile the results from the individual II checklists onto a master checklist to facilitate interpretation. S, Computer scoring can be done using HAPPER or a data base program. Interpretin~ II Results: 1, Discuss gross rater disagreement. 2. Review strong likes, Note dislikes. 3. Use of the II should not disregard the need for training in unenjoyable areas. However,' users are 'encouraged to promote the individuals involvement ~n a routine that has activities/interests that he/she 'enjoys as a central theme. From the individuals perspective, the primary reaspn for completing an activi ty is, to acquire items of enjoyment. From the trainers' perspective the II prOVides a means to build in motivatipn for skill development that may be Page - 2 .... . ...... .......... I \,v ue mot ivatcu to (:ump I c lc or fJro~rc:;~ In. 4. C\Jnsit..lcr the indlvll1ual$ l:llcrc.::.;t arca::; to (ocu:; prlyrlty trainln;.: n<:t~US wh,~n IICSI!(ninl( thc [([Po For eXllClple, strong Interests In the food clltcgory mllY suggest thllt the inulVidulll mllY bc succcs3rully trllifiad to prepllre their own snacks, mix their own drinks or perha.ps prepllre the i r own mcal s, For more developmentally challenged individuals having them access, open, and/or pour their food and beverages, allowing them to partially participate, may be a meaningful program focus. ConverselY the lack or success in a ,given training area is often traced to a lack of interest and/or opportunities to practice the ski II in their natural environment. 5. The ID team needs to focus on the fact that needs are more than skill deficits. The II serves as both an assessment tool and a curriculum guide to apply this notion, 6. The lack of ratings on the II can also provide useful information. The fact that individuals have not been e:.:posed to a variety of activities/events may suggest increasing their environeental awarenes's is a critical need, Expanding an individual's awareness in the conte~t of e:.:posing the individual to an existing interest is often productive, 7, The ultimate challenge to an individuals' program plan should be: Why would the individual want to participate in program? The II serves as a catalyst to help teaes' design programs to address this query. 8, Finally the current treatment directions in the field emphasize training'that is.conducted as part of a routine. The II helps to map areas of interest that can be coupled with adaptive training "needs. to design routines. Developed by W.5. Hickey HS Copyright 1990 Functional AJternatives RD 3 Box 434 Hiddleburg, PA 17842 (717) 374-8648 Revised April 1991 References Cautella, J,R:. &, Brion-Heisels, L. 0(79). A Children's reinforcement survey schedule, Psvcholo~ical Reports, 44,327-338. LaVigna,G,W., & Donnellan, A.H.(IS8S). Reinforcement Inventorv. Alternatives to ounishment: Solvin~ behavior problems with non- aversive strate~ies. New York: Irvington Publishers, Inc. Page - 3 UNIT: L..~. : INTEREST INVENTORYct2J'<I</v NO. 'CF fU~7ERS: SCOREr-.\: DATe CQI'Ir.':I_ED: t\h~N::: :' A NO ACTlVI TY OISUP, NONE LITTLE F'AIR MUCH V.MUC = =n ======~=~==~==~==~==~==== :-::1"':'==.-:.= ===:-:== ------ ------ =::;::=== ------ -___h_ ~==-=" A I) ====~D[F.LES/LIQUlD5==== c------}C------}C------>c--____}C______>c_____ n CClr,dy: K i r,d~ C } . )( }{ >< }{ . A b. C H , . }{ :c }{ . , A c, C \ . )( )( :c }{ .\ A .:. Ice Cr'aar.l:Klr,Cl';'~ C H )( }{ H }{ r.. .:: b. C :-{ >< }{ >< }{ A - ~,,:,p c';,,"1"'. C :\ )( ;.C }{ }{ H 't Cheese Cu,'ls C }{ ) < }{ ,. }{ . \ A ~ ,:.,:.t~t':, Chips < }( }{ }{ ;( }{ ... A E. Ft"erlch Fries C H )( H }{ }{ H 7 Pi:::a { >< >< H- >< }{ A E: H~'ag i es " }( }{ >{ }{ >C A ':J HL\!l1b,.It"gcr~ { , . }{ }{ }{ 'J{ " A 1 (. Cet"eal Kirlc ';' CI~ C H }{ }{ }{ H A 1(' b. { , ( }{ }{ }{ }{ ( , A 1(. c. { }{ }{ }{ }{ }{ A 11 N'.lt s { }( ;~< }{ }{ }{ A 1 ~, Mai SlYIS { }{ }{ H }{ }{ .:. A 13 F....tit :r;irod7 ALL { \' }{ H }{ : c . \ A 13 { , ( )-.: }{ }{ )( b. (. A 14 C~.I'.e { . . }{ H }{ )-{-- A 15 Ce,c,ki es { }{ }{ H }{ -H A 1E. S-:,da { H : -: }{ H }{ A 17 FrlJi t JLiice C }{ H }{ H H' Ii 18 C~,ffee { }( :-{ }{ ,}{ }{ A 13 Te~. C }{ H H -)( }{ A 2r) ~1 ilk C >.: }{ , . }{ }{ , . A 21 Hc,t Che'ce,l~, t e C }{ ....... H H H . , A 22 Mi lk Shakes C . ( .. H }{ \ . ( , . \ A -:.,,:, Speci~.1 Di!?: F':..:,d: ( " j': }{ }{ ~~ . . A 24 Othel' Fe,-:,d/D"ir,l-.s: a, { }t ;{ }{ }{ H . A 24 b. { . ( }{ }{ H ( , . . A 24 c, . H j\ H }{ }< A (. . -' -(. . . . . , }{. , , , , , }':. , , , , . }{ . . . . . . }{. . . . . . }{. . . . . . -~ 8 (I === ITEMS TO COLLECT=== <------}{------}C------}<-_____}{______}<______ 8 Me'd e 1 Tra i r,s C H ;.< }{ }{ H 8 2 Ph.:'te'gr~,phs . C ;.; --;,.,: , ( }{ }{ j, 8 - Pc,st Cards C " ~... }{ }{ }{ ~ . . . . 8 4 8~,seba 11 C~,rds C j.i }{ , . H \ ' j\ ." E< ~ Dc,lls C :. : -;{ H H H ... 8 6 St '.1 Ffed Ar. i '.1 a 1 5 { . ( }{ H }{ }~ - ( , B 7 Other Itetns:?.~Ob'...3 { \ . }.: }{ }{ H . \ 8 7 b. C }{ , . }{ H 'j . ( . 8 7 c. C }{ \( "0' H }{ . , ." 8 (I '3 <. . . . . . }{. . . . . . }{ . . . .. . . >{. . . . . . >{. . . . . . }{. . . . . . C (I ===ENTERTAINMENT=== c------}{------}{------}C------}C______>c______ C 1 Watch i r,g Televisie,r. < H H H H \{ C 1 Favc'dte Shc,w7~.0' { H ;.c H }{ H- - C I b. : . < }{ H H }{ H C '"J Mc.vies/VCR C H ". H .... >< .. , \ j, C ~ Le,c,k at 8~c.ks/M~.gCl= i r,es < H-- }{ $ \ . }{ . , ." C 4 R!?ad i r'9 { >< :~ ~: }{ H >~: C ~ Listening te, Music < }( H }{ }{ } : ... c ~ Fave'ri te:CGUn+V1..tr { H \ . H " . H ... .. . \ . . ,I:ll:.: II T: L. A. : NO. OF CiArG:RS: SCORG:I~: DATE CO~II:'ILEO: n NO i=lCTIVITY 01 5Lr K NONE LITTLE FAIR MUCH V.MUCH .- .~~ una=~~~=~an~~n=nn=D~=cac~ ccn=c= neeaea n=c~=a a=am=~ ====== =aaaa. S b. < H }( }( }( }( )- ::; c. <}( }( H }( H )- 6 PI"y Me,s!cill Ir,strulolerot < H j{ H }( }( )- 6 K I rod 7 <}( l < H }( }( )- 7 51r,glr09 <}( H }( }( -,.< )- e OLlr,clroq <}(}(}(}(}()- '3 O,....wlr'g (}(}(}(}( l < } ~ I':' Bui ldirlY .M.:.dels <}().C H }( }( )- . II W,"'kir.g with Te.e.ls ( }( H }( }( }( } : 12 W.:.r'klr.q with CI...y < H }( }( }( l< } . 13 L...tch-He.,.k (}( H }( }( H } : l4 P'air,tir,g by N'.lr,\be,'s < H H }( }( H l- : 15 Pu::les < H }( H H .< } : 16 Ot~eria m!r1ti'f\S1t < H }( H }( -,< l- 16 b. I-"~$< H l-.< H H H l- 16 c. ' < H H H H H } 15 d. ' (H H H H H l- c) 25 {...... ><. . . . . . }<. . . . . . )(. . . . . . )(. . . . . . )(. . . . . . > o ===SPORT5 nNO GRMES=-- <------l-<------l-(------l-<------}(------l-<------} 1 pOlLlyir.g Catch < l-: H H H 'H )- ;:: Playi'r,g B...seb...l r < H H H H }( l- i 3 ather' 8all GaMes:a. < H -H H H H )- i ..:. b. < H H H H H . " i, 4 Ridlr.g a 8icycle <" H lC H H H l- 5 Swir"r.,ir'g < H l< H H H l- ,i 5 Skating < H H H H H l- t 7 Hikirlg < H H H H H l- II 8 Ho~r'seback Ridir.g < H H H H H l- '3 80ard GaMes: a. <" H H H )( H l- I ,\ '3 b. < H }( H )( H > Ii 1(1 Card GaMes:a, (l-e ->< H )( H l- I I') b. < H H H H H :- .\ 11~ ~~Shi~,g <(~; l( :-< )( H : , ..::. ~oLrl~ ~'.:.rlg r~ l-< r< l-( l-< H )( )( :- I 14 Sleddir.g < l-t- H H )( H )- I I 15 Cc.rnp'Jte,'/V i de.:. Garnes ( H H ,H )( )( > 'I 16 ather: a. {}()( H H )( )- I i 16 b. {)( )( )( )( H l- 16 c. {)( H )( )( )( l- 16 d. (H H H H )( l- 16 e. {)( )( )( )( H > 16 f. {)( H H )( )( )- (I 24 <......}<......}{...... }{. . . . . . }<. . . . . . }{. . . . . . )- o =~XCURSIONS/COMMUNITY= {------l-<------l-(------l-{------l-{------>{------l- L Ride in Vehicle:a.Vo.n < H H H H H l- L b. < H H H }( H > 2 Goir.g t.~ Car.,p {}( H H- .< H > 3 Visitir,g Relatives { H >< H }( H 1 4 Visit Beach/State Pa,'k < H }( H H H l- 5 Picnic' {H H H H H l- 5 GoJing to Fair' {H}( H ) { H l- 7 GCoir,g to Parades < H H H ) e }( l- 8 G'Jing c"Jt to LIJnch/Dir,rled H H H H H ,. '3 Visit a City < H }( H H H :- c C C 'i r: L. A. : ~IO. OF R~ riORS: 5COm::R: DATE CO~l~' I LE:): NO ACTIVITY OISLIK NONE LITTLE FAIR MUCH V.MUCH ,= UDnaaa~~=~==n=cac=n=~=n=a ====== =~=~== =~n=== ~===== ==~=~= ~~C~=a ::; E",'ly AI','!val ELlr'ly OisMiss,)l Assistin~ Tr"iner/Staff G.:.ir,g t.~/f,'.:.r,l via: 8'.15 b. Vi\r, C. C...,. d. Walkir,g ELlI'rd r,g M.=.r.ey '.6 7 8 & 8 8 '3 (. 'J 1 18 ==DOME5TIC i=lCTIVITIES== ~Iakir'g, th" 8ed 2 Han~lng up Clothinq _ Keeping Clothing neat 4 Keepin~ the Rgor.: ncat 5 Sweep i r,g ., Vac'JIJfI1ir,~ 7 ~Ie.pp i r,g 8 W~shing Windows '3 Oustir,g 10 Setting the Table 11 Makir,g sr,acks 12 8L\kir,q 13 Cc.c.k i r,g 14 Preparing a Meal 15 She'ppir,g '6 Repairing or Building 17 Rakir,g Leaves 18 Shoveling Snow l'3 Garderli rig !O Going on Errands !1 Doing Laundry ~2 I r"~lrti rig !3 Washing the CL\r ;4 5ewir,g :5 Cafeteria Helper :5 Decorating own ROO~l :7 Othe,': a. :7 b. '7 c. < )( )( H 1< H )- ( )( }( H >< }( )- ( )( )( H H )-"1: )- ( >( H H- H )( )- < H H }( H )( )- < H H >< l< }( > ( H H >< H H } < H r< }( H }( > < . . . . . . }{. . . . . . }{. . . . . . ><. . . . . . :-{. . , . . . )(. . . , . . } <------l-(------}<------}(------)-<------}<--____} ( H H H H H > < )( r< H H >< )- < H '1< H H H } ( H- H H H H )- < H l< H >< H l- ( H H H H )( l- < H H H H )( :- ( H H H H H > ( H J< H H >< > < H H >< H }( > < >< H H H >< > ( H H H )( H :- ( H H H H >< } { H H H H H l- { H H H >< H ~ { l-t l( l-( >( l-( l- < H --H H H H l- < :-<- : ( H H H l- ( .H ;{ H H >< l- ( H H H l{ H )- ( H ;{ H H H :- ( H H H H >< } ( H >< H >< H :- ( H >< H H >< )- < H H H H >< :- ( H ,( H H >< > < H H >< H >< l- ( >< H H H >< > < H H H H >< :- 2'3 {...... ><. . . . . . } {. . . . . . }<. . . . . . }{. . . . . . :r<. . . . . . } <) (I ==SE~SORY STIMULRTION== <------>(------}{------l-(------l-(------>(------> I Chewir,g Things (}: J< H H >< > 2 Suckirlg Iterl's < H H H H H :- 3 Observe M.:.ving Objects ( H ,}( H H >< } 4 Marlip'Jlatir,g lter"s:a. { H H H >< H )- 4 b. {H H H H H > 5 Lc'c.k at Bl'ight Lights ( H l ( H H H > '" Lr.,,~k at Bright Co:.lc.rs ( H H H H H )- 7 Vib"atie.r, (H H H H H l 9 Stir."JI,js/ObojectChL\nge ( H H H ;l:.{ H l- '3 F!!!!lir,g Textures:a..uJ2-7~""< H H H H H- 1: '3 b.'S-IIkJ- U-' -7) { H }{ H H H -> ) He.ldH-,g Objects' { H H >< H H ; ; ;:ec if i fc or,es? a~it~~ ;~ ~~ ;~ ;~ ;~ ; \:~~t-l(:; : NO. er- RATERS: SCOREr;: JNI T: L. n, : DATE CQMr.'ILED: ~_ A NO ACT,VITY D!SLIK NONe:: L: TTLE FAiR NUCf-i V.NUCI " " "" ".:JI;t! II ::r.:l1lr.t1...::1 11":'1: C ':':In =";..: = ':t ':"!:I ~:'1:l'::=':"! -....--- ==:-;==c ------ =r.n==::: .... - -~.- - -."..-- =:.lI;2n~' I II Hi-V i r,~ HI.' it' EoI.\.I~hed { -H )( )( }( }( I 12 H,""v irll,l 8~cl", R'.ICbCd { H )( }( }{ }( I 13 H,""v i rig F..,cC! S t ,'e.ked ( l< )( )( }( }( I [I. &ci r.q 'Tickled ( }( }( }( }( }( - I 15 Lister,ir,g t..:. : c..~e.. ( }( }{ }( }{ }C I 15 b. { }( J-{ )( >< >< >< }{ H }{ I Ie b. { >< }{ }{ }{ >< 1 1'3 R.:.cllir,g { )-( }{ }{ }{ ~( I 21) ~Te fc,-}-ed Tcr,lp~,.a.t '.l".~ >< >< }{ 0,' }{ . ~ I 2(1 Exar,'plee: { }{ >< H }{ }{ I 21 Ph.:.t.:.s tP i ct 'Jr'es: ".. ( }{ )( J{ }( >< >< ~.:. I 23 Othcr': a. < >< >< }{ }( >{. . . . . . i(. . . . . . >(. . . . . ...)(. . . . . . }<. . . . . . J (. ==PERSONAL i=l"'PERRi=lNCE== (______}{______>(______l-{______}(______>(______ J 1 Gett ir,g 1"'lew C l.:.t h es . }( . , }{ H ..( , , J ~. P'Jt t i r,g ,:'1"'. M~_ee\p { >~ H >< }( 0:. . . J ..:. WE!a,'ir,g special Cl,=.thes ( }{ >< H H >< J 4 O,'cse i r.g i 1"'1 a C c. s t LUlU? { ;.: >< H H >< J ::; ~Iear' i r,g Othc." s Clc.thir,g ( H . H H H '0. J b ~ett ir,g a H". ir'cut { H >< H H H J 7 Havir,g H'a.it- Cu,'led ( ;.: .. .. H H H J e Havir,g Hair Brl.lshed { -H >{ H H H J '3 Hilv i r'9 Hair' C.:.r,lbed { H ' , }( H H ., J 1(1 Hav i r,g Nails dC'Y'le , H H H H }( J II HLlvir,g Pcd i c 'JI'e ( H -}{ H H H J 12 Wc:a.' PC:l'reu"e e.r'" Cc. I c.gr,e , H H } : -.,}{ H J 13 Wear- i rig Jewc 1 r'Y ( )~ H }{ H ..., . , J 14 We ad r,g a Watch { ><~ ,... }{ H ' . ,', J 15 Weil,'i r,g ". Tie { }< -H H H ' . r', J lb Takir,g a Bath , )( H H H }{ J 17 Takir,g LI Sh.:.wE,' . )( H ' , H -.r-: '. " J Ie Wcari r,g C I earl Clc.thes { H H )( H H J 1'3 PIJ.t t i r,g c.rl T",IC'Jr,l Pe.wder ( l-' .H H H >< .. J 2(1 ather': a. ( >< H H H H J 2t) b. { H H H H H J (1 21 < . . . . . . }<. . . . . . }<. . . . . . }{. . . . . . >{. . . . . . }<. . . . . . K (I =OTHER EVENTS/RCTIVITIES={------l-{------l-{------l-,------l-(------}{------ K 1 Stayir,g up late at Night: { ..., >< . , H ' I , . ' , 1', ~ G.:.ir,g to:. 8ed ear'ly ( H ' , H ;.: ----H ..::. /, 1', ..:. Sleepir,g late i 1"'1 M~'l'''rl i :"Ig ( H H H ;. . .... .. . K 4 Gett ir,g IJp Eat'ly { H >< }{ H H K 5 Us i rig a Tc.wr, Pass ( H ' . H H H . . K 5 Hilvir,g F,'ee Tir,le ( }{ H H H H 1'. 7 Having a Pet { >t-'- )'1; H H H K 8 Talk i r,to Tape Recorder { H H H H H 1', '3 Seefr,g ~idec's "f Self ( }v 'L" H H H " .. v 10 Hearl r,g Tapes c.f Self { H H .... 'v l'': " ... . ~ K 11 ~ol arl the Day'!; Activity { '\..t. K H H H . , v 12 Rtter,cing Meet i rig 5 { :-~ : -: \..~ H ..., .. . , . . 1', I:; geir,g Cc.rlltl\i t tees ..;.{ H H ' . c.r. ", #..:- ,.. L. n. : NO. OF RAfERS. HCORE~: OATG: CON~' IL'Z!:': I d , ,q NO ACT IV!TY OISLIK NONE Ll TTLE: FAIR ~lUCH V.MUCH ~ u~ n..aa.=aa=nn==~aaaa=na~aa nnaUQ-U z:naa== a=uzaDQ =ml'u:III::I= nC==aa.: =Ua=aa 14 ~la!la:ir,o:! S,.,bse:"ipti.:.r, < H H H H H )- ., K 1S G.:.ir,g O'Jtslde AI.~r.e ( }( H }< }( }< } 'i K' 15 Sit ir, a/fico ~ >< H H >< }( )- ,: II, 17 S''''pr'iSli!!3 < H >< H H ..( )- K 18 Sleepir,g (}( H H >< )i I 0' K 1'3 T.:.bLlcc.:. (1-< H H H }( )- K 2" L.:.bby/Cer,tar' e.f ntter,t i.:.r,< H >< H H l< )- K :::1 Age-ir'L1pp",:.pr'iLlte T':'Y!3 < H H H H r( } K 22 Va"iety/Chu,ge irl R.:.,..tir,e< H )-: r{ >< }( } II, 23 Othcw:a. < H H H H H } K 2.3 b. < H H H H H } K 23 e:. < H H H H }( ) K 23 d. < H H H H }( } K 23 c. < H H H H }( } K 23 f. { >< >< H H H } K .) 28 {......}<...... ><, .. .. . l-(.. .. .. }{. .. .. . l-<.. , .. . l- " L Q. ===TOKEN RE I NFORCERS=== {------ H ------ >< ______ H ______ H ______ H ______} I' ~ 1 sta,'s '~r, a Cha,'t { H H H H }( l- ': - ;:: Happy/srni 1 ir,g fae:es < H H H H H } 3 spee:ial Badges., {H --;.{ H H H l- 4 Cer'tifie:ates {H- ;( H H H } 5 N.:.tes or. .r.:.b ~'ell d.:.r.e { H H H }{.. ) C l- 5 Marbles/P.:.ker' Chips < H J< H H H l- 7 SigrlatlJrcs (H) { H H H :r . 8 Poir,ts " (H l< H H 'H } ii '3 Mor,ey (H r( H H' H l- - ,: . 1 (I Toker, Ca.rd < H H H H H } ,: 11 Play Morley (H' X H H H l- 12 Gift Certificate < H }( H H H l- 13 Graph .~f P".:.gress- ( H r{ H H, >< ) ii. 14 Other:a.~ ~111:~ H H H }( H- _ l- 14 b. (H H H H H )- -, 14 c. {>< }( H H }( l- 14 d. (H H H H H :r 14 e. <}( >< H H H l- I) 18 <...... l-(. . . . . . l-{. . . . . . l-{. . . . . . l-(. . . . . . l-(. . . . . . l- I . . . " if .. I 'I I < >< }( { >< H I < H >< < H H I 'right "'., F"^otlo^.1 ""orn"I.,<. """OM! 'I irrnatic.n ar,d ir.terp,'etive guidelir,es are avail".ble f,',:.roJ 'I :ti'~na.L Alte,'nat:lves RD .3 !k.x 43't Middleb'J"g, PR 17842 I ,I :1 , 'H H H H H H H H .'}( H H H :r ~ . l- } ..,""'"'.,-"_"""_ef.'_'....,.>t.~,.-..-.'_. " - -. - '-.' ~.. (1\~ ~~-,,"\ o Louella turned 66 years old this year and celebrated with a small gathering al her home. She is doing remarkably well! Louella still visits her mother once a month at her mother's home in Blain. PA, Usually they have lunch there or go oul to eal. Both continue to enjoy the visits, made possible by residential staff providing the transportation, LOUELLA P. SMITH - YEAR 2004 As guardian of person I attended her April quarterly and October quarterly team meetings, visited her several times, made several calls to her staff to check on her and reviewed the quarterly reports which I received for January and July. She enjoys numerous outings on a consistent basis and attends the UCP Alternatives day program Monday - Friday, She attended Camp Eagle Springs for two one-week sessions this summer and had a blast. Medically, it has been a stable year for Louella, Her results of the Dec. 2003 colonoscopy were normal. She has had routine medical exams which have shown normal results for bloodwork, circulation, eyes, dental, etc. Staff assist her with eating and drinking, with taking a sip following each bite. They thicken her liquids with Thick II. This year her instances of vomiting are less frequent than in years past. occurring now occasionally instead of regularly/almost daily. Her team also discussed investigating Messiah's Adult Day Services program. The thought was she may like a quieter day environment, if Messiah would accept her into the program. She did go and visit very briefly, then followed up with a trial visil. At this writing Messiah is tentatively considering her for a "three times per month" schedule, her group home supervisor is unsure how lhis will be implemented. As guardian I continue to oppose any change to an unstructured "one-on-one" program at home, only because I have seen these results firsthand. What happens is that the group home inevitably falls short on staffing, the slots at the day programs are all filled, and the person that was supposed to receive more attention winds up in a nursing home. Louella continues to do well in her group home setting; she is always clean, well- fed and well cared for. Her staff know her preferences and her likes and dislikes, such as funny movies, country music, having her back lightly rubbed or her hands lightly rubbed, and having a great sense of humor. In my opinion, Louella could not get better care anywhere, and I hope she stays in her home as long as possible. Enclosed are her annual reviews from her residential and day program providers. Respectfully submitted, <--/]:/<--~:i tJrfh.f3- Je~fufer Wo~ach Bo~es < .. '['//5 1072-11 Lancaster Blvd, Mechanicsburg, PA 17055 . ,., r Enclosure. _ CPARC annual. uCP onnuol r . --- --,...'.---.. , - Name: Louella Smith Address: 4811 Vtrginia Road Mechanicsburg, PA 17050 Telephone: (717) 730-0346 Date of Plan: April 6, 2004 Review Dates program Specialist Signature cc: Individual: Louella Smith Parent/Guardian: Aletha Smith. Jennv Wolback Advocate: Sue Kissinl!er County Support Coordinator: Alaina ThomSDon Day program Alternatives - West Office File "- 0~ ~ Identifvinl! Il1formatlo..!! '. 'Nmnc: Louella Smith Sex: Female Blnhdate: 10-23-38 Date of Entry: 4-1-85 Social Security Number: 180-56-5890 BSUNumber: 5020-0603 Suppon Coordinator/Address: Alaina Thompson, 16 W High St., Carlisle, P A 17013 Primary Physician: Dr. Christina Burkhart, Hershey Family Practice, 845 Fishburn Rd. Hershey, 17033 General Medical Diagnosis: Blind, Microcephaly, chronic constipation, traumatic cataracts (both eyes), unsteady gait, bursitis in left shoulder, irritable bowe~ hiatal hernia, GERD, kyphosis, arthritis of the right knee, conjunctivitis, osteoporosis, profound mental retardation. Mental Health Diagnosis (DSM IV): N/A Major D1nesses or Injuries in the Past Year: N/ A Allergies and Precautions: Positive reaction to TB test (Tine and Mantoux) Medicallnsurance/Clnim or Policy Number: Gateway ID #22240780 Medicare A + B 185-01-4598-C2 Prescription Plan (Type and Number): Gateway ID #22238872 1 nellllh ,Annual Physicnl ElJImination General Physician: Dr. Christina Burkhart Address: Hershey Family Practice, 845 Fishburn Rd. Hershey, PA 17033 Telephone Number: (7] 7) 53] -8] 81 Dale of Exam: ] 1/] 1/03 Height: 5' 6" Weight: 136 \02 Ibs, BIP: 100/60 Laboratory TestsIX-rayslOther: Urinalysis Findings: Bladder infection TreatmentlRecomrnendations: Prescribed Vancocin ]25mg, 2 caps TID for ten days. Follow-up on 11/18/03. General Physician Visits Date Reason for Visit Report of Visit 6/12/03 Blisters on right ann and No sign of infection or virus. Prescribed Neosporin right thild1. BID. 7/8/03 Urinalysis Results received 7/10/03 showed UTI. Prescribed Bactrim DS tablet. ] lab BID for seven davs. 8/] 8/03 Tetanus shot Injection wven. 8/27/03 Ear wax build-up Prescribed Debrox eardrops every day until gone. Once aone continue use once a week. 9/10/03 Ear wax build-uD Ears irriaated. Continue Debrox as directed weeklv. 9/30/03 Flu shot Injection given. Reintroduce milk products gradually. Monitor for svmDtOms ofintolernnce. 10/2/03 Verbal confinnation Due to insurance changes Prilosic 40mg, ] tab am was chanaed to Prilosec 20ma. 2 tabs 8 am. 11/6/03 Annual Dao Results received 12/1/03, normal. 11/18/03 FoUow-up to UTI of Ccntinue Vancocin 125mg, 2 caps TID. 11/11/03. 1/8/04 Constipation Prescribed fleet enema. If no results on 1/8/04, use again on 1/9/04. Prescribed Miralax ] 7 grams in 8 oz. Of fluid daily for 1/8/04, 1/9/04, and 1/10/04 then PRN. 2/18/04 Urinalysis Results received on 2/]9/04, positive for UTI. Prescribed Bactrim DS tab BID for seven davs. 3/23/04 Congestion and cough Acute bronchitis. Prescribed Augmentin 125mg BID for ten days. 3 Annual Dental E:lluninntioll Delltist: Dr. Fredrick Hecht Address: 238 AleXllllder Spring Rd, Carlisle, I' A 17013 Telephone Number: (717) 249-7007 Date of Exam: 4-18-03 Findings: Annun! exam: possible swelling in back of jaw. TrcatmentlRecommendations: monitor for signs of discomfort. If no problems return in one year. Plan for Dental Hygiene: Stalfwi\1 nssisl Louella with brushing her gums daily. Louella will visit the dentist annually. Optometry optometrist/Ophthnlmologist: Dr. Robert Thompson Address: Medical Arts Building Suite 207, Wilson St, Carlisle, P A 17013 Telephone Number: (717) 243-2331 Date of Exam: 9/25/03 Findings: Mucus in left eye. TrcatmentlRecommendations: Prescribed Bacitracin eye ointment at bedtime. Return in one year. , [ 1 1 , I . I I i I , Podiatry Podiatrist: Dr. Neil Blake Address: University Physicians Center, Suite 400, Hershey, P A 17033 Telephone Number: (717) 531-5638 Date of Exam: Findings: TrcatmentlRecommendations: General podiatry Visits Date 7/18/03 10/6/03 12/8/03 2/9/04 Reason for Visit Routine visit Routine visit Routine visit Routine visit Re ort of Visit Toenail reduction. Toenail reduction. Toenail reduction. Toenail reduction. 4 Other: Endoscopy Pmctitioner: Dr. Abrahnrn Matthews . Address: University Physicians Center, Suite 400, Hershey, PA 17033 Telephone Number: (717) 531.8346 Date ofExnrn: Findings: Treatment/Recommendations: General Endoscopy Visits Date 11/20/03 Reason for Visit Initial exam for colonscopy Re ort of Visit Colonoscopy scheduled for 12/3/03. Colyte prescribed to be used as directed da rior to colonosco . Procedure cancelled due to Louella requiring anesthesia. Colonoscopy rescheduled for 12/30/03. Appointmentfor anesthesia consultation scheduled for 12/17/03. Results were nonna!. 12/3/03 Colonscopy 12/30/03 Colonsco Other: Practitioner: Hershey Medical Center, Pre-Admission Office Address: University Physicians Center, Hershey, P A 17033 Telephone Number: (717) 531-8333 Date of Exam: 12/17/03 Proceduresffests: Medical history and physical for anesthesia to be given on 12/30/03 for colonoscopy. Treatment/Recommendations: Colonoscopy scheduled for 12/30/03. Other: Pmctitioner: Hershey Medical Center, Radiology Address: 670 Cherry Drive, Hershey, P A 17033 Telephone Number: (717) 531-5319 Date of Exam: 7/3/03 Proceduresffests: Mammogram Findings: Results nonnal. 5 Medications Dlood Medication Purposcl Reviewing Frequency Levels And Diagnosis Physician of Review Necessary Dosage Metamucil, I Tbsp. With Bowel regularity Burkhart Annunlly No 8 oz. Water daily Colace 100 mg, 2 caps Stool softener Burkhart Annunlly No QDHS Reglan 10 mg, I tab ~ Digestion Burkhart Annunlly No hour prior to meals and bedtime. Thera-Tab, 8:00 am Dietary Burkhart Annunlly No supplement Os-Cal 500 mg tablet 2 Cnlcium Burkhart Annunlly No tabs at 8:00 am supplement Prilosec 20mg, 2 tabs QD GERD Burkhart Annun11y No am Clnritin-D 24 hr 1 tab Allergy symptoms Burkhart Annunlly No QD Debrox ear drops as Wax build up in Burkhart Annually No directed weekly ears Eye wash solution, 8:00 Cleanse eyes Burkhart Annunlly No am and 8:00 pm Balmex ointment PRN Skin irritation Burkhart Annunlly No Nystatin 100000 u1gm, Skin irritation Burkhart Annunlly No TID PRN Thick-It Original use 1 Prevent coughing Burkhart Annunlly No tbsp with menls and at meals snacks. Miralax Powder 17 Constipation Burkhart Annunlly No grams on 8oz. Fluid daily, PRN Celebrex 100 mg, QD Joint pain Burkhart Annunlly No PRN 6 - -' J - . "" -. --,.......--~.. .' How will medications be administered? (Check appropriate spaces) _ Completely independent with self-administmtion. (No staff involvement) _ Independent with self-administmtion by 1iIling daily or weekly (circle one) pi11bolt. Staff monitoring or no monitoring (circle one). _ Self-administers by recognizing hislher medication. _ Self-administers by picking out correct amount. _ Self-administers by Irnowing when to take hislher medications (not necessary to know correct time). --X.. Completely administered by staff. Plan of Behavioral SUDDOrl Is medication prescribed to treat a maladaptive behavior or psychiatric diagnosis? 0 Yes (x) No Does the Behavior Support Program utilize restrictive procedures? DYes (x) No 7 , J -. ~_..... .... Which best describes the method used for mobility? o walles independently (x) walks with support of another person (for stairs, etc.) (x) walks with an assistive device: 0 cane (x)walker 0 braces 0 other (x) uses a wheelchair: (x) manual 0 electric 0 other (x) transfer skills: 0 independent (x) minimal assistance 0 total assistance. Residential support provided in the area of mobility: Louella is dependent on assistance from staff to ambulate. Staff encourage Louella to use the handrails in the home and her walker. Staff must be present. Staff transport Louella to all her appointments and activities. A wheelchair is used for these occasions. Which best describes the method(s) of communication used? Receptive Expressive (x) Verbal (x) Verbal: 0 Proficient (x) Limited o Gesture (x) Gesture o Sign - Basic Words 0 Sign. Basic words o Sign - Fluent 0 Sign - Fluent (x) English (x) English o Spanish 0 Spanish o Other Language 0 Other Language Which best describes level of communication? o can make needslideas known to the general public and understand responses (x) can make some needslideas known to familiar persons and understand responses o need support of other(s) to expressl'mterpret needslideas Residential support provided in area of communication: Staff will continue to encourage Louel\a to expand her vocabulary skills. Louella will usually repeat words she has heard. 9 Lonl! Term Galli #25 Implementation Date: 4/11/03 Name: Louella Smilh Describe Present Stremrths: Louella is able to walk short distances with staff assistance. She is able to stand up and dance with staff assistance and use her walker and handrails in her home. Long Term Goal: #25 Louella will become more independent with mobility in her home. Target Dates Short Term Goal Projected Actual Procedure STG #4: Louella will use her 5/18/04 Staff will guide Louella to the walker for short distances within handrails and walker. Staffwill her home five times a week, as monitor Louella while she is well as use the handrails two using the handrails and walker times a day. to ensure her safety. 12 Lonl! Tenn Goal 1126 Name: Louella Smith Implementation Datc: 5/19/04 Describe Prcsent Stremrths: Louella is able to use a dishcloth to wipc thc tablc and also pick itcms off the floor. Long Tenn Goal: #26 Louella will complete simple household chorcs within hcr homc. Short Tenn Goal STG #1: Louclla will wipe off the kitchcn table after one meal each day. Target Dates Projected Actual 8/19/04 Proccdure StaIr will provide Louella with verbal and physical prompts as needed. STG #2: Louella will put her worn clothes in her laundry basket each day with verbal prompts. 11/20/04 Staff will provide supplies needed by Louella to complete chore. STG #3: Louella will dust her furniture in her room with staff assistance once a week. 2/21/05 StaIrwill remain with Louella as she completes each chore to ensure her safety. STG #4: Louella will pick up her belongings in the living room each 5/22/05 day. 13 . " Long Term Goal (continued) Criterion for Completion: S T 6- -# ( Q 0 :nll7\iLJ , S T(,. -tJ ;) . :=; T (,..:t/.. 'I 9 (J an//) 9 0 ::I:i/YT'J '..0 I 7-.T&--t:i. 3 I';) ami/.) ~ Individual's Signature m~~~mre ~,I.M Pl6 Specia1ist'~~mre '/~ Associ te Director' ignamre ry 11/;. -j PA ey ~c1..wi..,J, #01. 'V Dc;. 4, ~/W 4- (9-0Y Date V/vh~ , Date J..f I (p {(Jlj Date Date(s) to be reviewed for possible revision: Date -.... "- .. - 18 RESIDENTIAL SERVICES Individual Louella Smith POC ANNUAL REVIEW Page I of I Status LTG #25: Louella will become more independent with mobility in her home. STG #3: Louella will use her walker for short distances within her home fives a GA week as well as use her handrails three times a week. ID: 10/28/03 TO: 1/28/04 Ei\'T: 2/29/04 GA: 2/17/04 Status Jan, 6-31: Handrails: 14 times Walker: 0 times Feb. 1-17: Handrails: 9 times Walker 0 times STG #4: Louella will use her walker for a short distance within her home five times a week as well as her handrails two times a day. ID: 2/18/04 TO: 51! 8/04 MT Status Feb. 17-29: Walker: 7 times Handrails: 5 times March: Walker: 31 times Handrails: 61 times April 1-6: Walker: 6 times Handrails: 12 times 16 . " his P C co Dins services and activities to meet the needs and wants of 1 POC Interdlsclpllnarv Team Partieipants: ---....... Individual ....... p;:flt:r4,{df~ ;1 L JI~AMVA , AdVoCllte . _ ~aOM~~~ CaseMBnagi4 p{!!Jdvfuor ~~ ~~/O(.,l..UfIlA ~ '1/& lot.! Date ~/& /.;2001 Date I l./J J:/IJ L/ Date . L( / (PjCf-/ Date '1- { -IJY Date Program Advfuor Date Program Advfuor t~&rR~k~l^ Residential S . or Date Date Treatment Specialist d;n I< P gram Specialist 8..y. ~jN~ y Services Representative Date 1-1/ (p/f) t( Date If! Ii /6'-/ Date ~~dL- Asso t Directo Date /fIlet /IJ./- Date Reviewed 22 . - -. --.. -" -' Substitute Health Care Decision Making Information ....'".~"..;.'~~;~ D~.r""'" I$);~ 31:' Perr.ancntadchss: ) ~ ~':llYllr?'11JlC I "l 5() Name of 'Benoy providing ....identiaJ ,crvi=: ~:::::::b~~~ ~ 2~;.,~gA_ k~IW3 a.-eutive Dim:lor: Supporu CoordilUllor: 1\.10 ,I n('L... Lh~ ~~ -0 Counl)' orne: providing ,",vices: Suppo", Coordil1ll1or', Daytime phooe number: Does the iodividu:1l bave 0 (DNR) Do Not RCSllSeit:lle Order? Yes Docs tbe iDdividual bave a LlviDg Will or AdvaDeed Directive? Yes I o NA (]Cyes, all:1ch copy to this Cono) I NA (JCyes, all:1ch copy 10 this Conn) When n~cll3s:lry, substitute decisionmnkers should be chosen in the foUowing order: 1. Docs tbis IDdividual bove a be:lltb core proxy or attorney iD fact for be:lItb care decisioDs? Yes ~ Name: U RcIBliDlUhip 10 Individual: Daytime phone: E vcning phone: Cell phone: :z. Does tbis iDdividual bave a court appoiDted guardi:lI~ I No Name: :"Pnnt-Rt Ll'{\)lmt h RcIBlion.ship 10 iDdivi~: :y( i Q nd Dayti.mePhonc:~ ~- ~~~~~~t~} Evenmg phone{; 'l - lAD h ) , Cell phone: 3. ]100 ooe bos been designated bva cou'r! or bv Ihe iDdividual. Ust the followiDg Dext of kin iD order of priority aDd as available aDd willlog to make decisioD's 00 t1ie IDdividual's bebalf: tbe spouse, aD adult SOD or d4ughter, ,either pareDt, or aD adult brother or sister: Name: Rcllllioruhip to individual: Oaytim~ phone: Evening phone: Cell phone: Name: RclBLioruhip 10 individual: Daytime phone: Evening phone: Cell phone: Name: Rclllionship 10 individual: Daytime phone: Evening phone: Cell phone: Page : of : GC:NEF..-\L KEOICAL t:.:v~'11i't/\TLl.'rl - K!:.~LUt.J'~J.ru.. -=>c..ny L'-....... R~v_ Ill/':14 . . USE R.."VERSE SIDE FOR AIry FlJRTIlER c~rr:; OR WSTRUCTIONS 1. HeiQ!lt1i ,. "Lll- 2. lJt!lght !;, 6 '- opr-J II _' _" J3~LI-lbs. J. Vl~ion (aC'.lJ.ty) 'I, Bleed Pressurd: /001' Normal 'c' -1.L Normal ' ,,0 -.!t.- A1Jnormal J/){ 6LIIJO/ll. S J _ A1Jnorma.1 -'" 5. Hearing (audicmet::-y or eqW.valllnt) L Normal A1Jnormal 7. Urinalysi~: ~ _ Normal' _-L t\bnormal 9. Hedical Scre.!ni.ng: Normal 6. HeWttis ~~eeni.ng: result results Da te : /I I ~ ~ b 8. T:.Lb:rculin HantoLL'{: ENe1{ ~ years Normal .J:T-: Abnormal Date: rko/ c:..;J~ /flrfD(J N0 Ant i lib:; eves ears/oose" v /lOuth/throat v cardiac '~ lungs Abno~ . /~ ~'.'~e~~~ . 1\..01017).. eXtremities/joints spine ,skin/lymph nodes 10. For Individuals 17 Irrmuniz~ions DTP (Diph eria- Tetanus-Pe sis) years or under: Date 2 Has. 4 Has. 6 Has. Ecoster Eooster . 'Measles Mumps Rubella .'\, 15 Has. + . . 15 Hos. + \. . - 15 Has. + \.;:- 2 Has. ~ 4 Has. ~ 10 Has. 4-6 Yrs, 4-6 Yrs. Head Cir~Jmference Mdress ~1f5" r-IS!Jt3I1ft{J ~ ... s: I-rl'l ( Phone Date HO, OIP, (/fJ(?.ISl'/vJ~ f. (!;;t/(<J41fJlt'P/ tI"'f:? Normal V ~ AlJr:-ormal If;F u ,.-- 11. Ir.di viduaJ.s 18 years O~tvie: Diphtheria (DATE) ,11 d3 I I. Tetanus (DATE) 2 / 'i (j7... I 1/ Prostate Exam (Men 40 years +): Normal t\bl'.ormal 12. 13. GyIl.ecological Exam~ , Pap ..smear: ~ , v Normal t\bnormal 1/ b oj Breast EXam: '--' L/ Normal Abnormal 14. Hamrogram - Every 2 years for at;es 40 - 49 and Annually for at;es 50 + V No. '\.bnor;nal s d-' 15. Is?e n free of colm1UIl.i.cable disease? y f~S Yes/No? wri.e precautions on reverse sice. 16. RS"..::nur.ended further Tests or c:xa.'i\inations : Diet Iamm.izations Vision = Hedical-~ecify Growth Hearing KGB Bleed Pressure GH neT = -Chest X-ray _ Develo~menta.l (su..-pected TB) PrC9l'ess OT:~: tJ/fl ~fl'\.0--' ~I ~ /1ll/lq) '-' - UCP Ccntrall'A 925 Linda Lanc Camp Hm, l'A 17011 ALTERNATIVES ype of Review: Initial Development ofIPP ,/ Annual IPP ReviewlRewrite -L n\d SW\~+\l - ldividual's Name: have attended the annual Individual Program Plan meeting for the above named individual and approve the Ian as discussed pending rev~w of the final copy. If! do not agree ,vith the final copy,I will request a team .' leeting in writingtOthe Pro m Director within five (5) days of receipt. ) Lu-u.lQD.~ G~ Date Alternatives Director BAllot{ 0)M\Q )U~ Date Alternatives Supervisor ~I~ ' Advocate ~ ~ Date -+ Date . ;;'/i Z/o'l Date :ldividual ~f!)~J,~"~ :ase Manager _'arent/Guardian Date &\ \I\NI Ittr ~/IIIrJ( Date ~JM{ Date 2)%('o~ ~;P.L\ ~esidential Progr Family Member Date Alternatives Instructor Date ..f'. Other (Specify) Date Invited, did not/could not attend: IPP was reviewed with ~ (')\1 P M Individual b~\O\t\~~i:Sr.>1f1 Staff Date NOTE: At least three members ofthe interdisciplinary team must be present at the Annual IPP. .' . , " . Allcmatil'cs Louclla Smith Profile Louclla is a 66 ycar old woman functioning in thc profound range of mcntal rctardation. Louella ambulates with an unstcady gait and requires assistance/walker to walk aboulthe program building. and a wheelchair opcratcd by staff for distanccs. Louella is blind and has vel)' limitcd communication skills. Louclla is scrvcd by CPARC's rcsidential program, and livcs in a ncw group homc in Mcchanicsburg. Shc movcd last year along with hcr housc mates to the new homc after rcsiding for many ycars in a homc on Drcxel Hills Blvd. in Ncw Cumberland. Louella attcnds Allernativcs 5 days a weck. It had becn considered that Louella attcnd a scnior program onc or two days a weck so thai shc can spcnd somc timc with pccrs eloser to hcr own agc and broaden her social contacts. Scvcraltrials wcrc attempted with Louella. but it did not work oul and at this poinl Louclla will continuc to attend Allernatives five days a weck. The team did discuss thc possibility of Louclla casing into rctircmcnt by starting to cut back one or two days a wcck . this will not bc donc untilthc tcam fclls that Louella nccds it and we will rcvicw thc possibility at hcr trcatmcnttcam mcctings and hcr annual. Shc currently scems to cnjoy the timc Ihat shc is hcrc at Allcrnatives and shows no signs of exccssivc tiredncss. Suc Kissingcr is Louclla's advocatc. l\ledical Louclla has a diagnosis of profound mcntal rctardation, microccphaly (abnorn131 smallness ofthc hcad), blindncss with traumatic cataracts of both eyes, Kyphosis (cxaggcration of normal postcrior curvc of the spine). and GERD. Pastmcdical rccords also listed: unstcady gail. chronic constipation, hiatal hernia with gross reflux. ostcoporosis.), arthritis ofthc right kncc, bursitis in hcr Icft shouldcr, irritablc bowcl syndrome and conjunctivitis. Louella had one scizurc in 1973, but has becn seizurc frcc sincc thattimc and is on no anti-convulsion medications. Sec attach cd Mcdication Record for mcdications. Louclla takes Mctoc1oprnlidc one half hour beforc lunch whilc she is at Alternatives. Louclla uscs a lift in hcr Icft shoc. Louclla uscs an Atlas walker at home and at Altcrnativcs. Louella is cdcntulous and rcccivcs a purccd dicl.. Food should be moist. Avoid orangc juice and dairy products.. Louclla continued to havc occasional problcms with vomiting ovcr thc past year. but sincc thc rccommendation was givcn that Louella should cat onc small bilc of food and thcn takc a drink bctwccn cach bite for thc duration of thc mcal and putting Louclla on " J I '1 a lactose restricted diet. over the past several months they have begun to reilllroduce diary one item a wcek for Louella and she has been tolerating this very well. Louella very rarely vomits at meals now. We did notice an increase in coughing when Louella was drinking and the suggestion was made 10 try her with thickened drinks, this is currently being tried and seems to be helping. Louella is negative for Hepatitis B antigens and positive for Hepatitis B antibodies. She is immune and cannot transmit Hepatilis B. Louella is postmenopausal. Louella's skin is very sensitive to some soaps, detergents, elc. Always check with the residential stalTbefore using lotion on her skin. Louella has a history of a positive response to the PPD test. Tuberculin skin tests are not applicable to Louella. An x-ray of 2000 showed Louella negative for tuberculosis. Louella is incontinent and uses disposable undergannents. It is important that she be taken to the restroom on a regular schedule. once every two hours, or more olien if necessary. OT evaluations of 1/12/98 recommended Louella perfonn activities at a table to improve posture. . - Alternatives Individual AsseSSl11enl Louella Smith STRENGTHS: Feeds self with monitoring Uses toilet with toileting schedule. Some verbalizations Very pleasant Enjoys contact with staff Keeps hands busy with preferred objects/activities Possesses most dressing/undressing skills Simple household skills(wipe table, dishes in dishpan, pick up objecls from floor). Identify familiar objects, some prepositional terms and some descriptive terms. Responds to simple commands. Louella's verbalizations throughout the day continue to increase. She is putting words together more. She repeats many words during a conversmion. WANTS: Attention Time to manipulate objects/time by self. Community outings. Relatively quiet atmosphere. NEEDS: Skin very sensitive. Check with residential staff before using lotion. etc. Sit up to table frequently throughout day to help encourage an upright posture. Lift in left shoe, shoes that fit securely for safety when walking. Use Atlas walker wilh staff assistance High-sided plate or deep bowl, non-skid pad, clothing protection during meals Disposable undergarments Object in hands \'.: \ ~ . ('\. '\ 'I S LOUELLA p, SMITH - YEAR 2005 Louella tumed 67 years old Ihis yem and celebrated with 0 small oalherHlO al her home, She is doing remarkably well! Louella slilllravels to Blain. PA once a monlh to visit her mother. 80th conlinue to enjoy the visits. made possible by Ihe residenlial stall who drive (Louella's mother does nol drive,) As guardian of person I attel1ded her October quarterly team meeting. visited her several times, made some calls to her slallto check on her. I reviewed the quarterly reports which I received for Jal1uary. April and July. Louella enjoys numerous outings on a consistent basis and attends Ihe UCP Alternatives day program Monday - Friday. She attended Camp Eagle Sprll10S aOOlI1 thiS summer al1d enjoyed herself. Medically, it has been a relatively slable year for Louella She was hospitalized once for dehydration & vomiting, An ultrasoul1d revealed oallslol1es and she was treated with: IV for rehydration. Cipro for UTI and el1emas for stool in the rectum_ Staff have been keeping a close eye on her and she has had 110 furlher problems. She had two follow-up appointmenls with her family physlclal1l11 November (shortly aller the hospitalization) and had bloodwork laken -Iirslllllle the polassium was a litlle high, second time it was normal, Stall continue 10 assist her With eating and drinking, with taking a sip following each bite, They Ihickel1 her liquids wllh Thick It, Louella continues to do well In her oroup home setting; she is always clean, well-fed and well cared for. Her slall know her preferences and her likes and dislikes, such as funny movies, country music. havino her back lighlly rubbed or her hands lighlly rubbed, and having a great sense 01 humor. They accompany her in shopping and social events. Louella is still an active mpmber of the community. Her current goal in Ihe home selling is to brush her hair once a day by herself - she just achieved the goal of brushing her hair with hand -over-hand assistance. Staff continue to assist her with ambulalion inside the home. she really doesn't use a wheelchair once she's in her home, In my opinion, Louella could not get better care anywhere, and I hope she stays in her home as long as possible. Louella is now part of a smaller. quieter group at her day program. This new room opened early this spring and it has provided a calmer environment for Louella. Her current day program goal is to make & send a card or art project to her mother. As guardian I continue to oppose any change to an unstructured "one-on-one" program at home, only because I have seen lhese results firsthand, The group home inevitably falls short on staffing. Ihe slot allhe day program is given to someone else, and the person that was supposed to receive more (one-on-one) attention gets put in a nursing home. As a former Ombudsman. I have also seen the care that people who cannot speak for themselves receive in nursing homes. Again I say, Louella could nol oet better care anywhere. and I hope she stays in her home end day prooram os lono as possible_ Respectfully submilled. )" ; . '" 1/""'" ; Jeni11fer Wolboch Bowes 1072-11 Loncosler Blvd Mechol1icsburo. PA 17055 ',' .' ).i') .. ..- [n(ln\lIl. Ifnuhtl1l1i11 AnnUAl (now compiled by CfP MRS) PI. Prinllndividual Support Plan Page:! of 34 Registration County/Joinder: Social Security Number: If Social Security Number not provided, specify why: Date Of Birth: Race: If Race Other, Specify: Ethnlcity: Gender: School District: Graduation Date: Original Registration Date: Current Living situation: Primary Language: Primary Language In the Home: Ambulatlon: Cumberland/Perry 180-56-5890 10/23/1938 White Non-Hispanic Female 07/06/1976 Community Home (2 to 4 persons) English NON-AMBULATORY-CAN'T MOVE INDEP CAN W/ ASSISTANCE Profound 318.2 Cumberland Yes- . Pennhurst 7177300346 Diagnosis: County Of Residence: Are you a US Citizen?: Special Indicator: Home Phone: ' Work Phone: Mobile Phone: Other phone: Pager:' Confidential: Confidential Details: Status: Reason Status: Active ":--. Address Address Type: AddressLlnel: Address L1ne2: 'Address L1ne3: City: State: Zip: Emall: Additional Notes: Effective Begin Date: Effective End Date: Residential 4811 VIRGINIA ROAD MECHANCISBURG Pennsylvania. 17050 NEW ADDRESS - PHONE # - 717-730-0346 02/21/2003 Print Individual Support Plan I'ugc 3 of ~4 Alternate 10 Identifier Type: Identifier: Effective Begin Date: Effective End Date: Identifier Type: Identifier: Effective Begin Date: Effective End _Date: Identifier Type: Identlfler~';: ' Effective Begin Date: Effective, End Date: Identifier Type: Identifier: " Effective Begin Date: Effective 'End : Date:: . : - Identifier Type: d . "': ,-",':""',-,,' ",'';- :. I entlfl~r,:'~':,;,;_;. -., Effective Begin Date: . ~ . - '. .~ "., - EffectIVe end Date:- .' , BSU 5020000603 07/06/1976 MA 0026370700 ,-' , MCI .' 002637070 01/31/2004 . ,:~,...t':~~::~~;~:}~~ ""... ',i'.., .:,:.~:(. .": "' ,. . , :.~:" , . " . . . ~"', ' ).. .: .' " . MEDICARE , ,_,,<; -1.~501459BC2- 07/05/1976 ;' .... " .t='~i.~,:.'~~_.:;-~~~: "::'. . .~ ...... '!;'~~.:.>" '. .~:- ~ .:~ :::~:~ ,.~j~~ [-~;:.:Y,: ,- ,.~:,::':..y. SSN ..:;.1;8b~56-5B90 07/05/1976 ,C""." ..... "::~~ .'..~~~~i~/.~~I..: .:. .'.l(:ct:~<,; , . -~ : ~,'~::::~~~:~~::~,\~~,"~~~~~~~;'-:','~y c ....... Medicaid 0026370700 ',' '-.. ::;~~GATEWAY: Medlcald(MA) Number: Provider: ;'i'~r'.." --':; ,~. , _. .. '..... _ 'r .. Provider Type: 'provlcle'j-"Poficy ,Nu.mbe.rT ,: .-..:~- 'J~:_"~:.t~ -'_ ;.:':'~< ~~.:'f.,,~"_Q()26370i6o .. Assistance was provided In applying for MA?: Y ~ll~di~id.EligIlJliltY EffeCtive BeglnDai:~:,':~';'t 03jgl/io02' MedicaId Eligibility Effective End Date: ., ... ,~~ . " - .:...: ,.... " .- , t~;:'~:'-:'~:'"...~".,~:.;"J:'t~'~~.:~ . .'....,. ,t. ~')~f'::--:._" Contacts BECKY "', ',' ;<;':.'~:.,:\":'> :,>~:s~NbE'R> '. Arst Name: ., .... -.., . last:Name:'. Middle Initial: Suffix~ ',' .,".. (:"I:'~l.~.'.f~'.:,,~..:: .,' . - Relationship to Individual: Other '-. " .- , . :'.' ".,.- ,... ':"".... ....,...,. ',' ',' - ,- Role: _ - ' " >;-::,'. ~:;: Support_Team-Member, If Power of Attorney, Is document on file at agency? : If Legal Guardian, Is document on.fIIe af',' .., agency?: ' ',,' If Living Will, Is document on file at agency?: , " ..,... -,'j.'.::' . -. '-. i : '. .~. _! ''':': .~: . , - .' ~ " , I......... "..___.. t..._.._........:......... ,.t.,t~ ,VI ","/h,.cic_1"p/n(JlT\/f'c:nn~PPT A~P 1/312006 Page 4 of 34 I'rinllndividulll Support I'lan If Caregiver Indicate Dote of Birth: Address Llne1: Address Llne2: Address Llne3: City: State: Zip: Home phone: work phone: Other phone: Emall: Preferred Contact Method: Best Time to Contact: Contact Notes: Effect\ve Begin Date: Effective End Date: Arst Name: Last Name: Middle Initial: suffix: Relationship to Individual: Role: .- .-.' If Power of Attorney, Is document on file at . agencY?:.':: :...:' . If Legal Guardian, Is document on file at agency? : If l.ivlng Will, Is document on file at agency?: If Caregiver Indicate Date of Birth: ~,..' "' ," Address L1ne1: Address Llne2: AddressLlne3: City: State: , Zip: Home ~hone: Work phone: Other phone: Emall: Preferred Contact Method: Best TIme to Contact: Contact Notes: Effective Begin Date: Effective End Date: First Name: Last Name: 4811 VIRGINIA ROAD MECHANICSBURG Pennsylvania 17050 7177300346 Other Afternoon (12:00 - 6:00) 02/21/2003 ALETHA SMITH Mother. Support Team Member " " R.D.#l, BOX 738 BLAIN Pennsylvania 17006 7175363255 Home Phone 02/02/2003 USA BYE I " i I , j j j ~ I 1 1 I I II Middle Initial: Sufnx: Relationship to Individual: Role: If Power of Attorney, Is document on file at agency? : If Legal Guardian, Is document on file at agency?: ' If Living Will, Is document on file at agency?: , If Caregiver Indicate Date of Birth: ';-- Address Llnel: Address Llne2: Address Llne3: C'lty. :.. " - . ~; .. ".,'. State: ~Ip.:',~'-, " Home Phone: Wi:n-i'_Phol'lih. .' Other Phone: 'EmalF '~:"':":;--'.:" """. .,: 'l ~~.,-:-' ,'-.,.. '"" Preferred Contact Method: Work Phone B~~'t 'lJme io .C'ont~ct:' ~I. ~'..', ~. .,;~ ti~:- ':.~~.::i::.l;i/::.(jf~ j:'~;i;:~:;:;~~~.~/:.: '., ~:'" .. Contact Notes: EffectlveiB'egin .Date: Effective End Date: ,F'I-rs"t'N'_,a'm' ',e",-,-,,-,,-'-',,:~,'-,,'.'~, .' ,'~- ..' "',"!',';,-:.";~.",-'.~,,.'.',',--,..:.;__',""'.'\'U"R!',-,-E--,:-':,"::,"""""",-::, .',":;:,., '--' ,.,., ~. -"'.". _ _' _ , _~. _ _ _ ,LJ\ " _ _ ~ - . ''':,.:~'.J;;:;~.::;~.~~ ::~'~:f.~~:~~}tg~~~: Last Name: FOOSE ,,' d'd'"I--' - ......I..-l:~--~. -' ..; ,- ...., ,'t...." I'.":r- ...... '''>::;'''1 "'"Ol "'-..:.~.' iI' ..~1 .., ".. .,'1.,~'.ok,;~:'-:'.~...;;.~..;'~::'!,\I')~".i~"~". MI eJni~a"':-r::"'~,...., .'.j'!' I" :,~.!.~__,'~-' "t:::;:: '.,~/"::;,>"'P " ~./:;":-;.:<.., ';o,~:,,:':~~~""~~\:~'...~~~;:!:.t..:r....z"~l~~{~ Suffix: R -I' tl-' hi t 1 dlld I /. ," ":.;.-.,.I'..1....i'I.;".- OHt"h""- '--"",~ ". ",.... "'. "'~"'" ,'" " ea' :on'~ .'P... ~. n 'v' ua :-:.. ~":" . ,..;: -:' .7:, -;::~'.:,..;~~~:.~...., .~r:.. : " .:.!~:--"~ ; ::-"- ...:::~~~i~~(,~~;.~:.;-[~:RG~~.:;;.1~'~2~>;. Role: Support Team Member If Power of~ttorriey,ls-docuinerit-i:jn 'flieat~-. ''-'C' ',:-:3:;' .v.~:'" "-' " - ";~ ,::: agencY?::':~:::' .' ": - ".:_.~ ~ '~::;~'~" ~.;t;:'..,~~;.~:.,.....;.::: ,'.-' :~~'~ . If legal Guardian, Is document on file at agency? : IfLlvlng,WIl1, Js-~ocurT1e:nt:!inflle',at:~gei1~7,~:;:/e.'.~::;: -' If Caregiver Indicate Date of Birth: A'd"res' s' Llne1:''',,,,--, '; '.;0'. ' "" '-.;.,., ':.:'-::,'/,:):-,- ::.-" '7.';; -''ASH' ':"ND'.AVE'-.'" .u,.. _ " ~:I"" .' '...,~":- .,.t.....tl... ....;'... . +., .,~, ',', ," Address L1ne2: AddresstJI1e3 : City: State:. .. ','t. Zip: Home Phone: , Work Phone: Other Sup-port Team Member 71 ASHLAND AVE ,...e,,' .. '. ..~,:: .,:::_.;:H';. CARUSlE, Pennsylvania ,. '. ')"~'i'~--; lZ013. ,,' , '~ ..'~./., .: ;:~.~? 7,i7.i492611 . .'t'~ ':"',:: ?: ~ .~,?: ~\~'~ ~'. ;t.~~;~:~~L~~.,,; ~~~'. ,~:. . Page 5 of34 .' " ",'. '. ,', ,',1. .. ",...; ., 't'..-':"'". ". : .,.,,':....', .' .;;.;:~ :;..}.~~~~.~.:1.'~:t.,: ;.',' 1 .:. ...:.;..~~.-:..':~~. ~~;j~~ -, . '~-; ~ : ~~;.r~~f.;~.~f1::~ ..... '~~ .:~ ./i ,~&:.;~~~.~~~\' {~~~ . ;; :. ':'::;1::: ~'.~~:; .~;;\;t \'i':~~~~ -,;", ,;.;_.~)':;;.. . ~.~:.{~~.;.~~f~.\f.;()21i~Y.~9P:f ~,..{:::'., ,~' ,(-: -. . ~,~~ :Ji,:".:.;:.~~':.:~.;}~,~:~j~:;;.~;f?: ......... .:: -' "0 :'( :.~,;-~:.. (..;,-~, .' .' ,,' .... .- "\"0 -.:.,-o~-:- .'" .. ';", '. .. ,\'::: CARUSLE .... . '- . "ell~!;yl,!at:lla,~'. : 17013 or'... .:':': :-;~. .:1......: , , " , ~.." 7172492611 .'. ..... .,-_..' ... , "._____.1..._.._....._.:........ ...............OJ u..Ih,....;r.'r_I"(Tf'n/'Jc:nn~P'PT A ~p -. \~~5,:r~1X.r-~~:,~:~f?\ , . ;:: ';\.:. i:.~~'.~~~;t:~':,"_":~[l~:i'!i"::'~<~ .. ~:.~ i;;:~.:~~>;.;:'. ..t~:~t!,~:~~f,."~~(::, . ." ~ .;', '~,.::....~:.i,~}"~'~i~'~'_';: .. "'" '.'J".}.: .f,.,....,'\.-..:\ , ; ....... '.' .~, !' . ~ :. .~j.~~:It:;..~::'.:~... / . .. ~ . ~ ..' ~', . '''.' .' ,~.,~ ,; :.1:. ';0 1/3/2006 Prinllndividual Support Plan LOUELLA CAN GENERALLY BE TALKED OUT OF HER BAD MOOD AND REDIRECTED, OVERALL, SHE IS USUALLY IN A GOOD MOOD. HOWEVER, ALTERNATIVES HAS BEEN SEEING MORE BAD MOODS AND THEY ARE HAVING A MORE DIFFICULT TIME IN REDIREcrING LOUELLA. KnoW and Do What does the consumer/family think someone needs to know to provide su pport?: IT IS IMPORTANT FOR LOUELLA'S SUPPORTS TO KNOW THAT SHE IS CAPABLE OF FEEDING HERSELF WITH VERBAL PROMPTS OF WHEN AND HOW TO MANIPULATE THE UTENSILS. LOUELLA ALSO NEEDS PROMPTS TO FOLLOW THE DOCTOR RECOMMENDED BITE/DRINK ROUTINE. ALSO, IF LOUELLA HEARS IN HER ENVIRONMENT, SOMEONE WHO IS TALKING TO SOMEONE ELSE NEGATIVELY, LOUELLA MAY CHIME IN WITH HER OWN CHOSEN WORDS AND BECOME AGITATED, EVEN IF SHE WAS NOT ORIGINALLY INVOLVED. ' IF LOUELLA DOES BECOME AGITATED STAFF MAY NEED TO RUN THROUGH A UST OF POSSIBIUTIES BEFORE THEY FIND OUT WHAT IS BOTHERING LOUELLA SO THATTHEY CAN CALM HER. IT IS IMPORTANT-FOR LOUELLA'S STAFF TO KNOW THAT SHE DOES HAVE A, MEDICAL GUARDIAN. LOUELLA DOES NOT HAVE ANY SELF-PRESERVATION SKILlS SO SHE NEEDS ASSISTANCE IN EVACUATING THE HOME. LOUELLA IS A PERSON WHO IS BUND ' AND DOES AMBULATE; HOWEVER, SHE NEEDS, ASSISTANCE TO GET TO HER HANDRAILS ' ' OR EQUIPMENT. FURTHERMORE, WHEN LOUELLA IS USING ADAPTIVE EQUIPMENT, STAFF. , MUST STAY NEARBY IN THE EVENT THAT ,LOUELLA MAY NEED THEIR SUPPORT, LOUELLA ALSO NEEDS ASSISTANCE IN Au:., AREAS,-'-'OF CARE, INCLUDING HYGIENE, EATING, AMBULATING, ETC. ' IT IS ALSO IMPORTA, NT ,FOR LOU, ELLA'S STAFF TO ,KNOW THAT SHE, . . .' .. . UKES TO HOLD SMALL MANIPULATIVE THINGS IN HER HANDS TO PLAY, WITH. WHEN SLEEPING, LOUELLA PREFERS TO HAVE THE' COVERS OVER HER HEAD WHENIN, BED, CURLED Up. WHEN SHE FIRST WAKES UP, LOUELLA MAY NOT BE IN THE BEST MOOD. IT IS ' OFTEN A GOOD IDEA TO TALK - TO LOUELLA BEFORE SHE is TOUCHED, TO AVOID STARTUNG HER. LOUELLA HAS A UFT INSERTED INTO HER LEFT SHOE AND SHE PREFERS COUNTRY MUSIC. FOR THE STAFF AT, ALTERNATIVES, IT IS IMPORTANT FOR THEM TO KNOW THAT LOUELLA HAS A SPECIFIC ROUTINE TO FOLLOW WHEN EATING/FEEDING, THAT SHE IS BUND, AND NEEDS ASSISTAN.CE WITH WALKING. LOUELLA HAS APPEARED, MORE UNSTEADY WHEN WALKIN.G WHILE ~T.A_LTERNATIVES. Desired Activities What are the activities that the Individual would like to participate In or explore? : IN THE NEXT YEAR, LOUELLA WOUL.D UKE TO CONTINUE TO ATTEND DANCES, GO TO THE' ' -MOVIES, OUT TO EAT, ACTIVrnES WITHIN THE COMMUNITY, VISITS WITH HER MOTHER , AND LOCAL, MUSICAL EVENTS. LOUELLA ALSO ENJOYS ALL OF THE CPARC FUNCTIONS, 'INCLUDING DINNERS AND PA.RTIES AT OTHER HOMES. STAFF MAY ALSO EXPLORE THE ' POSSIBIlITY OF TRAVEUNGEXPERIENCES FOR LOUELLA TO TAKE TRIPS OR GO TO CAMP. WITHIN HER HOME LOUELLA IS GOING TO CONTINUE TO UTIUZE HER HAND RAILS AND OTHER ADAPTIVE EQUIPMEN:r. LOUELLA WOULD, UKE TO CONTINUE ATTENDING ALTERNATIVES. IF LOUELLA INDICATES THAT SHE WANTS TO MAKE A CHANGE IN HER ROUTINE, SHORT DAYS OR FEWER DAYS, THEN THE TEAM WILL DISCUSS THIS OPTION. 'LOUELLA HAS AN INTEREST TO ATTEND MESSIA.H'S DAY pROGRAM A FEW TIMES A MONTH. THROUGH ALTERNATIVES, LOUELLA WILL HAVE, THE OPPORTUNIlY TO CONTINUE PARTICIPATING IN OUTINGS OF HER CHOICE. SHE WILL ALSO HAVE THE OPTION OF MAKING A CARD OR CRAFT AND THEN SENDING IT TO HER MOTHER. LOUELLA ENJOYS OUTINGS THROUGH ALTERNATIVES THAT INCLUDES WINDOW SHOPPING AT'LOCAL MALLS, GOING TO RESTAURANTS AND ENJOYING THE QUIET ATMOSPHERE OF A LOCAL MALL. VISITS WITH LOUELLA'S MOTHER ARE ALSO IMPORTANT ACTIVrnES THAT SHE WOULD .. . < ..._.:e__ _....... _.. ..../\......:.. ....I..."'...I........nc:::PPT A C:::P 1/'\1?00/\ Pagl: 8 or 34 I'rinllndividual Support Plan LIKE TO CONTINUE TO DO. STAFF ~'AY ALSO EXPLORE THE OPTION OF HAVING LOUELLA GET TOGETHER WITH OTHER FRIENDS INVOLVED IN CPARC. LOUELLA ALSO ENJOYS LISTENING TO COUNTRY MUSIC. Important To Important to Individual: IT IS IMPORTANT TO LOUELLA THAT SHE MAINTAIN HER PLACEMENT AT HER RESIDENTIAL PROGRAM WHERE SHE RECEIVES ASSISTANCE IN SCHEDULING MEDICAL APPOINTMENTS, ADMINISTERING MEDICATIONS, MEAL PREPARATION, TRANSPORTATION AMONG OTHER SERVICES NEEDED FOR DAILY LIVING. Priority: Essential Important to Individual: IT IS IMPORTANT FOR LOUELLA TO MAINTAIN HER PLACEMENT AT ALTERNATIVES DAY PROGRAM. FURTHERMORE, IT IS ALSO IMPORTANT THAT SHE HAVE THE OPTION OF DECREASING HER DAYS IF NEEDED, OR TAKING VACATIONS DAYS WHEN NEEDED. Priority: Essential Important to Individual: IT 1S IMPORTANT FOR LOUELLA TO CONTINUE TO HAVE THE OPPORTUNITY TO ATTEND , RECREATIONAL ACTIVrnES WITHIN THE COMMUNITY. STAFF WOULD HAVE TO PROVIDE ASSISTANCE TO LOUELLA IN SCHEDULING THESE EVENTS AND PROVIDING TRANSPORTATION. THIS WOULD INCLUDE COMMUNITY ACTIVrnES AND VISITS. WITH HER MOTHER AND OTHER FRIENDS. ;: .~ Priority: . Essential Important to Individual: IT IS IMPORTANT TO LOUELLA THAT SHE CONTINUE TO HAVE A MEDICAL GUARDIAN WHO PROVIDES ASSISTANCE IN ALL AREAS AS NEEDED. Priority: Essential What makes sense Whose Perspective: DAY PROGRAM What Make~ Sense: '. IT MAKES SENSE FOR LOUELLA TO MAINTAIN HER ROUTINE AND CONTINUE ATTENDING ALTERNATIVES, AS LONG AS SHE TOLERATES AND LOOKS FORWARD TO GOING. IF SHE INDICATES THAT SHE NEEDS DAYS OFF, STAFF SHOULD HONOR THIS REQUEST. What Does Not Make Sense: - IT DOES NOT MAKE SENSE FOR LOUELLA TO NOT HAVE THE OPTION OF TAKING A DAY OFF OR TO HAVE HER GO TO ALTERNATIVES IF SHE DOES NOT WANT TO GO. Whose Perspective: DAY PROGRAM What Makes Sense: IT MAKES SENSE FOR LOUELLA TO HAVE A CALM AND QUIET ENVIRONMENT THAT PROVIDES PEACE AND RELAXATION. LOUELLA WILL BE IN A NEW ROOM AT ALTERNATIVES ONCE IT OPENS. What Does Not Make Sense: IT DOES NOT MAKE SENSE FOR LOUELLA'S ENVIRONMENT TO BE LOUD OR NOISY OR DISRUPTED, THIS MAY CAUSE HER AGITATION. Whose Perspective: TEAM What Makes Sense: Prinl Individual Support Plan Page 9 of31! IT MAKES SENSE FOR LOUELLA TO MAINTAIN HER NORMAL ROUTINE AND NOT MAKE ANY UNNECESSARY DEVIATIONS. IT ALSO MAKES SENSE, IF THE ROUTINE DOES CHANGE, THAT STAFF EXPLAIN THE CHANGE BEFORE IT HAPPENS. LOUELLA APPRECIATES WHEN SHE IS AWARE OF THE CHANGE IN PLANS AND THERE IS LESS POTENTIAL FOR HER TO BECOME CONFUSED OR UPSET. What Does Not Make Sense: IT DOES NOT MAKE SENSE TO DISRUPT LOUELLA'S ROUTINE, OR TO NOT EXPLAIN TO HER ANY CHANGES THAT MAY OCCUR. Medical Information Medlcatlonsl Supplements DiagnosIs: Medication/Supplement 'Name: Dosage: Frequency: ,,: Route: BIOO~v'JCl;'kRequlre[17: ",. If Yes, How Frequently?: Does"thePerson Self MedIcate?: . Name of Prescribing Doctor(Last, FIrst): Speclallnstructlons/Precautlons: '-. - - MIX WITH aoz OF WATER OR JUICE . .' ... , DiagnosIs: -: :..- Medication/Supplement Name: Ro.s,~ge:." .;~.~: ~:. -.."....., .-:" Frequency: Route: :'" -, '-' Blood Work Required?: If Yes,_l:!ow frequently?:' Does the Person Self Medicate?: Nal)1eof pres,crlblngDoctor(U!st, First): Special Instructions/Precautions: " USE AS;DiRECTED .-' ',.:..' .... , 0" _ . .. .01- Diagnosis: Medication/Supplement Name: Dosage: Frequency:' " . Route: Blood Work Required?: If Yes, How Frequently?: Does the' Person Self Medicate?: Name of Prescribing Doctor(Last, First): BOWEL REGULARITY METAMUCIL 1 TBSP QD'_: ' By Mouth 'No,7i".- .;: . . _._ .' ..... I'" . :;'- ;: :, ~\ " ~ . .... ';. Nci' ...'!...~...- . DR. BURKHART "." '." . ,.; ,:','-;.',., " .r:.'. ...... .:','(',,'.;; .~ .< .1;': .' '. . 5100LSOFTENER DOCUSATE SODIUM ." ipQMG_ HS , . Ei'y Mouth;^' No .' .,.-: ..,.. . . ~ . ~ .-;, . ',~ .-.. No b~: . BURKHART . . ~. :'-~..j,.~~,.;': .~.~,~ " "j .'. ~. ~ :.,.... EAR WAX BUILD-UP . DEBROX 'EAR DROPS . 6.5% 15ML - Other.;." ", Drops No .' . ". No DR. BURKHART .' ...11.._:_ _...I__I...._nC'DOT f:J.~p 1/1/2001i APPLY SOLUTION TO corrON BALL AND CLEANSE EYES. Diagnosis: DIGESTION Medication/Supplement Name: METOCLOPRAMlDE Dosage: 10MG Frequency: QID Route: By Mouth Blood Work Required?: No If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/Precautions: TO BE TAKEN 30 MINUTES PRIOR TO MEALS AND AT BEDTIME. Diagnosis: DIETARY SUPPLEMENT Medication/Supplement Name: THERA-TAB Dosage: 1 TAB Frequency: QD Route: By Mouth Blood Work Required?: No If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/Precautions: USE AS DIRECTED Dlag nosls: . Medication/Supplement Name: Dosage: ' F!equency: Route':..: -", Blood Work Required?: If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor( Last, First): Special Instructions/Precautions: USE AS DIRECTED Diagnosis: Medication/Supplement Name: Dosage: Frequency: Route: Blood Work Required?: If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/Precautions: USE AS DIRECTED No DR. BURKHART ':: -; . - - No DR. BURKHART ....,. - " _.: ';-, '.... '.;..'...... . ; ... . .'", CA~CIUf>:1 sUPPLEMENT-- Os-CAL : .,.,.;1,OOOMG- QD . ,'-'. -By Mouth. No , .. ~ - . .'; .-~ ." " 'f.... , '..'; .. " ,.',,: . No DR. BURKHART GERD .. , F'RILOsEC 40MG QD: By Mouth No t. -. No DR. BURKHART . .. --. I...... ----_.:_.... .......... ...... ..,./h"'I"':r4rp/nn",,/';u:'nfl<::PPT A ~p 1/3/2006 .. Pugc I:! of34 I'rinllndividuul Support Plan KNEE PAIN CELEBREX 100MG QD By Mouth No Diagnosis: Medication/Supplement Name: Dosage: Frequency: Route: Blood Work Required?: If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/precautions: MAY TAKE AN ADDITIONAL 2 TABS AS NEEDED FOR PAIN Diagnosis: PREVENT COUGHING AT MEALS Medication/Supplement Name: THICK-IT Dosage: 1 TBSP Frequency: Other ~~ ~~~ Blood Work Required?: No If Yes, How Frequently?: Does thePerson Self Medicate?: No Name of Prescribing Doctor(Last, First): DR. BURKHART speclal_!nstructlons/precautlons: . MIX WITH UQUIDS DURING MEALS AND SNACKS FOR THICKENING PURPOSES. , ,.. Diagnosis: CONSTlPATION-' Medication/Supplement Name: MIRAU\X Dosage:. 1'7GRCAPFUC Frequency: PRN R.oute: By_ Mouth Blood Work Required?: No If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/Precautions : . MIX MIRAu\X IN B OZ OF FLUID IF BOWELS ARE IRREGUU\R Diagnosis: CONSTIPATION Medication/Supplement Name:' MIRAU\X POWDER Dosage: USE 17GM IN B OZ. OF FLUID Frequency: PRN Route: By Mouth Blood Work Required?: No If Yes, How Frequently?: Does the Person Self Medicate?: Name of Prescribing Doctor(Last, First): Special Instructions/Precautions: NONE No DR. BURKHART . ~ I,', ,," ,- -": No DR. BURKHART .. ". No DR. BURKHART Allergies Known Allergy: Reaction: Required Response: POSITIVE REACTION TO TB-MANTOUX SKIN RASH CHEST X-RAY ONLY, CONSULT PHYSICIAN AS NEEDED Health Evaluations Type of Appraisal: Specialist Type: Medical Contact: HERSHEY MEDICAL CENTER Date of Appraisal (MM/DD/VYYY): Frequency of Appraisal: Person Responsible for Arranging/Completing: If Respons!ble:Persoflls 'Other', Specify: -:: '> :'.~:' ' Type of Appraisal: Sp_ecia'l~tT,ype:~;::::. '::~':,~ -' " Medical Contact: . ';D'R' BLA"K' E : .:~ t;" , . '- .}'..:;o ~ ";';._.;-~",,~.,.. . .':~_ ~.:.:';;' ;;;," . . . .. -; -. I . " ". ' ......:. .\:' ,~.; "~', . '. :; . I ,,_ "'*INSURANCE NO LONGER COVERS~_WILLHAVFTO,SELF PAY ON A PRN BASIS " :' , . Date of Appraisal (MM/DD!yyyy): 12/13/2004 . .' '.'" . ',-. -, -. - ..... ' ~ . ,-...-.... ~ . ~.. . ... Frequency of Appraisal:" , , '-, ',' :,'.: ::.: ~',~: Asl'leeded: Person Responsible for Arranging/Completing: Provider If Responsible PerSori I~-'O.therr;,?peclty:, ,', ' :.:.-:: ?r~~,- " Type of Appraisal: Dental ."...,J. "'..., ," .- ;'~-.,- .'~' ..' n. .;.........,.., I' "1"'.'. ", "I""" . Speclallst!.yp.e: - ,oo'_ ':.-~::.;. ..~;' :,':';,,;<;-.":'DEt:m5T,:' Medical Contact: :. -DR.-FREDRICK,HECHT" ' ',_. . , , " ':: ,>'c:', ';. ::: Date of Appraisal (MM/DD/VYYY): 04/16/2004 Frequency dfAppralsal: ':. -:, -, :"".. 'J:- :Ve,ariy-.:,~ Person Responsible for Arranging/Completing: Provider I(Respo,;sible PerSon Is 'Other:;,Spedfy:" :',:':(;-" ,: Type of Appraisal: Hearing Spedall!itType~: - ,,',': :-:: ;.::,,;:, PRIMARY PHYSICIAN Medical Contact: DR: CHRISTINA BURKHART Date of Appraisal (MM/DD!yyyy): Frequeney' of Appraisal:', ' cO': . . , Person Responsible for Arranging/Completing: If Responslbie Person Is 'Other', SpecifY: , -_ Type of Appraisal: Specialist Type: Medical Contact: Mammogram ',' RADIOLOGIST ',. . ......:. . :'.- .... . 07/12/2004 Yearly Provider ' ',I" Other . ..;~:;:;::: ~9j:>I.A.TRIST ,::.:~ ' ',' . ::~- ,~.' ':'~', , ,.". -.' '.' ~ ';:}; " ....":'.-.., '.." - .'.. . ~ .' I.... ." ,-"". ,,' "::",,. i' '-~':~T''''~~~~! . 'f ","_ .. '<'~"~~"~~",~.': I, ." \ ; ,'. ~. ~.- .. . ) ,J., ", ~! . '. . '- . ' :;. . ., ',. .' '.. .,' '. 11/17/2004 Yearly. .. Provider . " Physical -,- .'. PRIMARY PHYSICIAN ~- . " .... '.. _..1....- tTC"nn"r ^ <:'0 II1/') 1101> Page 14 of34 Prinllndividuul Support Plun DR. CHRISTINA BURKHART Date of APpraisal (MM/DD/YVYY): Frequency of Appraisal: Person Responsible for Arranging/Completing: If Responsible Person Is 'other', Specify: Type of APpraisal: Specialist Type: Medical Contact: DR. CHRISTINA BURKHART Date of Appraisal (MM/DD/VYYY): Frequency of Appraisal: Person Responsible for Arranging/Completing: If Responsible Person Is 'Other', Specify: Type of Appraisal: Specialist Type: Medical Contact: DR. ROBERT THOMPSON Date of APpraisal (MM/DD/VYYY): Frequency of Appraisal: Person Responsible for Arranging/Completing: If Responsible Person Is 'ather', Specify: Type of Appraisal: Specialist TYpe: Medical Contact: DR.-CHRISTINA BURKHART . ' **.DUE :rOLOUELLA'S REACTION TO THE TB TEST, SHE ONLY WILL HAVE THE TEST IF TB .. .sYMPTOMS APPEAR. . . ' '. . - . ,.. . . -. " Date of Appraisal (MM/DD/VYYY): 01/19/1996 Frequency of APpraisal:' As needed Person Responsible for Arranging/Completing: Provider If Responsible Person Is 'Other', Specify: Type of Appraisal: Specialist Type: Medical Contact: ,RYAN WILSON-RUT Date of Appraisal (MM/DD/VYYY): Frequency of Appraisal: Person Responsible for Arranging/Completing: If Responsible Person Is 'Other', Specify: 11/17/2004 Yearly Provider GYN PRIMARY PHYSICIAN 11/09/2004 Yearly Provider Vision OPHTHALMOLOGIST 09/24/2004 Yearly Provider Other CHEST'X-RAY ....... -' , Other VASCULAR LAB 09/27/2004 As needed Provider Medical Contacts CHRISTINA BURKHART P Arst Name: Last Name: Middle Name: HERSHEY FAMll YPRACTlCE PRIMARY CARE PHYSICIAN 845 FISHBURN ROAD Clinic: Specialist Type: Address L1ne1: Address L1ne2: Address L1ne3: City: State: Zip: Phone Number: First Name: Last Na-riie: Middle Name: Clinic:' ;"; ,: Specialist Type: Address L1ne1: Address L1ne2: Addr~ss L1nE!3: ' City: state:;.::.':.':' -.,~ ; - ..' Zip: pfion~-Nulj,tier.: First Name: liist'Name::':, ' Middle Name: CllnlC-:~"'.;,/:~; _ __~.~.: ':;'-.;', 2~;~t\- U~i~ERSITY- PHYSIOANS CENTER :"::::.~::':j\T;;;:~:;P, Specialist Type: PODIATRIST ~dcir.~s~:i:1~ei(,:.:' ;;._,ix,q{- <,,-':;' :::~i.. :;'; ';~2D\'0iJ,fu~(ER.SfrY PHys~d~NS CEN..~:;':;_2,t"'7~~',.jt; Address L1ne2: UNIVERSIlY DRIVE SUITE 400 ,"" _ .. - _.. '" "J . " ~ddr'eS~ 'l,lii,e'3: , City: State: -_..;:~, Zip: ph,one Nu_mb~r: ^ First Name: Las(NarTi~:._ Middle Name: Cllnl'c'-' ',', ..; -- . ~ .' 'r::.;' Specialist Type: . . ". ..... Addfess'Une1: Address L1ne2: Jl,ddress L1ne3: City: State: Zip: Phone Number: HERSHEY Pennsylvania 17033 7175318181 " . .. .~' ,.', . .... .' ,y ," HERSHEY MEDICALCE!'ITER RADIOLOGY ',,:_,:-,670,bIERRY DRIVE' : , " ". 1 :~,~:~ ,~~~;._; ">.,:,,', 'L'.:~ ;'\-' ,:1 ;. .!..' ....>.......'. ,.-, " . "~. . :. . , .,-:... i, .~ ' "." ~.'"-'~.:I::HY2~~ .' .' HERSHEY ,', :;'-,'-,/:,,'.:{ E~n'risYlv'ania-- - 17033 .....',. . ."" "...-.... ."'oJ' .... -......,...,. .. , ~::,": ",,,;/,):~!>, .:7.175315319 NELL I,....' _." ,..:' ~~: ;':, '~.~~.~~~:7':~?':!1'~:~':: 'l~~~, '" ?~_::',~::~' ":~~ ..~:-:. .-:~' t\:~~:~~iJ~~:;~;rl~:~1J~ ' - .~,-.,;~:;.~~..~t-:'~~r:~t:;rL',' ~~~E"~'~,~" -..' ,'.,~ '~;.'..'~, :' ":~:'!", .::.:~.:.t::~:j-;5~i~:7~~~n~ ,~ . :" .;.:~ '~-\t;'f/:~r.~7 ;;~~}~t!~~{:l~ <':~ , ,~...:' " ..;f....., '., "'~ ~~~:~ .::~~;.~..T~.1"1'~.~~t;~4.'?". ...: ," - LJ!'1.~ -~.- ,:~....,..:..~'i~~~!r,fI.;'.~ , .:. . HERSHEY ',:'.'."_:: 't;.;~~:':~; :~en~siivania/':\:" 17033 -," :: '~-;~i: .:', ~J.1753}563~' .,' " FREDRICK ,;, ;.:'.:" ":;-",, H"'C"uT ':'_:_' ..'~ _ : l< ~:'.., t; ~ . ."" :':,: 1'-~~J!~:~':>:':~';~;j,~. . ~. ~ .;,'. ' ...~~:~' ~t:,~"~f~~3~S.j ..,r..'. '. '~".: ";:~ '~1:~:.'~'~>::~ ~;~~~~t '-'. '_~' ::....: :-;: .:~,.:~~."'.11..~::.:~'..:.t~'~''''''I' ' .: ,t: ~!' ,.~.:.~: .:~'\ .,~,~:,;":;.~r[:'~:,~<r~i~ :_ c' .. ~ :', "-",' . ... 'or ~. ".;'''' Y ,.'f '- :' .:, '~,,:' DENTIST . 238 ALEXAt\JDER SPRING ROAD-', ,.\,'''7';;: ~-.:~:: ;.:",! - - . ' ' .... .......'.. ,.0:....,. , 'o".' . .~;~'. , , ", ':':">~"('~' . . . >J~":...,~~.!; ," ~ '-:::'- CARUSlE . . . -:;. ~ ~enrisylitania 17013 7112497007 .- ,.: . ;,;~ . ". : '.' ~-. '. ~ c. ,~.; , " . ,.. ... ,___ nC'lnnT A C'D 1 /'~l?nM Page Iii of 34 Print Individual Support I'\an First Name: Last Name: Middle Name: Clinic: Specialist Type: Address L1ne1: Address L1ne2: Address L1ne3: City: State: Zip: phone Number: First Name: Last Name: Middle Name: Clinic: Specialist Type: Address Llne1:, Address L1ne2: Address-L1ne3: City: state: Zip: phone Number: ROBERT THOMPSON OPHTHALMOLOGY MEDICAL ARTS BUILDING SUITE 202 CARUSLE Pennsylvania 17013 7172432331 RYAN WILSON VASCULAR LAB VASCULAR LAB HERS,HEY HOSPITAL 500 UNIVERSITY DRIVE j'~ . . HERSHEY Pennsylvania 17033 7175316955 --. " Current Health status Current Health Status: . " ' ,"", ", '~..:: ' LOUELLA IS AMBULATORY WITH PHYSICAL ASSISTANCE- OR BY USE OF WHEELCHAIR OR WALKER. LOUELLA IS A PERSON WITH PROFOUND MENTAL RETARDATION WHO ISBUND IN BOTH EYES DUE TO TRAUMATIC CATARACTS. LOUELLA HAS BEEN DIAGNOSED WITH MICROCEPHALY. SHE HAS KYPHOSIS, . IRRITABLE BOWEL SYNDROME, -CHRONIC. CONSTIPATION, ARTHRITIS OF THE RIGHT KNEE AND BURSmS OF THE LEFT SHOULDER DUE TO A SEPARATION ON 2/8/1962. LOUELLA HAS TESTED posmVE FOR HEPATITIS B AND FOR TUBERCULOSIS. SHE HAS BEEN EXPOSED TO BOTH DISEASES AND DE\(ELOpED IMMUNITY, AND SHE IS NOT CONTAGIOUS. LOUELLA SHOULD HAVE ,,'A PUREED DIET. LOUELLA WILL AT TIMES VOMIT AFTER EATING. BY DOCTORS~ RECOMMENDATIONS, LOUELLA SHOULD TAKE ONE BITE OF FOOD, FOLLOWED BY ONE SIP OF, A DRINK. LOUELLA . IS ALSO TO USE THICK-IT IN HER UQUIDS DURING MEALS AND SNACKS TO PREVENT COUGHING. LOUELLA HAD A BARIUM SWALLOW- AND CHEST X-RAY -ON 9i24/1995. RESULTS SHOWED A LARGE HIATAL -HERNIA WITH GROSS REFLUX AND INTERMmENT ASPIRATION. LOUELLA BROKE HER COLLARBONE ON 1/5/1995. LOUELLA WAS SEEN ON 12/28/2000 BY DR. CASSAL,GASTROENTEROLOGIST' FOR FREQUENT VOMmNG.DR. CASsAL RECOMMENDED COMPLETE SUPERVISION OF ALL MEALS TO MAKE CERTAIN THAT FOOD IS SWALLOWED BEFORE HER NEXT SPOONFUL AND TO NOT ALLOW 'LOUELLA TO LAY DOWN WITHIN 4 HOURS AFTER A MEAL. HE ALSO REFERRED HER FOR A SPEECH EVALUATION REGARDING SWALLOWING FOOD. SHE RECEIVED A SWALLOWING EVALUATION ON 1/4/2001. THE SPEECH THERAPIST RECOMMENDED CLOSE MONITORING WHILE LOUELLA IS EATING, GIVING HER SMALLER PORTIONS AND GIVING SMALL SIPS OF A DRINK BETWEEN BITES. ON 8/23/2001, DR. CASSAL ORDERED AN UPPER GI SERIES AND LOWER INTESTINAL X-RAYS. THE RESULTS SHOWED NO PRESENCE OF A PARA- ESOPHAGEAL HERNIA. INSTEAD, THERE IS A LARGE SLIDING HIATAL HERNIA WITH GASTROESOPHAGEAL REFLUX. RECOMMENDATIONS WERE THAT LOUELLA'S MEALS SHOULD CONTINUE TO BE MONITORED, GIVEN IN SMALLER PORTIONS AND BE LACTOSE FREE. LOUELLA IS CURRENTLY BEING INTRODUCED TO DAIRY PRODUCTS. ON 10/31/2002 IT WAS DISCOVERED THAT LOUELLA'S BLOOD PRESSURE WAS BORDERLINE HIGH AT 150/88. HER BLOOD PRESSURE WAS CHECKED MONTHLY FOR THE FOLLOWING 3 MONTHS. HER BLOOD PRESSURE IS CURRENTLY WITHIN THE NORMAL RANGE. LOUELLA USES THICK-IT IN HER DRINKS TO PREVENT CHOKING AND COUGHING. AT LOUELLA'S ANNUAL PHYSICAL DR. BURKHART REFERRED HER FOR A COLONOSCOPY WHICH WAS COMPLETED ON 12/30/2003. THE RESULTS WERE NORMAL. ON 09/13/2004, DR. BLAKE (PODIATRIST) RECOMMENDED THAT LOUELLA HAVE AN ABI TEST PERf=ORMED TO CHECK LOUELLA FOR VASCULAR DISEASE DUE TO REDNESS IN HER FEET. ON 9/21/2004, LOUELLA SAW DR, BURKHART (PCP) AND SHE REFERRED LOUELLA TO THE VASCULAR LAB AT HERSHEY MEDICAL TO CHECK FOR VASCULAR DISEASE ON HER LEGS/FEET. ON 9/27/2004, ABI TEST PERFORMED BY RYAN WILSON AT THE VASCULAR LAB. THE RESULTS STATED THAT THERE WAS NO EVIDENCE OF FLOW REDUCING STENOSIS OR ARTERIEL OCCLUSION. ON 12/13/2004, LOUELLA SAW DR. BLAKE FOR A ROUTINE TOE NAIL REDUCTION AND SHE' WAS GIVEN A COpy OF THE ABI TEST RESULTS. SHE STATED SINCE THESE RESULTS SHOW NO SIGN OF VASCULAR DISEASE,' . LOUELLA'S INSURANCE WILL NO LONGER COVER THE TOENAIL REDUCTION SERVICE. SHE ." WILL NEED TO SELF PAY ON A AS NEEDED BASI,S. . -- . - ON 5/13/2004, BLOODWORK WAS TAKEN DUE TO INCREASE IN. SLEEPUNESS. ON 5/20/2004, BLOODWORK RESULTS WERE NORMAL. ON 07/01/04, LOUELLA HAD HEAD AND CHEST CONGESTION AND SHE WAS DIAGNOSED WITH ACUTE BRONCHmES AND POSSIBLY SINusms. SHE ALSO HAS BODERUNE HIGH BLOOD PRESSURE AND SHE IS TO HAVE HER BLOOD PRESSURE CHECKED ONCE,A MONTH FOR THE NEXT TWO MONTHS. ON' 11/19/2004, LOUElLA HAD A UTI AND DR. BURKHART PRESCRIBED BACTRIM DS ONE TAB BID FOR FIVE DAYS. ' _.." . Developmental Information Developmental Information: LOUELLA WAS BORN 10/23/1938. THE ONLY DEVELoPMENTAL MILESTONES INFORMATION AVAILABLE IS THAT LOUELLA BEGAN TO WALK AROUND AGE 2. SHE WAS ADMITTED TO THE PENNHURST INSITUTION AT AGE 4 ALONG WITH HER lWIN SISTER, AND UVED THERE FROM 11/1942-4/1985. LOUELLA EXPERIENCED FREQUENT UPPER RESPIRATORY- INFECTIONS DURING CHILDHOOD. LOUELLA HAD HER TEETH REMOVED lN EARLY CHILDHOOD AFTER A HISTORY OF BmNG. ' ;.' PsychosocIal Information Psychosocial Information: LOUELLA DOES NOT HAVE A CLINICAL MENTAL HEALTH DIAGNOSIS. WHEN LOUELLA IS UPSET OR NOT IN A GOOD MOOD, SHE WILL SCREAM LOUDLY AND ROCK BACK AND FORTH IN HER CHAIR. LOUELLA MAY ALSO YEll AND CURSE AT THESE TIMES. SHE WILL ALSO SCRATCH HER FACE, WHICH RESULTS IN BLEEDING AT TIMES. SHE WILL ALSO RAKE HER. . FINGERS THROUGH HER HAIR, WHICH MAY ALSO RESULT IN HAIR LOSS. WHEN SHE IS AGITATED THIS WAY, SHE CAN USUALLY BE REDIRECTED. LOUELLA GENERALLY SLEEPS THROUGH THE NIGHT AND NAPS FREQUENTLY DURING THE DAY AT HER LEISURE. physical Assessment . ,~._.:.. _... .......... ...... .....Ih.u.:r rp/nnrn/'H'nnC:::PPT A ~p 1/3/2006 Print Individual Support PI:1Il Page 18 of 34 System Area: Vision Description: LOUELLA IS BLIND IN BOTH EYES DUE TO CATARACTS. System Area: Dental Description: LOUELLA IS EDENTULOUS SO ALL OF HER MEALS ARE PUREED. System Area: Digestive Description: LARGE HIATAL HERNIA W/ GASTROESOPHAGEAL REFLUX, LACTOSE INTOLERANT (BEING RE-INTRODUCED TO DAIRY), IBS, CHRONIC CONSTIPATION, MAY VOMIT AFTER EATING. RECOMMENDATIONS-1 BITE OF FOOD, 1 SIP OF DRINK & NOT LAY DOWN W/IN 4 HRS OF EATING A MEAL. USES THICK-IT IN LIQUIDS. System Area: Musculoskeletal Description: LOUELLA HAS KYPHOSIS, ARTHRlllS OF RIGHT KNEE AND BURSIllS OF THE LEFT SHOULDER. Immunization booster Name Of Immunization/Booster: If Immunization/Booster Is 'Other' specify: Date Administered (MM/DD/VYVY): Name Of Immunization/Booster: If Immunization/Booster Is 'Other' specify: Date Administered (MM/DD/VYVY): Name Of Immunization/Booster: If Immunization/Booster Is 'Other' specify: Date Administered (MM/DD/VYVY): Name Of Immunization/Booster: If Immunization/Booster is 'Other' specify: Date Administered (MM/DD/VYVY): Name Of Immunization/Booster: If Immunization/Booster Is 'Other' specify: Date Administered (MM/DD/VYVY): Health and Safety General Health and Safety Risks Diphtheria 08/18/2003 Tetanus 08/18/2003 Haemophllus Influenzae type b 10/12/2004 Inactivated Polio 09/17/1971 Pneumovax 11/11/2003 LOUELLA'S MEDICATIONS ARE COMPLETELY ADMINISTERED BY STAFF ACCORDING TO DOSE AND SCHEDULE. LOUELLA IS DEEMED INAPPROPRIATE FOR REVIEW OF THE SELF MEDICATION ORAL REVIEW TEST. LOUELLA NEEDS ASSISTANCE IN ALL AREAS OF DAILY LIVING AND SHE DOES NOT HAVE ANY SELF PRESERVATION SKILLS. LOUELLA HAS A MEDICAL GUARDIAN. LOUELLA IS NOT AWARE OF HEAT SOURCES, HOT WATER, HOT PIPES, ETC. Page :W 0[34 Prinllndividual Support Plan PLATE AND SPOON. LOUELLA REQUIRES MONITORING WHILE EATING SO THAT SHE DOES NOT EAT TOO MUCH, TOO FAST AND DOES NOT CHOKE. SHE MAY VOMIT AT TIMES. STAFF CONTINUE TO ENCOURAGE LOUELLA TO SIP A DRINK BETWEEN BITES OF HER MEAL. LOUELLA USES THICK-IT IN HER DRINKS AND LIQUIDS TO HELP PREVENT COUGHING AFTER TAKING SIPS. supervision Care Needs supervision Care need Type: Number of hours of supervision: Description: LOUELLA IS SUPERVISED AT ALL TIMES WHILE AT HOME. THERE IS AN AWAKE OVER NIGHT STAFF AT HER HOME. THERE IS ALWAYS AT LEAST 1 STAFF FOR THE 3 INDIVIDUALS WHO LIVE IN THE HOUSE. OVERLAPPING SCHEDULES PROVIDE FOR DOUBLE COVERAGE AS NEEDED. LOUELLA HAS BEEN DEEMED INAPPROPRIATE FOR IAT TESTING. Is Intensive supervision required in this setting?: No Supervision Care need Type: Community Supervision Number of hours of supervision: Description: LOUELLA IS SUPERVISED AT ALL TIMES WHILE IN THE COMMUNITY. THERE IS ALWAYS AT LEAST 1 STAFF FOR THE THE 3 INDIVIDUALS WHO LIVE IN THE HOUSE. DOUBLE COVERAGE IS PROVIDED AT TIMES. LOUELLA HAS BEEN DEEMED INAPPROPRIATE FOR IAT TESTING. Is Intensive supervision required In this setting?: No supervision Care need Type: Day Supervision Number of hours of supervision: Description: LOUELLA IS SUPERVISED AT ALL TIMES WHEN AT HER DAY PROGRAM. THE STAFF'RATIO IN HER ROOM IS 1 STAFF FOR 5 INDIVIDUALS IN THE ROOM. LOUELLA ALSO MUST BE IN THE VIEW OF STAFF. LOUELLA MAY BE ALONE IN THE BATHROOM WITH FREQUENT CHECKS. - Is Intensive supervision required In this setting?: No Home Supervision ~ .. - .- if staffing Ratio - Day I Provider: Type: Day: Start Time: End Time: Comments: RATIO 1 STAFF, 5 INDIVIDUALS Provider: Type: Day: Start Time: End Time: Comments: , RATIO 1 STAFF, 6 INDIVIDUALS ALTERNATIVES DAY PROGRAM Monday 9:00 AM 3:00 PM ALTERNATIVES DAY PROGRAM Tuesday 9:00 AM 3:00 PM ALTERNATIVES DAY PROGRAM Wednesday 9:00 AM' 3:00 PM Provider: Type: Day: Start Time: End Time: Comments: RATIO 1 STAFF, 6 INDIVIDUALS Provider: ' Type: Day: Start Time: End Time: Comments: RATIO 1 STAFF, 6INDIVIDUALS, ", -'- >"~::' :,,:'::': :.' provider: ALTERNATIVES Type: .;'.:". DAYPROGRAM Day: Friday StartTlme;. :.-::,:: ,~9:'oOAM End Time: 2:00 PM com"men'is{:: ~. ;".~ ':..' \.'~~> . .~~:;. ,,~ :..::.-.: .:_}:;~=t.~~\!:~:~~i,:Zj::~2:~'" RATIO 1 STAFF, 6 INDIVIDUALS .~.< ALTERNATIVES DAY PROGRAM Thursday 9:00 AM "3.:00.'PM;'-' " ,,':. '~'~'~;.';" -. . ~ - . . ,.... ."_h . ," .:'.;.... :-~.::':':-: . .::.,<-~~~': ~::"'::. " . ~' '- ," '. -,'. Staffing Ratio - Home Day: stBrtilme:' End Time: Monday :,,:"'L i7-"::iio'AM': 9:00 AM ,'. .: >.'. ":~:.':. .~. .. . '" ~. ....,:, ..'~' , ,:-:- :"~'1",;:,:4'):.7:; .'< ~, . 1, , ' -..;; '.",1"' c9ijim~nts:l.~:~' ,-. ~;'.~~'_:~;{ ~"~'~-.;~~.r\ ;;'. ~::.::)~::~'~.-/:~,~~-:~.~L;.;.~;~t.:.~~~;:~~~~~~~~.:- ~:-. :,;. .. ..' 1 STAFF, 3 INDIVIDUALS Day:,:" ,., " ',-:-- - , Start Time: End Tlme:'_ , . . Comments: : - i STAFF, 3 INDIViDUALS' Day: Start:nriie: :..': End Time: comments: 1 STAFF, 3 INDIVIDUALS Day: '. . Start Time: End Time: Comments: 1 STAFF, 3 INDIVIDUALS Day: ,:-~.~:::~~~K ..,_", :.!: ~.':j:'-':;~-i_:.~'r r:;:~ncfa.yi;::.' :' , .. . ", ", '~.~ ..:/.'.~ ~:';, ':'; '..'.... 3:00 PM .'. :"', -'","-::: ".' 1-1:'3-0' 'pM- , . '"." .:~::. ;':'r.. ".:, ".'.. ..-, . .;, '....- .: ". .:. ", ,~:..~;.;.;:: ~ '.... ': ..,.... Tuesday ..":, .. .'.",", ...... ", . . " ,,': ',,_,.'-c'i, ',12:00,AM 9:00 AM ','.' . . " ~ ...... .;:':::, " . ,... '" ',.... ~.. '., '_,;~;. ... . i .:-" ..... "",- ';' ,'. d.-,' -...-i'Tuesday:'.- 3:00 PM : ;:/:- .., '11':30 PM 'I .,.". "",' Wednesday . .. " ___...1..._..__...._.:...... ........,.. ..... n",Ih"'r;r_Y'PO/nrn-n/OJl:nlT~PPT A~P 1/3/2006 , Page 22 of34 Prinllndividual Suppon Plan Start Time: 12:00 AM End Time: 9:00 AM Comments: 1 STAFF, 3 INDIVIDUALS Day: Wednesday Start Time: 3:00 PM End Time: 11:30 PM Comments: 1 STAFF, 3 INDIVIDUALS Day: Thursday Start Time: 12:00 AM End Time: 9:00 AM Comments: 1 STAFF, 3 INDIVIDUALS Day: Thursday Start Time: 3:00 PM End Time: 11:30 PM Comments: 1 STAFF, 3 INDIVIDUALS Day: Friday Start Time: 12:00 AM End Time: 9:00 AM Comments: 1 STAFF, 3 INDIVIDUALS Day: --. Friday , ~. Start Time: 2:00 PM End Time: ' 11:30-PM Comments: 1 STAFF, 3 INDIVIDUALS Day: Saturday Start Time: 12:00 AM End Time: 11:30 PM Comments: 1 STAFF, 3 INDIVIDUALS Day:. Sunday Start Time: 12:00 AM End Time: 11:30 PM Comments: 1 STAFF, 3 INDIVIDUALS Staffing Ratio Are there Awake Overnlght(A/O) staff in this Yes person's home?: Are the total number of full-time equivalent Yes Page :!4 of 3.\ Prinllndil'idual Supporll'lun STAFF WILL ASSIST LOUELLA WITH BRUSHING HER GUMS DAILY. LOUELLA WILL VISIT THE DENTIST ANNUALLY. Frequency of Support: Desired Outcome: Reason/Agency Responsible: Health Condition/Issues: Promotion/Strategy support Required: LOUELLA WILL BE GIVEN MEALS IN SMALLER PORTIONS, LACTOSE FREE DIET WITH GRADUAL RE-INTRODUCTION TO DAIRY PRODUCTS, SHE WILL TAKE A SIP OF DRINK IN BETWEEN BITE OF FOOD, SHE WILL NOT LAY DDWN WITHIN 4 HOURS OF EATING A MEAL. LOUELLA USES THICK-IT IN HER ORINKS TO PREVENT COUGHING. SHE ALSO TAKES PRILOSEC FOR HER GERD. Frequency of support: Desired outcome: Reason/Agency Responsible: DAILY BRUSHING, ANNUAL VISITS GOOD ORAL HYGIENE LOUELLA, CPARC GERD DAILY REDUCE GERD SYMPTOMS LOUELLA, CPARC Functional Information Physical Development Physical Development: LOUELLA IS DEPENDENT ON STAFF TO ASSIST HER WITH MOBILITY (GETIING TO HANDRAILS, IN WHEELCHAIR, POsmONING WALKER ETC..) LOUELLA ENJOYS TOUCHING. AND HOLDING MANY DIFFERENT TEXTURES. LOUELLA HAS USED PLAY DOUGH, FINGER PAINTS AND PUZZLES FOR STIMULATION. . . Adaptive/self Help LOUELLA NEEDS ASSISTANCE WITH GETIING IN AND OUT OF THE BATHTUB. SHE USES A TUB CHAIR WHILE BATHING. A TUB HANDLE BAR HAS BEEN PLACED ON THE TUB FOR HER USE. STAFF ASSIST LOUELLA WITH BATHING. LOUELLA IS INCONTINENT AND SHE REQUIRES STAFF ASSISTANCE WITH WIPING AND CHANGING HER BRIEF. STAFF TAKE LOUELLA TO THE BATHROOM EVERY 2 HOURS. STAFF CHOOSE OUTFITS FOR LOUELLA TO WEAR ON DAILY BASIS. LOUELLA WILL HELP WITH DRESSING BY RAISING HER ARMS TO PUT HER SHIRTS ON AND BY UFTING HER LEGS TO PUT ON HER PANTS, SOCKS AND SHOES. LOUELLA USES AN ADAPTIVE PLATE TO EAT AND CAN EAT WITH A SPOON WHEN STAFF GUIDE HER TO THE SPOON AND PLATE. Learning/cognition LOUELLA IS ABLE TO LEARN SOME BY REPETmON. SHE IS ABLE TO REMEMBER HER FRIENDS BY USTENING TO THEIR VOICES. LOUELLA REQUIES ASSISTANCE IN MONEY MANAGEMENT ETC. communication LOUELLA IS UNABLE TO FORM OR SPEAK IN SENTENCES. HER WANTS AND NEEDS ARE BEST UNDERSTOOD BY THOSE WHO KNOW HER WELL AND ARE CLOSE TO HER. LOUELLA Page 26 of 34 prillllndividual Support Plan Comments: Understanding communication When this happening...: THERE IS AN INCREASE IN COMMOTION IN LOUELLA'S ENVIRONMENT. The Individual does...: LOUELLA WILL TEND TO SCREAM, YELL, CURSE, ETC. We think It means...: LOUELLA THINKS THAT HER ENVIRONMENT IS TOO LOUD OR NOISY, OR SHE MAY NOT FEEL WELL. We should...: STAFF SHOULD TRY TO CALM LOUELLA DOWN, REDIRECT HER TO A MORE posmVE ACTIVITY AND CHECK FOR ANY SIGNS OF ILLNESS. When this happening...: ANYTIME The Individual does...: LOUELLA MAY RAKE HER HANDS THROUGH HER HAIR OR SCREAM. We think It means...: LOUELLA IS INDICATING THAT SHE IS FEEUNG DISTRESS. LOUELL.A IS 'UPSET ABOUT SOMETHING IN HER ENVIRONMENT OR SHE DOES NOT FEEL WELL. We should...: STAFF SHOULD TAKE TIME TO FIGURE OUT WHAT LOUELLA NEEDS OR WANTS IN ORDER TO CALM HER. When this happening...: ANYTIME The Individual does...: LOUELLA IS SHOWING AFFECTION, LAUGHING, AND/OR BLOWING KISSES We think It means...: LOUELLA IS HAPPY AND IN A GOOD MOOD. We should...: STAFF SHOULD ENJOY LOUELLA'S MOOD AND PARTICIPATE AND ENCOURAGE HER HAPPINESS. Other Non-Medical Evaluation Non-Medical Evaluation Area: If Type Is 'other' Specify: Name{Type of Evaluation: Date of Evaluatlon(MM/DD/VYYY): Evaluator Name(Flrst Name, Last Name): Evaluator Agency: GUIDANCE ASSOCIATES Non-Medical Evaluation Area: If Type Is 'Other' Specify: Psychology PSYCHOLOGICAL 02/26/1999 EUGENE STECHER Communication Print Indil'idual Support Plan Page 28 of 34 Policy Number: Address 1: Address 2: Address 3: City: State: Zip: Who has the original documentation?: Resource Type: Resource Value: Resource Name: Policy Number: Address 1: Address 2: Address 3: City: State: Zip: Who has the original documentation?: BLAIN CEMETERY BLAIN, PA LOYSVILLE Pennsylvania FAMILY Bank Account Checking 1412.94 M&T BANK 2570044862 M&T BANK 1 WEST HIGH STREET CARUSLE Pennsylvania 17013 CPARC Services and Support Individual outcome Summary Outcome Phrase: Outcome Start Date (MM/DD/VYYY): Outcome End Date (MM/DD/VYYY): Outcome Actual End Date (MM/DD/VYYY): Has the outcome been successfully accomplished: Outcome Statement: LOUELLA WILL CONTINUE TO RESIDE IN HER HOME IN MECHANICSBURG WHERE SHE RECEIVES THE NECESSARY SUPERVISION AND SUPPORT NEEDED IN DAILY UFE UNDER THE CARE OF CPARC. . . Reason for Outcome: LOUELLA BENEFITS AND ENJOYS RESIDING IN HER HOME IN MECHANICSBURG AND WILL CONTINUE TO UVE THERE SO THAT SHE CAN CONTINUE TO RECEIVE THE RESIDENTIAL, TRANSPORTATION, RECREATIONAL, PERSONAL SUPPORT SERVICES THAT ENCOURAGE AND SUPPORT HER IN ALL AREAS OF DAILY UVING. LOUELLA WILL ALSO RECIEVE ENCOURAGEMENT AND SUPPORT IN LEARNING ON HOW TO DO SOME SIMPLE HOUSEHOLD CHORES SUCH AS HELPING WITH LAUNDRY AND CLEAN UP OF MEALS. Concerns Related to Outcome: NONE Relevant Assessments LInked to Outcome: N/A RESIDENTIAL PROGRAM 04/11/2005 04/10/2006 Yes Outcome Phrase: Outcome Start Date (MM/DD/YVVY): Outcome End Date (MM/DD/YVVY): Outcome Actual End Date (MM/DD/YYVY): Has the outcome been successfully accomplished: Outcome Statement: LOUELLA CURRENTLY ATTENDS UCP/ALTERNATIVES 5 DAYS A WEEK. Reason for Outcome: LOUELLA WILL CONTINUE TO AlTEND UCP/ALTERNATIVES SO THAT SHE CAN CONTINUE TO BENEffi AND ENJOY FROM THIS SUPPORTIVE ENVIRONMENT WHERE SHE APPRECIATES THE INTERPERSONAL RELATIONSHIPS SHE HAS DEVELOPED WITH HER FRIENDS AND IS STIMULATED SOCIALLY AND MENTALLY BY THEIR PROGRAM. Concerns Related to Outcome: NONE Relevant Assessments Linked to Outcome: N/A _ Outcome Phrase: Outcome Start Date (MM/DD/yy:y'(): Outcome End Date (MM/DD/YVVY): Outcome Actual End Date (MM/DD/YVVY):" Has the outcome been successfully accomplished: Outcome Statement: LOUELLA WILL CONTINUE TO RECEIVE ADVOCACV SERVICES THROUGH CPARC. Reason for Outcome: . .... , :~..I .' ,".: ~<. , LOUELLA WILL CONTINUE TO RECEIVE ADVOCACY SERVICES THROUGH CPARC IN THE EVENT THAT SHE WOULD NEED AN ADVOCATE AS A COMMUNITY SUPPORT. Concerns'RelatedtoOutcome: -, '.;, C', . ' ..t. NONE Relevant Assessments Linked to Outcome: . N/A Outcome Phrase: - Outcome Start Date (MM/DD/YVVY): Outcome End Date (MM/DD/YVVY):' ',. Outcome Actual End Date (MM/DD/YVVY): Has the outcOme been successfully' '. accomplished: ' . Outcome Statement: LOUELLA WILL CONTINUE TO' BE OFFERED OPPORTUNmES TO PARTICIPATE IN COMMUNITY ACl1VmES. Reason for Outcome: LOUELLA WILL BENEffi FROM COMMUNITY INVOLVEMENT. Concerns Related to Outcome: NONE Relevant Assessments Linked to Outcome: DAY PROGRAM 04/11/2005 04/10/2006 Yes ADVOCACV 04/11/2005 04/10/2006 Yes ,.. '" .. ~. . .', -, .~.., . +.' , .' . . ," ',- ~ ., ',".,. COMMUNITY INTEGRATION 04/11/2005 .' ,04/10/2006 Yes , , 1..._...1I......... ...II__""..~..";,.,,C' C't"t,.. no:l I1cn'rc:ic_rp/nam/~~nll~PPT.ASP 1/3/2006 Page 30 of 34 Prinllndividual Support Plan PERSONAL HYGIENE 04/11/2005 04/10/2006 N/A outcome Phrase: outcome Start Date (MM/DD/YvvY): outcome End Date (MM/DD/VVVV): outcome Actual End Date (MM/DD/VVVV): Has the outcome been successfully accomplished: outcome Statement: LOUELLA WILL IMPROVE HER PERSONAL HYGIENE SKILLS SUCH AS BRUSHING HER HAIR AND BRUSHING HER GUMS. Reason for outcome: LOUELLA WILL BENEFIT FROM PROPERLY TAKING CARE OF HER PERSONAL HYGIENE. Concerns Related to outcome: NONE Relevant Assessments Linked to Outcome: N/A No outcome Action Plan Related outcome Phrase: RESIDENTIAL PROGRAM What are current needs: LOUELLA CURRENTLY RESIDES IN A HOME UNDER THE CARE AND SUPERVISION OF CPARC. What action are needed: LOUELLA WILL CONTINUE TO RESIDE IN THIS HOME IN MECHANICSBURG SO THAT SHE CAN CONTINUE TO RECEIVE THE PERSONAL SUPPORT AND SUPERVISION AND RESIDENTIAL SERVICES NEEDED IN ALL AREAS OF DAILY UVING. LOUELLA WILL ALSO RECIEVE ENCOURAGEMENT AND SUPPORT IN LEARNING ON HOW TO DO SOME SIMPLE HOUSEHOLD CHORES SUCH AS HELPING WITH LAUNDRY AND CLEAN UP OF MEALS. Who'S responsible: LOUELLA, CPARC, SUPPORTS COORDINATOR-WILL AUTHORIZE, MONITOR AND DOCUMENT SERVICES. Frequency and duration of actions needed: LOUELLA WILL BE SUPPORTED 7 DAYS WEEKLY. By when (MM/DD/VVVV): 04/10/2006 How will you knoW that progress Is being made towards this outcome?: MONTHLY TX TEAM MEETINGS, MONITORINGS, PROGRESS NOTES, CONVERSATION AND INTERACTION WITH LOUELLA AND HER STAFF. : Related outcome Phrase: DAY PROGRAM What are current needs: LOUELLA CURRENTLY ATTENDS UCP/ALTERNATIVES DAY PROGRAM 5 DAYS A WEEK. What action are needed: LOUELLA WILL CONTINUE TO ATTEND UCP/ALTERNATIVES SO THAT SHE CAN CONTINUE TO BENEFIT FROM THIS ENVIRONMENT IN WHICH SHE IS STIMULATED SOCIALLY AND MENTALLY. Who's responsible: LOUELLA, UCP, SUPPORTS COORDINATOR-WILL AUTHORIZE, MONITOR AND DOCUMENT SERVICES. Frequency and duration of actions needed: LOUELLA IS SUPPORTED AT HER DAY PROGRAM 5 DAYS WEEKLY. By when (MM/DD/VYYY): 04/10/2006 How will you know that prog ress Is being made towards this outcome?: MONTHLY TX TEAM MEEINGS, MONITORlNGS, PROGRESS NOTES, INTERACTION WITH LOUELLA AND HER STAFF. Related Outcome Phrase: What are current needs: LOUELLA CURRENTLY RECEIVES ADVOCACf SUPPORTS THROUGH CPARC. What action are needed: ,," - " LOUELLA WILL CONTINUE TO RECEIVE ADVOCACf SUPPORTS WITH CPARC SO THAT SHE CAN CONTINUE TO BENEffi FROM A COMMUNITY SUPPORT IN THE EVENT THAT SHE NEEDS ADVOCACf SERVICES. Wh.o's rEisponslbie: ," CPARC ADVOCATE FrequencY ~nd. duration of actions. needed :;';'~; LOUELLA WILL USE ADVOCACf SERVICES AS NEEDED AND ONGOING. By-when~(MM/Dci/Y'('iYj?' ,', ::,:: ,:::-,-;,:',:'; '~, ::"", 04j10/2006 How will you know that progress Is being made' towards this outcome?: , 'MONTHLY TX TEAM MEETINGS;;DISCiJssioNS WITH CPARC STAFF AND ADVOCATE. Related Outcome Phrase: COMMUNITY INTEGRATION what:are_2u~~rentrieeds: . :_> " /:~,:, '/' ..<;" ,'.: ,'; LOUELLA HAS A NEED TO BE INVOLVED IN HER COMMUNITY WITH SUPPORT. .. ....... ...... .~. - ~ :. .... to. j .'...' ,,'_ . ...' , ., .-,. :' -. ". .... ....,.' .". ... - What action are needed:,'" ';: :,~:--'-::, ,-- ;"" <-;' ."':',ct,_" _c-' :~: LOUELLA WILL CONTINUE TO BE OFFERED OPPORTUNrnES TO PARTICIPATE IN COMMUNITY ACTIVrnES. . . . '-,,' --, .... :~ '~'..' ,~-. , Who's ,resp'onslble: "':::::;"'-~-. :';,":',:' '--',.;' ',; " , '. ' CPARC Frequency al1dduratlon ofactlonsn.eeded:';:;<' "-., AS DESIRED AND AS LOUELLA TOLERATES COMMUNITY ACTIVrnES By'whe'ri.(MM/DD/YYYY): - " -','F, '," '~<.' '/_ 04/10/2006 How will you know that progress Is being made towards this outcome?: .TR~TME('f.I:".TEAM M~ETINGS;,.MONITORlNGS"AND COMMUNICATIONS WITH THE :reAM Related Outcome Phrase: PERSONAL HYGIENE ., ... ". 'I ..~,.' ,.... '. .... ,..'. -.".. ',," ',' 4 ':' 10 ..... ," What'are'currentneeds: ,~,.,.::---<':-.' ",,:,,;;-, :':',' '-'- LOUELLA CURRENTLY PRACTICES PERSONAL HYGEINE SKILLS. What action are needed:' :' , -'..""-;- -,J,:' ',',', . .. -., ..... LOUELLA WILL CONTINUE TO USE HER PERSONAL HYGEINE SKILLS SUCH AS BRUSHING HER HAIR AND USING SWABS FOR HER GUMS. Who's responsible: . ' . LOUELLA, CPARC Frequency and duration of actions needed: ' ADVOCACY ,,' . -.,' .::'~:;. '::",:~ '...:. " .' j.' . ., '- . - ~, ". ~~ . ,. - ~ " , .' "', , .~:.~; .~.,'- '.'.,~..;~" ~. . t,': - .' -~. ~...: ;. - - ~., ... - " j. :.,>~:-;'.t....' " '-' ,'..,..... .,.. ..,. - ~ ~.,. .-. :', ";"'-' httno'//WWUI hI 1 mnno"rvir.c...tate. oa. uslhcsis-relol!m/asp/IS PPT. AS P 1/3/2006 Page 3~ of 34 Print Individual SuppOrlPlan DAILY, WEEKLY, MONTHLY By when (MM/DD/YVVY): 04/10/2006 How will you know that progress Is being made towards this outcome?: MONTHLY TREATMENT TEAM MEETINGS, MONITORINGS, SERVICE NOTES, INTERACTION WITH LOUELLA AND HER STAFF. Service Details outcome Phrase: Service Name: Service Procedure Code: Provider MPI #: Provider Name: RESIDENTIAL PROGRAM Community Homes (6400 - Eliglbie)-l month W7222:00:00:00:00 100000460 CUMBERLAND-PERRY ASSOCIATION FOR RETARDED CITIZENS 0057 CUMBERLAND/PERRY ASSOCIATION FOR RETARDED CITIZENS 4811 VIRGINIA ROAD MECHANICS BURG, PA . 17050 $0/1 month 3 $0.00 $0.00 04/11/2005 06/30/2005 Pending Service Location ID: Site Name: Site Address: Service Unit Cost: Total Annual Units: Service Subtotal: Plan Budget Total: Expected Start Date: Expected Stop Date: Authorization Status: Authorization Date And TIme: Comments: outcome Phrase: Service Name: Service Procedure Code: Provider MPI #: Provider Name: RESIDENTIAL PROGRAM Community Homes (6400 - Ineliglble)-l month W7223:00:00:00:00 100000460 CUMBERLAND-PERRY ASSOCIATION FOR RETARDED CITIZENS 0057 CUMBERLAND/PERRY ASSOCIATION FOR RETARDED CITIZENS 4811 VIRGINIA ROAD MECHANICSBURG, PA - 17050 $0/1 month 3 $0.00 $0.00 04/11/2005 Service Location ID: Site Name: Site Address: Service Unit Cost: Total Annual Units: Service Subtotal: Plan Budget Total: Expected Start Date: DAY PROGRAM Community Habllltatlon(2380 - Base)-l hr W7062:00:00:00:00 100001501 UCP OF CENTRAL PA, INC. 0008 UCP CENTRAL PA/ALTERNATIVES WEST DAY PROGRAM 925 UNDA LN CAMP HILL, PA - 170116402 $0/1 hr. 360 $0.00 $0.00 04/11/2005 06/30/2005 Pending Community Homes (6400 - Ellglble)-l month CUMBERLAND-PERRY ASSOCIATION FOR RETARDED CrnZENS 3 $0/1 month $0 4/11/2005 - Community Homes (6400 - Inellglble)-l month CUMBERLAND-PERRY ASSOCIATION FOR RETARDED CrnZENS 3 $0/1 month $0 4/11/2005 Print Individual Support Plan Expected Stop Date: Authorization Status: Authorization Date And TIme: CommentS: 06/30/2005 Pending Outcome Phrase: Service Name: Service Procedure Code: Provider MPI #: Provider Name: Service Location 10: Site Name: Site Address: Service Unit Cost: Total Annual Units: Service Subtotal: Plan Budget Total: EXpected Start Date: Expected Stop Date: Authorization Status: Authorization Date And TIme: Comments: . d" Service Summary Service associated with the 'RESIDENTIAL PROGRAM' outcome: Service Name: Provider Name: Total Annual Units: Service Unit Cost: Total Cost:' - Expected Start Date: Service Name: Provider Name: Total Annual Units: Service Unit Cost: Total Cost: Expected Start Date: Service associated with the 'DAY PROGRAM' outcome: hll.....//.."",., hl1mono"rv;r,,,o otnt".nn, II~csis-relnl!mlasD/ISPPT .ASP Page 33 of 34 . 1/3/2006