HomeMy WebLinkAbout07-18-07
IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA
INRE:
) ORPHANS' COURT DIVISION
)
)
)
)
)
)
)
No. J 1-01- O(O~ 2-
DONNA L. NEAD,
AN ALLEGED,
INCAPACITATED PERSON.
PETITION FOR THE APPOINTMEN;r.,
OF A PERMANENT GUARDIAN OF ~";
THE PERSON AND ESTATE: 8 ;~~
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Petition For The Appointment Of A Permanent Guardian
Of The Person and Estate Of An AIle2ed Incapacitated Person
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AND NOW comes Petitioner, Shippensburg Health Care Center through their attorney,
Douglas A. Snyder, Esquire, and presenting their Petition to this Honorable Court for the
Appointment of a Permanent Guardian of the Person and Estate of DONNA L. NEAD an
Alleged Incapacitated Person, representing as follows:
1. Petitioner, Shippensburg Health Care Center (hereinafter "Shippensburg"), is a nursing
facility offering skilled care and long-term care and is located at 121 Walnut Bottom
Road, Shippensburg, P A 17257. Petitioner is licensed to participate in the Medicaid and
Medicare programs.
2. The Alleged Incapacitated Person is Donna L. Nead, a 65 year-old female residing
permanently at Shippensburg. Her date of birth is August 27, 1941.
3. Petitioner is an interested party because Petitioner is currently providing long-term care
and nursing services to the Alleged Incapacitated Person. Petitioner has a statutory and
contractual obligation to act in the best interests ofthe Alleged Incapacitated Person.
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4. The Alleged Incapacitated Person was admitted to Shippensburg on April 14, 2006. Her
prior residence was 48 Tiffany Drive, Shippensburg, P A 17257.
5. The Alleged Incapacitated Person is diagnosed with Vascular Dementia with Delusions;
Congestive Heart Failure; Type II Diabetes; Gastrointestinal Bleeding, and Chronic
Obstructive Pulmonary Disease.
6. To the best of our knowledge, information and belief, the Alleged Incapacitated Person
has never served in the Armed Forces of the United States of America.
7. The Alleged Incapacitated Person does not generally comprehend her surroundings to
such an extent that she requires consistent supervision in her activities of daily living.
8. The Alleged Incapacitated Person is incapable of handling her personal affairs, however
minor, and if called upon to grant informed consent to any medical procedure she would
be unable to grant it because of her inability to comprehend the nature of the procedure.
Additional information is set forth in the competency affidavit, prepared by her treating
physician Dr. Yogimdra Balhara, 761 Fifth Avenue, Chambersburg, Pennsylvania 17201
and incorporated by reference attached hereto, and marked Exhibit "A."
9. The Alleged Incapacitated Person is not expected to recover from her current condition to
become sufficiently independent to return to the community.
10. After reasonable investigation Petitioner has determined that the Alleged Incapacitated
Person has the following next of kin and interested parties:
Brian Nead (son)
1318 Wilson Ave.
Chambersburg, P A 17201
Pastor Dannie Keen (Power of Attorney)
P.O. Box 85
St. Thomas, P A 17852
11. After reasonable investigation, Petitioner has found that Dannie Keen is willing to act as
Guardian for the Alleged Incapacitated Person.
12. The Alleged Incapacitated Person has no known assets.
13. The Alleged Incapacitated Person receives Social Security income of $1 ,225.00 a month
which is applied to the expenses of her monthly care.
14. Petitioner requests the Guardian be assigned the following powers below described:
A. Making Medical decisions, which would include but not be limited to:
1. medication, antibiotics, hydration, tube feeding, respirator use;
11. situations related to the active dying process;
111. hospice selections;
IV. selecting or replacing the attending physician;
v. skilled care and acute care placement;
B. Maintaining order in the financial affairs of the alleged incapacitated person
which would include but not be limited to:
VI. establishing the Guardianship bank account;
V11. marshalling the Respondents assets;
Vlll. paying bills for the incapacitated person, including bills for nursing care
and services;
IX. making bank deposits;
x. writing checks for expenses;
Xl. performing all other acts necessary to avoid waste with respect to the
assets of the incapacitated person.
15. Petitioner knows of no available less restrictive alternative to the establishment of a
Permanent Guardian of the Person and Estate of the Alleged Incapacitated Person.
16. The Proposed Guardian is Dannie L. Keen, P. O. Box 85, St. Thomas, Pennsylvania
17252.
17. Dannie L. Keen has no interest adverse to the Alleged Incapacitated Person, has agreed to
act as Guardian of her Person and Estate if this Court shall so appoint. The executed
Consent of the Proposed Guardian is attached to this Petition as Exhibit "B".
18. Neither Petitioner, nor Proposed Guardian, is related to the Alleged Incapacitated Person
nor does either have an interest in the estate of same.
19. The Alleged Incapacitated Person completed an Advanced Health Care Directive naming
Dannie L. Keen as the Proxy for making health care decisions. A copy of the Advanced
Directive is attached as Exhibit "C."
20. The Alleged Incapacitated Person executed a Limited Power of Attorney listing Dannie
L. Keen as the Attorney-In-Fact. The named Attorney-In-Fact has only the power to
discuss the Alleged Incapacitate Person's medical, physical, and psychological conditions
with any and all Doctors and medical staff. The Limited Power of Attorney is attached to
this Petition as Exhibit "D."
21. The Limited Power of Attorney provides no authority for the Attorney-In-Fact to manage
the financial affairs of or make medical decisions for the Alleged Incapacitated Person.
The existing Power of Attorney was for the limited purpose of discussing medical,
physical, and psychological conditions with Doctors and medical staff and does not
provide for access to or management of any financial information.
22. The Cumberland County Assistance Office requires financial information to accurately
determine whether the Alleged Incapacitated Person is eligible for Medical Assistance.
23. An application for Medical Assistance benefits was filed on behalf of the Alleged
Incapacitated Person.
24. A new application for Medical Assistance benefits is pending appeal for Donna L. Nead.
25. If appointed by this Honorable Court, the Guardian will act in compliance with
regulations promulgated under Court Order in Pennsylvania Bulletin 931, et seq., April
19, 1975.
26.20 Pa.C.S.A. g5515 states "... provisions relating to a guardian of an incapacitated
person and her surety shall be the same as are set forth in the following provisions of this
title relating to a personal representative or a guardian of a minor and their sureties:..."
Section 5122 (relating to when bond not required).
27. 20 Pa.C.S.A. g5122 (d) states "in all other cases, the court may dispense with the
requirement of a bond when, for cause shown, it finds that no bond is necessary."
WHEREFORE, Petitioner respectfully requests this Honorable Court to:
1. Award a Citation directed to DONNA L. NEAD and others as the Court sees fit to show
cause why DONNA L. NEAD should not be declared an incapacitated person and why a
Permanent Guardian of her Person and Estate should not be appointed;
2. Appoint Dannie L. Keen as Permanent Guardian of the Person and Estate of DONNA L.
NEAD.
3. Dispense with the requirement that the Proposed Guardian obtain a bond.
Respectfully submitted,
CAPOZZI AND ASSOCIATES, P.C.
Date:
1/16/01
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DOUgl~~' ~:rre5~
Attorney ID No.: 204384
2933 North Front Street
Harrisburg, PAl 711 0
(717) 233- 4101
Attorneys for Petitioner
IN THE COURT OF COMMON PLEAS CUMBERLAND COU
INRE:
) ORPHANS' COURT DIVISION
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN OF
) THE PERSON AND ESTATE
)
DONNA L. NEAD,
AN ALLEGED
INCAP ACIT A TED PERSON.
I,
VERIFICA TION
5~e.~'1 i\. DCvNVJ \\ , am
an authorized representative of
Shippensburg Health Care Center, and I do hereby depose and state that the facts contained in
the foregoing Petition are true and correct to the best of my knowledge, information and belief. I
understand that false statements made herein are subject to the penalties of 18 Pa.C.S.A. Section
4094, relating to unsworn falsification to authorities.
Date:
(. \ \;,~ 01
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IN THE COURT OF COMMON PLEAS OF CUMBERLAN
ORPHAN'S COURT DIVISIO
15 ~~~O~~ ~
n J U L 1 6 2007
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[ COUNTY, PENNSYLVANIA
It
IN THE MATTER OF DONNA L. NEAD, :
an Alleged Incapacitated Person : No.
: Petition for the Appointment of a Permanent
: Guardian of the Person and Estate
Affidavit of Dr. YOQindra Balhara in Support of Petition to
Adiudicate DONNA L. NEAD, an AlleQed Incapacitated Person
1. My name is Dr. Yogindra Balhara.
2. My occupation is as a physician.
3. My business address is 761 Fifth Ave, Chambersburg, PA 17201
4. My educational background is as follows:
a. State Medicall Graduate School
MedAW~ RoHTf!'<-l '" DI-t9{'I1P-fYJ/~I(7'Olli ~T. LIS/)
u Q)fI/ ~ fk'TH cerv 7'/26' /
b. State Undergraduate 1\/ _
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5. I am licensed by the State of Pennsylvania as M.D.
6. I specialize in !JnA~ ~(~
7.
I am affiliated with Shippensburg Health Care Center
8.
10.
1 last met with DONNA L. NEAD on
I have been affiliated with Shippensburg Health Care Center., since
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I first met DONNA L. NEAD in !.f ler /06 '
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9.
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1 last reviewed DONNA L. NEAD's chart on
12.
EXHIBIT
A
DONNA L. NEAD's pertinent diagnoses are:
Vt4~ ~ ~ ~~ 'fUT DM~ Coff). CIJ-/ etll1 GJ'J-IJ.CE(2:f)/
HJ-~~~ / fJ-T~ e 12-( 'IVS r ~ nil ~ ~t\1 J!t,pf~ ~-Pe-Py jJj.
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22,
23.
24.
13. DONNA L. NEAD currently takes the medications on the list attached to this Affidavit.
15.
good fair ~
DONNA L. NEAD's prognosis is:
16,
The extent of DONNA L. NEAD's ab~T . ommunicate is as follows:
a, Verbally good fair
b. In Writing good fair oor
c, Other Means good fair poor
17.
The extent of DONNA L. NEAD's abilit to receive information is as follows:
a. Reading: good fair 0
b. Hearing: good fair poor
18.
DONNA L. NEAD is capable of independently performing ONLY the following activities of daily
living. (Circle all applicable) ~.. 1'7 _" )
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6) Eating. (()..). J-eu:?> ~ W.. '"hO~ A>r-' r~ ' p ~1' .
"l( Groommg
c. T oileting
d. Transferring
e. Taking medications
19.
DONNA L. NEAD has emotional limitations in the form of:
20.
DONNA L. NEAD iS~~ABteto interact socially on any meaningfulleve!.
If ABLE, then please describe: ....
DONNA L. NEAD does not generally comprehend her surroundings to such an extent that he
requires consistent supervision in her activities of daily living. As a result of her condition, she
requires specific one-on-one assistance with taking medications. She absolutely could not
manage any of her own activities of daily living without supervision or assistance.
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DONNA L. NEAD~capable of handling her personal affairs, however minor. ~
requires total assistance in these areas. l!JF
DONNA L. NEAD, if called upon to grant informed consent to any medical procedure, however
minor or straightforward, would be unable grant it because of her inability to compreh~the
nature of the procedure. UIF
DONNA L. NEAD absolutely cannot actively and effectively participate in monitoring and
managing her own medical care and medication. He requires supervision in this areaC5f
27.
28.
29.
30.
25.
DONNA L. NEAD's limitations relevant to this guardianship proceeding are not likely to
improve neither in the immediate future nor over time. To the extent relevant change ~ely,
it will be, in my opinion, expressed with reasonable medical certainty, for the worse. (JlF
26.
I have been made aware of the statutory definition of "incapacitated person" under ,::>r.
Pennsylvania law. \J'r
My opinion, based on my examinations of DONNA L. NEAD and my review of her medical
records, expressed with reasonable medical certainty, is that DONNA L. NEAD is tota!Jh
incapacitated as to matters affecting her person. l!fr
Based on the opinions that I have expressed, my opinion, expressed with reasonable medical
certainty, is that DONNA L. NEAD requires the appointment of a guardian of her pers(j}
My opinion is that DONNA L. NEAD could possibly be harmed if he were required to attend her
guardianship hearing, however, I feel this point is moot because DONNA L. NEAD would not
be able to contribute in any way to the hearing. (f/F
My opinion is that DONNA L. NEAD would not understand nor benefit from participation in a
court hearing regarding a determination of her capacity to handle her own personal a~
financial affairs. VIr
I, Dr. Yogindra Balhara, being duly sworn according to law deposes and says that I make this
Affidavit on behalf of Donna L. Nead and that the facts set forth in the foregoing Affidavit are true and
correct to the best of my knowledge, information, and belief.
I verify that the statements in this Affidavit are true and correct. I understand that false statements
herein are made subject to the penalties of 18 Pa.C.S.A. S 4904 relating to unsworn falsification to
authorities.
Date: 1-lih)9 '
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Dr. Yogindra Balhara
Sworn to and subscribed before me this q A day of J 0 '}-
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NO. Public
My Commission Expires:
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NOTARIAL SEAL
LAXMIKANT J. MODHA
CHAMBERSBURG ' NOTARY PUBLIC
MY COMMISSION ~RA'IR NKUN COUNTY
.....".. ES JUNE 27, 2009
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IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
IN THE MATTER OF DONNA L. NEAD,
an Alleged Incapacitated Person No.
: Petition for the Appointment of a Permanent
: Guardian of the Person and Estate
Medication list pursuant to paragraph 13 of the foregoing Affidavit of Dr. YOQindra Balhara
Supporting the Petition to Adjudicate DONNA L. NEAD an Alleged Incapacitated Person.
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IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA
INRE:
) ORPHANS' COURT DIVISION
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN OF
) THE PERSON AND EST A TE
)
DONNA L. NEAD,
AN ALLEGED
INCAPACITATED PERSON.
CONSENT OF THE PROPOSED GUARDIAN
I, Dannie L. Keen, am the pastor and Limited Power of Attorney for Donna L. Nead, and
do hereby certify that I am willing to act as the Permanent Guardian of the Person and Estate of
Donna L. Nead, if the Court shall so appoint me.
Further, I do hereby certify that I am not a fiduciary of any estate in which the alleged
incapacitated person has an interest, nor have I any interest adverse to the alleged incapacitated
person.
The facts and opinions contained herein are true and correct to the best of my knowledge,
information and belief.
~ /~ 'f/D7
Date
~MMdNw!N.m~rn~k1fxRl1Pe this
NOTARIAL SEAL
JENNIFER KAIN, Notary Public
Eut Pemsboro Twp., Cumbert.Id Ccuiy
My Comm,~sslon _~,~plr:~ Oct. 7, 2009
,2007.
My Commission Expires:
f)~ 7-/ 2/)0 CJ'
TI ~~~D"re ~
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JUN 26 2007
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EXHIBIT
j B
SHIPPENSBURG HEALTH CARE CENTER
MEDICAL CARE GUIDELINES
To my family, my friends, my physician and
all others who may be interested.
I, ~ fJ.u.o{
. request. that I . be . fully informed of my medical
condition. Whenever possible I want to participate in
. decisions regarding my medical treatment, including
whetheJ;any measure should be taken to prolong my
life: If my physicians deternline that I am incapable
. of making my own. health care decisions, this
directive shoUld be used to ascertain my decisions.
. , . In the event my physicians determine, to a
reasonable degree of medical certainty, that I have a
terminal ,condition or that 1 am permanently
unconscious, I direct that I not be provided medical
treatment which will serve only to prolong my dying
orconUnue my unconscious state. In such an event, I
do . want ,those. measures which will keep me
comfortable and relieve pain, even if they will render
me unconscious or hasten my death.
I . Specifically. do,
following treatment:
I~do
or do not, want the
do not want resuscitation.
. I _ do'b... do not want mechanical respiration.
I ~ do _ do not want tnbe feeding or any other
artificial or inYasive. form of nutrition (food) or
hydration (water).
I ~ do _ do not want blood or blood products.
I i do _ do not want kidney dialysis.
I i do _ do not want antibiotics.
I ~ do _ do not want to be transferred to a
hospital if my medical condition(s) cannot be treated
in the nursing facility.
I realize that if I do not specifically indicate my
preference regarding any of the forms of treatment
listed above, I may receive that form of treatment
Other instructions:
This directive was made after careful consideration
and is in accordance with my strong convictions and
beliefs. I want the directions followed to the extent
permitted by law. I release from. legal liability all
persons and entities ,involvedJncanying out of. the
directions . wel direct my' legal' representative( s) to
honor this release.
Proxy Designation Clause (Optional)
Irr.the:event:rI lose: capayity to' ni~e;'health
care decisions, I authorize the;.foIlowing"persons to
make those. decisions. orr ~my behalf 'iru,.acg~rdallce
with this directive,. giving priority in the order. listed:
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1. Name: .,.."...~t
Address:
p~~
Phone:_
2. Name:
Address:
~IPIN N~
Phone:
Sig1>'<l)L j;j~~ f. ~
Date:
Witnessx0"'^~ ~ Jljft... ~e-A
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EXHIBIT
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limited Power of Attorney
(with Durable Provision)
............................................................................................................................................................
NOTICE: THIS IS AN IMPORTANT DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW
THESE IMPORTANT FACTS. THE PURPOSE OF THIS POWER OF ATIORNEY IS TO GIVE THE PERSON WHOM
YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO PLEDGE, SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT
ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. YOU MAY SPECIFY THAT THESE POWERS WILL EXIST
EVEN AFTER YOU BECOME DISABLED, INCAPACITATED OR INCOMPETENT. THIS DOCUMENT DOES NOT
AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS FOR YOU. IF THERE IS
ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN
IT TO YOU. YOU MAY REVOKE THIS POWER OF ATIORNEY IF YOU'LATER WISH TO DO SO.
TO ALL PER ONS. be it nown, that I, Po}.l N.,A L ~
of ~ I AIV . .J 1 E' J 72 )'1
as Princi do hereby make a a grant a limited and specific power of a orne to
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of
and appoint and constitute s Id individual as my attorney-in-fact.
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The authority granted shall include such incidental acts as are reasonably required or necessary to carry out and perform the
specific authorities and duties stated or contemplated herein.
My attorney-in-fact agrees to accept this appointment subject to its terms, and agrees to act and perform in said fiduciary
capacity consistent with my best interests as my attorney-in-fact deems advis,,!:lle, and I thereupon ratify all acts so carried out.
I agree to reimburse my attorney-in-fact all reasonable costs and expenses inr med in the fulfillment of the duties and responsi-
bilities enumerated herein.
Special durable provisions:
This power of attorney shall not be affected by subsequent incapacity of the Principal. This power of attorney may be revoked by
the Principal giving written notice of revocation to the attorney-in-fact, provided that any party relying in good faith upon this
power of attorney shall be protected unless and until said party has either a) actual or constructive notice of revocation, or b)
upon recording of said revocation in the public records where the Principal resides. rurthermore, upon a finding of incompetence
by a court of appropriate jurisdiction, this Power of Attorney shall be irrevocable until such a time as said court determines that I
am no longer incompetent.
Otherterms: fJ,is ~;f; m~ ;)~tt; jV 1!f cl~ J
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EXHIBIT
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Signed under seal this / tJ day of
Signed in the presence of:
Witness: ~~H:~
WItness: _ _ _
(7P1! II.. ~oot .
Prindpal f}~ :J;fM
State of
County of
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On before me,
appeared
personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed
to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity. and that by
his/her signature on the instrument the person. or the entity upon behalf of which the person acted, executed th~ instrument.
WITNESS my hand and official seal.
Signature:
Affiant_Known_Produced ID
Type of ID
(Seal)
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C 2004, Socrale~ Media. llC
lF240-1 . Rev. 04/04