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HomeMy WebLinkAbout03-0057JAN 2 2_ 003 IN RE: JEANNE R. KELLY · IN THE COURT OF COMMON PLEAS · CUMBERLAND CO., PENNSYLVANIA · ORPHANS' COURT DIVISION PRELIMINARY DECREE c~~'- day of "~ ,2003, upon consideration of AND NOW, this the attached Petition, IT IS ORDERED that a Citation be awarded and directed to be served personally on Jeanne R. Kelly, the alleged incapacitated person to show cause why she should not be adjudged an incapacitated person and why Kathleen M. Cleveland should not be appointed as the Plenary Guardian of her Estate and Person. A Hearing will be held on %.,~~ /._,R , 2003 at ///-'O~ /~./V/, in Courtroom ~. Jeanne R. Kelly has--the right to request the appointment of counsel and the right to have such counsel paid for if it cannot be afforded. IN RE: JEANNE R. KELLY · IN THE COURT OF COMMON PLEAS · CUMBERLAND CO., PENNSYLVANIA · ORPHANS' COURT DIVISION PETITION TO ADJUDGE JEANNE R. KELLY AN INCAPACITATED PERSON AND TO APPOINT A PLENARY GUARDIAN FOR HER ESTATE AND PERSON AND NOW, comes the Petitioner, Kathleen M. Cleveland, through her attorneys, Purcell, Krug & Hailer and files the following Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person and avers the following: 1. Petitioner is Kathleen M. Cleveland, an adult individual with a current address of 2231 North Third Street, Harrisburg, Pennsylvania 17110. 2. The alleged incapacitated person is Jeanne R. Kelly ("Jeanne"), who was born on November 21, 1957 and is forty-five years of age. 3. Petitioner is the only sister of Jeanne. 4. Jeanne is currently a resident at Keystone Residence located at 6 South Road, Mechanicsburg, Pennsylvania 17050, having been admitted to Keystone Residence in June of 2002. Attached here to and marked Exhibit "A" are true and correct copies of the Personal Support Plan for Jeanne prepared by Keystone Residence in September of 2002. 5. Prior to Jeanne's admittance at Keystone Residence, she had resided her entire life with her Mother, Rosemary C. Kelly at 302 Manchester Road, Camp Hill, Pennsylvania 17011. 6. Jeanne's Mother died on March 24, 2002 and between the date of her Mother's death and her admittance to Keystone Residence, Petitioner moved to 302 Manchester Road to live with Jeanne. 7. Jeanne is single, has no issue and her only presumptive natural kin/adult heirs are Petitioner and their brother, Patrick M. Kelly, who resides at 218 Swarthmore Drive, Lititz, Pennsylvania 17543. 8. Jeanne's gross Estate presently consists of a Members 1st Checking Account No. 216683, with a balance of approximately $625.00, a Members 1st Savings Account No. 216683, with a balance of approximately $300.00, and twenty-one shares of common stock with Metropolitan Life, worth $569.10 as of November 8, 2002. 10. three months. 11. 9. Jeanne is one of three residuary beneficiaries who will share equally with her two siblings in the Estate of her Mother, Rosemary C. Kelly. It is anticipated that Jeanne's one-third share will be approximately $25,000.00. Distribution of the Estate of Rosemary C. Kelly is not anticipated to occur for another Jeanne's net monthly income from all sources is $557.00 in Supplemental Social Security and approximately $60.00 per month from her employment through the S. Wilson Pollack Center for Industrial Training. Petitioner currently serves as Jeanne's representative payee for her Supplemental Social 12. Security. 13. 14. Jeanne was never a member of the Armed Services of the United States. Jeanne has been diagnosed with mild mental retardation/Down's Syndrome, with additional significant brain dysfunction in the area of auditory processing and expression and has a full scale IQ of 54. Attached hereto and marked "B" is a May 27, 1994 Psychological Evaluation performed by Guidance Associates of Pennsylvania regarding Jeanne's mental capacity and condition. 15. Jeanne is unable to reside on her own, requires twenty-four hour supervision and guidance, and needs assistance with her finances. 16. Petitioner proposes to serve as the Plenary Guardian of the Person and Estate for her sister, Jeanne, and has consented to serve in that capacity. Attached hereto and marked Exhibit "C" is an original Consent signed by Petitioner. 17. Jeanne's only other presumptive natural kin is her brother, Patrick M. Kelly, who has also consented to Petitioner serving as the Plenary Guardian of the Person and Estate for their sister, Jeanne. Attached hereto and marked Exhibit "D" is the original Consent signed by Patrick M. Kelly. 18. Petitioner, as the proposed Plenary Guardian, has no interest adverse to Jeanne, the alleged incapacitated person. 19. No other Court has ever assumed jurisdiction in any proceeding to determine the capacity or competency of Jeanne. 20. Jeanne currently has no Guardian of the Person or Guardian of the Estate appointed. 21. Copies of this Petition will be served by regular mail on Patrick M. Kelly and Keystone Residence. WHEREFORE, Petitioner respectfully requests this Honorable Court to enter a Citation, directed to the alleged Incapacitated Person, Jeanne R. Kelly, and to such other persons as the Court may direct, to show cause why Jeanne R. Kelly should not be adjudged an Incapacitated Person and her sister, Kathleen M. Cleveland appointed as the Plenary Guardian of her Person and Estate. Respectfully submitted, Dated: ilzl (clients\cleveland\petition) Jill IV~Wineka, Esquire Atto~ey ID# 58802 Purcell, Krug & Hailer 1719 North Front Street Harrisburg, PA 17102 (717) 234-4178 Attorneys for Plaintiff 0CT-17-2882 18:11 EMPIRE MEDICARE SUS 717 565 3436 P.82/32 KEYSTONE RES!DF NCE ill f4n Agency of KEYSTONE HUMAN SERVICES TO: FROM: RE: DATE: The Interdisciplinary Team Jeanne Kelly & Nancy Hoke Personal Support Plan 9/30/02 Jeannie and I are sending you the enclosed copy of her Personal Support Plan meeting, as well as her assessment. Please rev/ew them to make sure that we captured all of what was discussed and planned for at the meeting. If you find any corrections or have any questions, please call Nancy Hoke. We thank you for your participation. 940 East Park Drive, Suite 100, Harr~burg, PA 17111 · 71%541-8322 · Fax 717-541-4354 · www. kss.org PERSONAL SUPPORT PLAN .leanne R. Kelly 9/4/02 Personal History: .leanne was born premature in Harrisburg Hospital on 11/21/57. Her lungs were slightly underdeveloped and she was hospitalized for a period of time before going home to live with her parents and siblings at 302 Manchester Road in Camp Hill. Within the first year of her life, she was hospitalized again with pneumonia. Tn her early years, it was noticed that she was not developing as fast as her peers but she did learn to walk by the age of three as 'well as gaining some independence in Self-help skills. When 3eanne was six or seven, she used to slip away from the hoUse and go to the nearby Weis market to "shop". In 1969, she lost her father but throughout her life, she enjoyed living with an extended family. Her Uncle Jim and Grandfather (Pop-pop) from her mother's side of the family lived with her and her sister Kathe (Kathleen) and brother Pat. Jeanne began to attend school around the age of 7 in a UCP sponsored program, then later attended Capltal Area Intermediate Unit classes in a church in Wormleysburg. Upon graduating at age 21, she began to work at C.I.T. (Center for :Industrial Training). First working in offsite jobs like Elby's Big Boy and then The Embers fixing salads, filling water pitchers, set tables and similar tasks. When the offsite jobs were discontinued, Jeanne began to work in the workshop with packaging, labeling and sealing jobs. She says she likes her job, mentioning labels most often and doesn't like to miss work for meetings or appointments. During her early adulthood she attended social activities at Aurora Club, which included dinner at various restaurants, picnics, dances, bowling, museums and other local attractions. She also enjoyed vacations with her mother, sister and niece ,at the shore in Wildwood and in the Poconos. Jeanne has expressed interest in pursuing these types of activities again. Tn .1992, .leanne showed signs of possible depression in a loss of interest in past'activities, was more quiet, crying, confused, wandering around talking to herself, and had disrupted eating and sleeping patterns. She had periods of decreased work and confusion at C.I.T. as well. She was evaluated at Hershey Medical Center in 1993 and !,994. At the time of the evaluations the symptoms had resolved but she was referred for psychiatric services at Behavioral Health next to Holy Spirit Hospital. She continues her medication treatment there at this time. Kathe noted that some of the behaviors Jeanne displays Increased as her mother's hearing and ability to get out in to the community decreased, l~n July 2002, she began to show confusion, difficulty keeping her balance, leaning to the left for a couple days and was evaluated for a possible stroke. Medical testing and exams were normal and she has since recovered, but consults and testing continue to try and determine the nature of the problem. On 3/24/02, Rosemary Kelly passed away and Kathe stayed with Jeanne in the house on Manchester Road. Kathe wanted _Jeanne to have the security of the only place she had ever lived until she found a new home. Jeanne visited two other supported residentla] places but did not want to stay at them. Then she came to look at the house at 6 South Road and arranged a time to visit. On 6/2'i/02, Jeanne came to South Road for a trial overnight visit and when Kathe came to pick her up on Saturday, she asked to stay. Her visit was extended until her admission on 7/:1.6/02. ~leanne says she likes her new home and seems to be feeling more comfortable over time. She likes to 'watch movies with her housemate, offers her help with household chores and is enjoying her back yard. Tn the community she often asks to go out for shrimp at Red Lobster and grocery shop. At home and C.I.T. she likes to follow a familiar routine and sometimes needs direction on what to do when she needs to wait for help or to use the bathroom. Jeanne mentions that she misses her Mom and will express this with brief periods of crying. Most of the time, she is happy, Interacts with others and takes an increasing part in the care and use of her home and resources. Jeanne also looks forward to visits with her Sister and family, whom she sees frequently. She seems to prefer to be called 3eannie, as her famlly'has always done. Jeanne's participation in developing this plan: Jeanne talked with the Treatment Specialist before her meeting and communicates most of her wants and needs on a daily basis, During her meeting she responded to questions and smiled at remembrances of her life. Likes/ Dislikes/Preferences: JEANNE'S ITKES JEANNE'S DISI TKES Spending time with Kathe and family Chocolate Working at CZT - "labels" Movie videos such as Greaser Ghost Busters Pink as her favorite color Musicr dancing Going out to eat Shopping, groceries and other thinqs Sleeping in on the weekends Sitting outside to watch people and traffic Attending mass with family Predictable routine for daily activities Helping with her things and around the house Hovies at the theater Foods - hot dogs, Shrimp, peanut butter, bal~gna and cheese, snack cakes, eggs, ~acon~ sausage, pizza and soda Helping water flowers in the back yard/red .tulips, to plant Hissing work Chan~]es in her routine The Italian dressing on Olive Garden salads Stairs~ u,neven surfaces or changes in color Walkinq long distances Cats~ unfamiliar doqs Lying on exam table at doctors Choices and how 3eanne makes choices: Jeanne will ask for things that she wants or needs and can usually be understood. She can answer yes/no questions reliably when she understands the question. She will sometimes give a response that she thinks is right if she is not sure of the meaning. Jeanne does not always enunciate her words and if you repeat what you think she said Incorrectly, she usually indicates this by looking down, saying no or giggling a little. JEANNE CHOOSES CHOICES MADE BY OTHERS What clothes to wear What doctors to see Where to live Financial decisions What to eat what to do with her leisure time -TV, movie... Where to go to eat~ shop or other activity To work at C.I.T. When to go to bed When to ,get up in the morning What bulbs to plant in the back yard Transportation to work 2 0CT-17-2002 18:12 EMPIRE MEDICARE SUS 717 565 34~6 P.05×32 Relationships: -- NAME '" ADDRESS PHONE ,. COMMENTS Kathe Cleveland~ sister 223:1 N 3~ Street H = 238~3156 Calls her brother-in- Robert Cleveland, B-I-L Harrisburg, PA 17110-18:14 law "Tommy" and Tyra . . niece Rosie Bascelli, cousin 325 Edgewood Ave (6:10)586-707~ Fol..s.o.mr. P.A 19033-,2419 aoberta Cleveland,. S-I-L 1605 North 2nd Street Hb.q.¢ PA :171:10 ... -]eanne'[~uchllt~r, cousin The Villages of Lady Lake (352)753-7840 212 Palermo Place Lady Laker FL 32159 Pat Kelly, brother 218 Swarthmore Drive ..... 626-:144:1 usually see him at Lititz~ PA 17543 holiday dinners Betty Clark, friend 304 Manchester Street 76:1-4446 neighbor where she .... Camp Hillt PA 1701:1 used to live Community Presence: NAME OF. P .LACE ADDRES.$ PHONE COMMENTS Rite Aid Pharmacy Windsor Park Plaza 766-2533 Wherb I~rescriptions are filled Mechanicsburg~ PA 17055 Giant Foods Simpson Ferry Rd Grocery shOpping is done at Giant Mechanicsburgt, PA 17055 Red,, ,L,°bster Silver Springs Commons ., Loves to eat here 'shrimp" Rascals Likes to eat here Nicl~s .... " 'Lik,.es to eat here What ! want my life to be like: To keep working at C.I.T. To spend time with family To stay at South Road To continue activities she enjoys (shop, out to eat, movies, etc.) To have vacations like the shore To do crafts (latch hook, painting, etc.) To have activities like Aurora Club again To explore other activities (puzzles, photo album, Uno, etc.) To consider joining a church (Catholic mass) Action Plans: Date General Area Specific Action ....... Completion Implemented date Self-Medication 3ear~'~e will learn the name of her medications (Prozac/Synthroid) and the reason for their use. 0£T-27-2082 20:22 EMPIRE MEDICARE SUS 717 565 3436 P.06/32 Support Plans: Plan for Community Involvement - This plan helps her explore and become a participating member of her community. Plan for Self-Medication - This plan is In place to assist in learning about her medications and how to take them. Financial Plan - This plan. is in place to ensure that her financial needs are met. Plan for Dental Hygiene - This plan is in place to help maintain good oral hygiene. SEEN - This plan supports her Social, Emotional and Environmental Needs. Team Recommendations: > Geriatric Evaluation and follow up on medical appointments related to medical problems In .~uly. 0CT-17-2082 10:12 EMPIRE MEDICARE SUS 717 565 3436 P.09/32 Dental Hygiene Plan Jeanne KellY Current LeVel of Performance: Jeanne is able to prepare her brush though she sometimes needs help with the cap on the toothpaste. She is also able to start brushing her teeth, but needs physical assistance to brush completely. Jeanne also needs reassurance at dental appointments and verbal prompts to follow directions from the dentist or hygienist, A~ssistance to be Provided: Support Staff will assist Jeannie as needed for brushing her teeth. She will have her teeth brushed at least twice a day for 2 minutes with a soft bristle brush. Jeannie will visit the dentist biannually, or annually as recommended by the dentist. Completed by Nancy Hoke Treatment Specialist September 4, 2002 0CT-17-2002 10:12 EMPIRE MEDICARE SUS 717 565 ~436 P.08/32 Self-Medication Plan Jeanne Kelly Current Level of Performance: Jeannie is cooperative with taking her medications. Support staff pour the medication and she will put the pills in her mouth and take them with a drink. She does not consistently identify her medications or state the reason that she takes them. Assistance to be Provided: Support staff will order medications for Jeannie as needed. Support staff will administer medications to Jeannie, along with her current level of ability. Support staff will report related information to her doctors, as needed. Support staff will explain to Jeannie what medications she is taking at the time that she takes them, and encourage her to participate in the entire process as much as she is able. Completed by Nancy Hoke Treatment Specialist September 4, 2002 0CT-17-2082 10:12 EMPIRE MEDICARE SUS ?!? 565 3436 P.09/32 Plan for Community Involvement Jeanne Kelly Current Level of Performance: ]eannle's favorite acUvlties are going out to eat and shopping. She is able to express where she wants to go, what to buy, what she wants to eat and other preferences when out. She seems to be open to trying new things and returning to some previous actlvities such as vacations and Aurora Club. Assistance to be Provided: It is the purpose of the team to provide as much opportunity for community involvement as ]eannie would like. She will be assisted in participating in at least two activities of her choice per month, and offered more opportunities as available. General support from all employees will come in the form of Informing her of opportunities, money management, transportation and assisting in scheduling activities as well as support staff to accompany ]eannie into her community, Support staff will Introduce ]eannie to others and encourage interaction. In the event that ]eannie develops friendships, support staff will sustain the development and preservation of these friendships. Support persons will encourage the inv~tal:lon of others and help ]eannie arrange activities with her friends. The Treatment Spedallst will monitor the Implemen[atJon of ]eannle's community involvement plan, in coordination with her teaching plans when applicable. The Treatment Specialist will communicate with the Program Director any needs or revisions. The Treatment Specialist will review the plan on a quarterly basis and make revisions as needed. Progress will be documented In the daily log, community log and in Quarterly Review reports. Nancy Hoke Treatment Specialist September 4~ 2002 0CT-17-2882 10:12 EMPIRE MEDICARE SUS ?i? 565 3436 P.10/32 Financial Plan Jeanne Kelly Current Level_of_Performance: Jeannie requires assiStance with all steps of money management. She can identify quarters and the difference between coins and bills consistently. She needs assistance to budget her money, give sufficient cash to purchase items and receive change. Assistance to be Provided: Jeannie will be present for lock box and banking transactions. Support staff will assist her with all financial transactions - banking, spending, maintaining lock box, and financial records. Jeannie's sister Kathe is her representative payee. Completed by Nancy Hoke Treatment Specialist September 4, 2002 0CT-17-2802 10:12 EMPIRE MEDICARE SUS 717 565 ~436 P.11/32 Jeanne Rosemary Kelly 6 South Road Mechanicsburg, PA 17050 (717) 791-9803 Keystone Residence, Inc bOB: 1i121/5~. SS# 194-42-8362 Access # 0028968451 Medicare# 197-22-5464C1 Lifetime Medical Primary Physician: Dentist: History Dr. Ira Packman Internists of Central PA 108 bowther St. Lemoyne, PA 17043 (717) 774-1366 Dr. Kalp 7 Chambersburg 51. Gettysburg, PA 17325 (717) 339-0880 OVERVIEW: Jeanne is a 44 year-old Caucasian woman with a Mild Developmental Disability and Dawn's Syndrome. 5he is able to bathe and dress with minimal assistance ~nd eats independently. Jeanne likes to watch musical movies, do crofts in her leisure time, and enjoys being with her sister and family. 5he shares her home with two other women, and works C.I.T. five days a week. DEVELOPMENTAL INFORMATION: Jeanne was born premature in Harrisburg Hospital after a normal pregnancy. Her lungs were slightly underdeveloped and she wa~ hospitalized for a period of time before going home. Within the first year of her life, she w~s hospitalized again with pneumonia. In her early years, it was noticed that she w~ not developing as fast as her peers were, but she did learn to walk by the age of three and gained some independence in self-help skills. Jeanne's sister, Kothe, reported that as children, they oil had Chicken Pox, Measles and Mumps. FAMILY/SOCIAL HISTORY: Jeanne grew up and lived in the same house in Comp Hill since birth, with her father (until 1969), mother, Rosemary Kelly, sister Kathleen and brother Patrick. When Rosemary passed away on 3/24/02, Kathleen moved into the house in Camp Hill and stayed with Jeanne until she chose a new place to live. On 6/21/02, ,Teanne had an overnight visit at South Road and when Kathleen came to pick her up she asked to stay. 5he has been living here since that day. Family medical history shows that her father died from lung cancer and was a smoker. Jeanne's mother had glauComa, cataracts and hypothyroidism. Her sister has high blood Pressure end arthritis. PAST MEDICAL HISTORY: Vision: History of 'depth perception problems and poor vision, wears corrective lenses. Hearing: Assessed by physician to be within normal limits. Respiratory: 1988. hospitalized for pneumonia, colds tend to effect her lungs. Cardiovascular: Has had high cholesterol but hc~ always had great blood pressure. July~August of 2002, showing symptomS of unsteady balance, leaning to the left when standing sit-ting or walking, sleepiness end confusion. 8/02, a chorotid test, echocordiogram and CT scan were done to evaluate for a possible stroke, wi'th normal results. She was placed on one Aspirin o day, which was changed to Ecotrin to reduce stomach irritation. 0CT-17-2002 10:12 EMPIRE MEDICARE SUS ?19 565 ~436 P.12×32 Digestive: Diagnosed with Irritoble Bowel Syndrome in the lost f~w years and was odmitted to Keystone with daily antidiarrhenl. It hoc never been fro~ a consistent food ~nd reported by ~i~¢er that ~ome of ~he diarrhea ~he h~d previously had could have been related ~o ~poiled food. ~/02, ~t~r¢~d on ~Jtruc~l for I~, Prevacid ~o prevent ~xc~s acid but no diet restrictions. Nervous System: No known problems ~usculoskelet~l: No known problems Genito-Urin~; P~p and pelvic I~f completed 3/00, mcmmogram 12/00, normal results. Endocrine/Lymphatic: At approximately age four, she had appendicitis. Her tonsils ~re inta~. Cue~ent]y h~ a Hypothyroid condition and takes 5ynthroid. ZntegumentaW: Minor d~ skin that responds to body lotions. Dental: Few cavifi~, possibly 3 or 4 in her life, good oral hygiene. P~chiatric/Behavioral: ~eanne is reported fo have a history of talking to an im~gina~ friend whom she h~ been known to call M~rk. 2/93, she was ewluated af Guidance Association of PA who reported fh~¢ a major depr~siw episode m~y hew occurred with significant brain dysfunction suggested in the area of audito~ processing and expression. The report also said that the behavio~ of talking with an invisible person m~y be ~n outgrowth of; language/communication. limitations, loneliness, mild psychotic process ~societed with depression, ~n organic process or just mak~ life inter,ting. 8/93, a germtric ~sessment w~ done et Hershey Medical Cen~er after a decline in job performance and confusion. Symptoms h~d returned to normal by the time of the oval. 6/94, ~erietric ~s~sment ~gain ~t Hershey with no signs of dementia or clinic~ regression observed, referred to Holy 5piri¢ Hospital for B~havioral Health Service. ~0/94, she was evaluated by the program and was started on Mzlbril. 2/95, Prozac w~ added and reports stated that the medicafio~ alleviated her depression. It w~ also noted'that tra~portation w~ an issue, which could contribute fo boredom and other behaviors. Currently takes only Prozac diagnosis from EH5 is Impulse Control Disorder, NOS. Kethleen reports that her d~ughter, Tyro saw one occ~ion where it appeared that ~eanne his herself when t~lking to her im~gina~ friend, but it w~ not hard enough to cause mark or inju~. This occurred sho~ly after her mother died while Kathleen w~ st~ing with ~eann~. 5inca she moved ~o 5outh Road, she h~ been observed talk to her friend on a daily b~is, will occ~ion~lly c~ at which she usually mentions her mother, and h~ shown no behdviors that are harmful to herself or others. 5he do~ display an often smiling and calm affect, and perio~ of c~ing are a few minut~ and not unusual for someone who h~ Io~ their mother ~nd had significant chang~ in her life. ALLERGIES/PREeA UTIONb: No Known Allergies IMMUNIZATI:ONb: Polio - no record available TB/Mantoux - 7/5/02, neg Hep B vocs - 7/02, 9/02 Annual Flu shot - MMR - reported to have measles/mumps DT- 1995 Pneumovcx- 1998 0CT-17-2~82 10:12 CURRENT HEALTH STATUS: Mild Developmental Disability Hypothyroidism Irritable Bowel Syndrome EMPIRE MEDICARE SUS ?17 565 bown's Syndrome High Cholesterol Impulse Con¢~ol Disorder, NOS P.1~/32 CURI~ENT MED]:CATIONS: Fluoxetine for ]:CD, NOS Synthroid for Hypothyroidism Loperamide for antidiarrheal Multivitamin and C~lcium for .utritional supplement Prevacid for stomach acid Ecotrin o~ ~ blood thinner ¢itrucel for bowel regularity/IBS 0CT-17-2002 18:12 EMPIRE MEDICARE SUS PEI~$O~ALDATA SUMMARY 717 565 34~6 P.14/32 Name: Jeanne Rosemary Kelly Address: 6 South Road, Mechanicsburg, PA 17050 Admission Date: 7/!6/02 Age: 44 Sex: Female tleight: 63" Weight: 163 D.O.B.: 11;21/57 Marital Status: Single Telephone: 79i-9803 Referral Source: Cumberland/Perry MH/MR Race: White 'Hair: Brovm Place O.B.: Dauphia County, PA ReligioUs Affiliation: Catholic Method(s) o£Communtcation: Speaks and understands English Identifying Marks: Mark on back of left calf Eyes: Blue Social Security No.: 194-42-8362 D.P.A. Number: lVIH/MR Case No.: Medical Coverage: Coverage No.: Acx. es~ #0018995423 00 211-05777 Medicare Caseworker: Caseworker: Caseworker: Contact Person: Mark Evaus FINANCIAL: Type(s) & Amount(s) of Income: SS/SSI: $517.00 Work Related Income: N/A Trust or Burial Funds? [] Yes [] No Detalia: Par~more Funeral Home Person(s) R,,sponsible: Kathleen M. Cleveland VA: N/A llR: N/A Trust Amount: Burial Fund Amount: 5UPI~RT: EMERGENC~ Eme~genq, ~n~ C~d~ ~mck. PD 791-9803 6 ~ R~ Me~b~~ PA 17050 pref~ ~ W - 56~3730 ~1 ph~c = 497-13~ Em~gm~ M~ Holy ~irit ~spiml 763-2316 ~03 N~ 21~ S~% Crop ~11: PA 0CT-!?-20~2 10:12 EMPIRE MEDICARE SUS 717 565 3436 P.15/32 Primm'v..Den .mi Dr. Kal[; __ 339-0880 ~7 Chambersbur~ SL,. Gettysburg. PA 17325 Primavd Vision Memorial E.ve . 65%2020 4100 Linglestown Rd, Harrisburg. PA 1.7I 1.0 .. ?odia~ .... N/A Audiology Polyclini'c Speech 8: 7824141 :2601 North 3rd St. Hm'risburg PA Hearin~ Clinic ~Iutrition/Diet N/A Nutting ' Becky Neaus 541-8322 x517 CONSUI~T~NLY,' btu-per 257-7005 ga-4p Mon-Fri Pharmacy .... ' '.., , Rite. ~d" 7/i6-2533 ' Windsor Park Plaza, MechanieSburg, PA 17055 O~er: Other: SPECIALI ~',lr~ THERAPIES Occupational ~/A Sp,eech N/A ,. Bchav/or N/A Visual N/A Visi .r~ng Nu~e . .. N/A . Rccrcgtion N/A SUPPORT SERVICES iResidentia! Provider Keystone Residence 5~1-g322 940 Emt P~rk Dr: Suite I0!: Harrisburg, PA 171 Casemanagoment Mark Evans 240-6325 16 West High St: Carlisle PA 17013 Da), Service Center for In& Ting 766-g512 925 Linda Lane, Camp HilL PA 17011 , Psychotherapy/Couns etin~ N/A Advoca~ N/A .. Transportation ... Cumbcrland Count~' 240-6341 I Courthouse Square: C, arlisler .PA. 17013 P,,2ax: Ka.~e Cleveland 238-3156 . . 2231 lq. Third S~cet, Harrisburg. PA Respite Care ~N/A Other: Other: Other:. ..... EMERGENCY lV[EDICAL TREA~ PLAN: I) The immediac~d of the ~ittlation is ass~sed · If the situation is a life threatening emergency, 911 is called to request an ambulance. · If medical attention is required, but it is not a life tkreatening situation, the supporting employee should provide transportation to the hospital emergency room. 2) If there are t~o or more .employees present, gathea'ing of the emergeacy packet and transpartation to the hospital (or accompaniment of the individual in the ambulance) will be provided by one employee, while the other remains on duty. The remaining employee will ut~e the.management support system to notify management of the incident. 3) If an employe~ is alone, the management support system should be utilized to contact management to secure support staffing so that transportation to the hospital can be provided by the supporting employee or an employee can follow the ambulance to the hospital to provide needed support. 0CT-17-2882 18:13 F~I l:)~, EMPIRE MEDICARE SUS 717 565 3436 P. 16/32 Medi~miion Dosage Physician Loperamidc (Syrnhroid) 12~ mg 1 ~ a d~y ~. C~ 600 mg 2 tabs a ~y ~, Pac~ M~fivi~in w~on 1 tab a ~y ~. P~ ~i~i~he~ l t~ a ~y Dr. P~ Fluoxg~c ~) 20 mg 1 time a ~y ~. Mill~ E~ I ~ 2 x a day ~. Pac~ Ci~cil I ~ in wacr d~ly Dr. Pa~an ALLERGIEStFOOD SENSITIVITIES: No Kn°wn Allergies tVFKDIC~CTIONAIL CH~I,I,RNGES (i~cludi~g any sda~,~ equipment used sad l~vel ofmemal rclardagon): Mild Developmental Disability, Dowa's Syndrome, Hypothyroidism, Irritable Bowel Syndrome, High Choleslero~, Impulse Control Disorde4''. TEMPORARY RELOCATION: Emergency Site: Other Keystone House Local Hotels or Sister's house Extended Period: Holiday Inn, State College, PA If central PA is evacuated (ie: TMr) 0CT-17-2002 10:13 EMPIRE MEDICARE SUS 717 565 ~436 P.I?x32 ASSESSMENT Assessment is based on --, "~t,,umen~, interviews, written observations. Name Individual Review of Assessment Re ul~z .~ V~ ~ Signatu~e -- i~~ Date ~gnature 'File ~py of leper used to send assessment to parenFguardian/advocate or case manager~aiver only) Relationship Date DATE: Person/s completing the assessment: Name Relationship Individual Review of Assessment Results: · Name Relationship Signature Date Program Specialist/QMRP Review of Assessment Results: Signature 'File copy of letter used to send assessment to parent/guardian/advocate or case manager(Waiver only) Date DATE: Person/s completing the assessment: Name Relationship. Relationship Name Individual Review of Assessment Results: Signature Date Program Specialist/QMRP Review of Assessment Results: Signature *File copy of letter used to send assessment to parent/guardian/advocate or case.manager0Naiver only) Date 5= 'Consistently completes task/activity independently 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1= Currently does not demonstrate skill/s to complete task/activity N/A= Not applicable or not assessed (must include reason why) II/C= Individual has chosen not to engage in task/activity Awareness of Danqer and Safety/Need for Supervision YEAR Understands dangers of poisonous ,materials safely uses poisonous materials ....... Pulls away from hot ~v'ai'e~: ~nd other hot surfaces identifies hot surfaces/heat sources ..... Avoids hot surfaces/heat sources Able and aware of stop/drop/roll procedures if clothes were 'on fire ..... Recognizes fire/smoke alarmsound (Wakinc.! hrs.) Exits buildincj when alarm is sounded within 2.5 minutes' :g .., (sleeping! hrs.) Exits building when alarm is sounded wlthin 2.5 minutes Goes to desi~lnated meetin~l Place .~ .. Operates ~larba~]e disposal ..... Able to regulate Water temperature safely ~ ,, Demonstrates ability to call staff for help while in the communi'ty' Demonstrates ~Jn abilit)/to call for emergency assistance (i.e. 911 ) crosses street safe,!y _'3 ,, FaSter~s seat~elt and keeps it on while vehicle is movin~i Other Page 2 of 19 0CT-17-2082 10:1~ EMPIRE MEDICRRE SUS 5= Consistently completes task/activity independently 4= Independently complete, s task/activity, but not consistently t3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1 = CUrrently does not demonstrate skil!/s to complete task/activity , N/A= Not applicable or not assessed (must include reason why) j I/C= Individual has chosen not to enga~le in task/activity VOCATIONAL YEAR' Verbalizes correct information about work supervisor's role Completes a job application ..... Participates in a, job interview ,, Does volunteer work Verbalizes correct information about own role as employee or'volunteer Accepts '~upervision Works cooperatively Calls employer when unable to go to work Asks for assistance when necessary Completes assembly tasks Completes tasks'in allotted time Works independently/attends to task ..... COMMENTS: COMMUNICATION YEAR Verbally expresses emotions 'il~leasure, pain, ~xc, itemen,t, etc.), ! Expresses emotions with body language/behaviors Communicates needs/preferences by pointin~l Communicates symptoms of illness or injurY Communicates need for help Reliably answers "yes" and "no" to questions Uses alternative method of communication: La. nguage board Sign language(English or American) Communication book Ey.e Movement Uses typewriter/keyboard/computer Speaks languages other than English '(specify: !., Communicates through writing Communicates own name Asks questions to obtain information Identifies Objects Describes objects or events Expresses thoughts or ideas using one or two words Chooses from two or more options ~_ Answers open-ended que.,stlons I Follows one step directions Follows two-step directions .... Follows multiple s~ep directions ,~ Engages in conversations (circle:( shor~ or long or bothi' I~t'roduces self to others k--..--/ ...... Listens, while others speak ?age 3 of ! 9 OCT-i?-28EI2 1El: 13 EMPIRE MEDICARE SUS 717 565 3436 Speaks clearly .... Speaks at approp~a~,e Speed and volume Calls and uses diredory'assistance ..... Leaves messages on answering machine Uses the telephone ~,1.,~"' .. Answers telephone .. J Takes telephone messages and relays them I ..... COMMENTS: Communication (How Jeanne Communicates) People communicate their needs to us in a vadety of w. ays in addition to (or instead of) Spoken words. When Jeanne,.. We think it means,., And we should.,, - leans over and whispers to a person who is not visible, points in to the air or makes motions with her finger. - stands and Watches others while they are completing a task or helping someone else. - is crying. - she is talldng to her invisible friend whom she has at times referred to as Mark. - she may be waiting for you to help her with a daily task or needs something. - she may be missing her Mom or not feeling .well. - ask her if she needs something and help her get it or engage in a conversation or activity with her. - explain when you will be finished and able to help her and/or suggest things that she can while waiting. - talk to her to find out what is wrong, help her if needed and reassure her. PERSONAL SAFETY Identifies and uses public telephones .... Recites own phone number ..... Recites own address Uses public phone book Uses personal telephone/address book Carries personal identification (type: ) ~ ~ ... Fastens seatbelt and keeps it on while Vehicle is moving} Walks on sidewalk or Side of road if no sidewalk .(j . Does not accept ddes from unfamiliar people Pays attention to surrounding~'a'nd traffic while Walking Crosses street safely Identifies and obeys "walk/don't walk" signs . .. Walks to and from one place i.n the neighborhood. 0CT-17-2002 10:13 EMPIRE MEDICARE SUS ?t? 565 ~436 P.21/32 -52 Consistently completes task/activity independently 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2-- Requires physical prompts to complete tasks/activities 1 = Currently does not demonstrate skill/s to complete task/activity N/A= Not appIicable or not assessed (must include reason why) il/C= Individual has chosen not to engage in task/activity Uses (Circle). '~axies public bus train local bus planes I '- -Reads/uses bus schedule I Demonstrates abilit7 to ask directions i{ lost / ...... Follows written/verbal instructions Takes house key When leavin~l the residence Operates I!~lht switches . -Locks doors when leaving reS'i'dence or before bed / Operates other types of Iock's(spe.cify: ..... t 0 t t, '), ) Identifies persons and places suitable to discuss perso,nal information Knows where to purchase items Asks sales, person for assistance when need .e.d OPerates vending machines COMMENTS: SELF-MEDICATION YEAR Rec0_~lnizes and diStinguishes his/her medication Knows when to take medication(s/ (within one hour)· /-~ Knows purpose of taking each medication Knows possible side effects of'each medication Opens child resistant caps ~pens non-child resistant caps . Removes medication from blister pack /¥ ~ ... Washes hands before administering medication Knows }mw much medication to take Applie.s.,'.o, intments as directed Pours specified amount of liquid medication ..... Secures medication in locked area, if necessary Identifies when refills are needed t, Calls pharmacy for refill Checks medication for accuracy " Comments: SOCIAL/EMOTIONAL 'YEAR Visits with others. Specify ~',-.'~" (-~ ~ ,P ./'[/¢'dcc -?'?,'4 ... L~ Plans social get-togethers "i Maintains self control When faced with failure or disappointments ~ _ Tries again when di.sap. Pointments occur Listens/eXplores opt.!ons and then chooses , .3 ,. ?ag~ .5 of' 19 0CT-17-2002 10:13 EMPIRE MEDICARE SUS KEY 5= Consistently completes task/~ndently 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1 = Currently doe,~ not demonstrate skillls to complete task/actlvlty N/A= Not applicable or not assessed (.must include reason why) I/C= Individual has chosen not to engag_e In task/activity Discriminates fact from opinion Makes decisions despite influences Discdminat.es im.agination ~ Understands :t~'~' concept of lending and borrowing Accepts change Follows ~lroup rules and routines and responsibilities Leaves provoking situation when possible Stands up for self ~.~,~, Seeks help when emotionally distressed i~ols physi~l responses when angered ~~~i~na~_m~tion '~~ a calm and helpful ~a~ ... ~self-calml~activities (music, nap, exercise, etc.) --Considers effects of actions before carrying them out' Makes/asks socially acceptable statements/questions __------- Maintains eye contacts -~-~intains social distance Offers assistance or support to others Waits In lines ~ates cooperatively in group activities Takes turns Respects other's~ Res ects other's privac~J__ I~,espec~ ~ ___~_ Requests assmtance when needed ~uietly In church, theaters, etc. Comments: Personal Life/Sexuality ~Verbalizes correct terms for female reproductive pads ~ ____. ~ correct terms for male reproductive _parts ~---------- -------- Verbalizes correct information/is aware of menstruation ------- Verbalizes correct information/is aware of sexual intercourse Understands that intercourse can lead to pre~nancy/babies / ~ Verbalizes correct information about birth control I ~ Uses birth control_Lt)'pe: ) /¢g' _ Verbalizes correct information about sexually transmitted diseases ~ Verbalizes correct information about prevention of such diseases ------ · I Maintains re~lular contact with signifiCant other ~ Dates l>a~¢ 6 of 19 0CT-17-2082 10:13 EMPIRE MEDICARE SUS ?!? 565 3436 ,'I 5= Consistently completes task/activity independently 4= Independently completes tas~activi~, but not co~lstently 3= Requires verbaJ or ge~ural prompts to complete ~s~activi~ 2= Requires physical prompts to complete tas~activities 1= Currently does not demonstrate skiil/s to complete tas~activi~ N/A= NOt applicable or not assessed (must include reason why) ii/C= Individual has eng. a~e tas~acflv[~ chosen not to in P.23/32 Seeks private place to engage in intimate behavior '1/'~_' Understands significance of long-,term romantic relationship UnderstandS significance and responsibilities of marriage COMMENTS: .~CADEMICS YEAR Counts to 10 Counts past 2(] Writes numbers up to 10 writes numbers up to 20 Adds/Subtracts or single di~iit n'~mbers ' ' I Adds/Subtracts multiple numbers I Reads numbers Sorts objects by type .... Sorts objects by color Reads own name Reco~lnizes safer7 sight word. s (i..e., danger, poison, etc.)~ I . Recognizes mobility sight words (i.e.e.x!!, bus, restrooms(,.~etc.) tt .. Reads alphabet Reads simple senter~c~s' .... Tales to read new words I Demonstrates reading comprehension ' ' /' Read~> newspaper/magazines/book Uses dictionary 'Alphabetizes Holds pencil/pen ~;orrectly Circle: Makes marks on paper with. penc~ , Draws lines Draws circles" Prints own name z./ ..... Prints address · I Writes (cursive) alphabet Copies printed words ~ ,., Prints up to 5' words other than own name Prints simple sentences " t Locates severe! ,,holidays on calendar ~ ,,, States own birthday. .... (4A.¢~ kc. ¥~-w., ~--' Names seasons .~ .~, Identifies current month on calendar Names days of week identifies current day of week on calendar I' Composes personal letters _. ' .... Parc 7 o5' 19 .t1-17-2~3~3.-' 18:13 EMPIRE MEDICPRE SUS Consistently completes task/amivity Independently 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1 = Cui'rently does not demonsb'ate skill/s to complete task/activity N/A= Not applicable or not assessed (must include reason why) I/C= Individual has chosen not to en~a~e in task/activity Prints/writes personal letters -Addresses envelope " - Reads cursive writing Reads numbers on clock Face clock (, ~.~ ~ ...... Tells time on clock Face clo. ck (~.~giL~,,/ ~ "' Associates routine activities with time of day ,c~-~ ~(v~,j Tells time (face clock) ..... (digital clock) Tejls time. by hour Tells time by half hour Tells tir~e by minute ..... Sets alarm clo(~k COMMENTS: MONEY/FINANCIAL INDEPENDENCE YEAR Carries wallet or purse Identifies coin denominations Identifies dollar denominations Indicates relative value of coins/bills Counts coins.. Counts bills Knows to expect change , Makes change f..or, a 5, 10, or 20 dollar bill Reads price tag.s. Pays for purchases Communicates need to purchase item(s) Pays for !tem(s) with enou!Bh money to cover costs Bud~lets miscellaneous spendin~l money Budgets money to pa), monthly bills Shops within their budget Si~..n.s checks for cashin~ Cashes checks 'V~rites and sig,,ns .checks Pays bills when due Makes/records bank deposits Make~)records bank withdraws Balances financial record(i.e, transaction Io~, check book, et~;) Uses credit card Protects mo..ney/..handles it discretely When in public Approximate amount of cash the individual handles respor~ibly: "' $ ..... pe.r day/month/week (circle one) COMMENTS: Pasc 8 of 19 0CT-17-2002 10:14 EMPIRE MEDICARE SUS ~%~onsistently completes task/activltylndependently '4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1= Currently does not demonstrate skill/s to complete task/activity N/A= Not applicable or not assessed (must include reason why) l I/C= Individual has chosen not to engage in task/activity SELF HELP/ACTIVITIES OF DALLY LIVING PERSONAL CARE/HYGIENE YEAR )- Od ,~. Controls bladder during! (.Circle) da, y ni.cLht ~ ~,~¢ Controls bowels during (Circle) ~ (fiig~h,~ Uses public 'restro°m (Circle) iar place~'--~ in public Elicits assistance in fln~lng. Rublic restroom · Indicates need to go to the bathroom by: (I,F ~,~_ -,~ ~S ~> ~ .~.,{,a/ Uses disposable undergarments U)¢. ~; ~ r¢~. >~),3 '- Identifies '~)rrec!.public restroom from signs '~'~ j Secures' clothing before leaving bathroom Washes hands after using the restroom ,- ik~4f,[.~ ,i~',r~ ~ ~ 'b,~ ~ ~'.h Uses toilet p..aper ' Flushes toilet after use Closes bathroom door while using..restroom (public and private) Gets in and out of bathtub or shower Washes b~'dy while bathin~t or showering(Circle: stands or(sits),} Dries body after bathing/showerin9 ,,~'Y'¢~t ~/g~,~,_ ./6 ~ /~"~'~'-"~ Uses. soap while bathing.. Shamp..o.o.s and rinses hair as needed ~ ~L~ ¢~4%- ¢,3 ~. t,, [~ r,',r- Uses hair dryer as needed Shaves under'arms and le~:.S. (Type of razor'!" ' ) Shaves face (Type of razor: ) ~-/L.4% ~',, ~,~. Identifies when haircut I~ 'needed Uses deodorant [ ~t'/5' i ~ "~ (~ ~ ~" '" ' Brushe~ teeth/cares for dentures ~t¢, ,v, .~ C~, ¢ Uses d~nta] floss Uses sani~:ary,,protection (female.) (Circle)' napkin "' tampon Disposes of soiled sanitary protection appropriately (female) Cuts/files nails ~'J" ~- ~ ~ ~,A~ ~.vv' ti( Uses make-up (female) Combs/brushes hair Arranges for haircut Uses colognelaftershave!perfume Covers mouth/nose when coughing or sr~eezing Uses tis'sues/blows nose COMMENTS: Assessm. eu! ~age 9 o£ 19 0CT-/?-2'~2 LE~:L4 EMPIRE MEDICARE SUS 7/7 565 3436 P.2~/32 5=' Consistently completes task/activity Independently 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1= Currently does not demonstrate skiil/s to complete task/activity N/A= Not applicable or not assessed (must include reason why) IFC= Individual has chosen not to engage in task/activity DRESS, APPEARANCE, AND CLOTHING CARE YEAR Select's'clothing which is clean and in good repair Selects.,. matching clothin~l Selects clothing appropriate for weather and o~:casion Dresses self L,~..~h~'i ~[n ~,./~ 1~'~: .... Undresses self Gets clotMng properly oriented (front side i.n....front, back in back) Puts shoes on ,,. ~ Takes shoes off "Ties shoe laces · Selects ancJ '~3urchases own clothing .. , Useswashin~lmachir~e ~11~,,".%[- '~'~', ,,~ ~,~ Uses dryer "~ Folds clothing Hangs clothing ............. Mends torn clothin~ Irons clothin~ . ,. Uses correct amount'of detergent/softener Places Clothing into draWer plaCes dirty clothing into hamper l'aunders clothing when needed COMMENTS: FOOD PREPARATION AND DINING YEAR Uses adaptive equipment for eating(Speci.fy: Eats with'a fork Cuts food with a knife Eats with a spoon Drinks from cup (specify if nece~s_~3j~: .' .,;-'7-' . ~ Drinks from.. _(Circle) ~"strawff ~.~(can) PutS bite slze amount of food ~'ifll~mouth ---- Eats at a speed that prevents chokin!~ or coughing .. Chews with mouth C!.osed I1. FOOD PREPARATION and DINING (CONTINUED) YEAR Chews fosd thoroughly before swallowing ~,' Uses napkin · 3 _ passes serving bowls' .~ Serves Self from servin~].bowl .. ,-'~ _ . .... Pours from pitcher ~ _ Page lO:Of 19 0CT-!7-2~02 19:14 EM~IRE MEDICARE SUS 7!7 565 34~6 P.27/32 -?~---"-- ConsistenUy completes task/activity independentiy 4= Independently completes task/ac,tivity, but not consistently ,3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete tasks/activities 1 = Currently does not demonstrate skillfs to complete task/activity N/A= Not applicable or not assessed (must include reason why) IFC= Individual has chosen not to en~age in task/activity Makes a shopping list of needed items Purchases groceries Prepares drinks iCircle)' '~_ Prepares (Cir(~l~) .(.breakfast ~1~l lunch dinner snacks Packs a nutritionally Mixes/stirs foods Chops/Brates foods Measures ingredients Follows instructions from food container Follows a recipe _ Sets tabl'e Clears table Stores food s, afel~.i,', " Other appliances: COMMENTS: KEY 5= Consistently completes task/activity 4= Independently completes task/activity, but not consistently 3= Requires verbal or gestural prompts to complete task/activity 2= Requires physical prompts to complete task/activity 1= Currently does not demonstrate the skill/s to complete task/activity N/A= Not applicable or not assessed (must include reason why). I/C= Individual has not chosen to engage in activity or task IV. HOUSEKEEPING YEAR Maintains clean and neat bedroom Makes bed Changes bed linens when needed Cleans kitchen after preparin~l foo..d, Cleans refri~r, ator Operates vacuum or manual sweeper SWeeps floors ' Takes trash out Mop. s floors Cleans windows/mirrors Selects appropriate clean. !ng supplies ... Dusts furniture · Uses appropriate amount of cleaning supplies L cieans bathtub or shower Page 11 of !9 ,_T-~ r-2~2 1[~:14 EMPIRE MEDICARE SUS KEY, 5= Consistently completes task/activity indepundently 4= Independently completes task/activity, but not consistently 3= Requires verbal or §estural prompts to complete task/activity 2= Requires physical prompts to complete ta~ks/activities 1 = Currently does not demonstrate skillls to complete task/activity 3436 P. 28/32 N/A= Not applicable or not assessed (must Include reason why) II/C= Individual has chosen notto enga~]e in task/activity Clean toilet .. , i. _ Cleans sinks. Sorts rec~clable materials/trash Loads dishes into dishwasher / ------'- Adds detergent into dishwasher ~_____ Washes dishes by' hand Puts dishes away Changes battedes Chanc, les light bulbs I Undo.ge toilet/sink with plun~ler Shovels snow Adjusts thermostat Cares for indoor plants Locates/Operates flashlight COMMENTS; LIKES/DISLIKES, PREFERENCES Dislikes P~Se 12 o~19 0CT-!7-2~[~2 Ie,:14 EMPIRE MEDICPRE SUS 5=,Consistently co~'11a~tes task/activity independentIy 4= Independently comp~task/activity, but not consistently 3= Requires verbal or gestu~ts to complete task/activity 2= Requires physical prompts to ¢om~ities 1-- Currently does not clemonstrate skill/s to complete~ N/A= Not applicable or n e reason why) l/C= Individu osen not to engage in task/activity LEISURE INTERESTS Indicate Individual's interest according ti this scale: $ - Strong or consistent interest C - Casual or intermittent interest O - No interest N/A - Not assessed or not applicable I ACTIVITIES (LIST OTHERS ON BACK IF NECESSARY) YF.~R:,,~,~ YEAR: YEAR; ..Dancing ~ - .Pla¥in~ musical instrument: '[~ Singing Listening to music. Favorite type(s): (.~c.' ....... .~ Concerts MovieS: Favorite type(s): '.~-T~z~ Theater (Attending or Acting..i,n plays) w..a~c~i3ing TV Favorite show(.s): ;hurch/church activities [Visiting museums ... Volunteer, organization work Walkln~l/hiking ...,Biking .... j~. Swimming Watching sports 'Playing sports "' ~'. Board/card games C Puzzles. Type: . (.. Fishing. , . ! .Boating G Roller-skating Gardenin~ (_ Camp[n~l - C ~b~' n ' "' C Metal or wood work .Sewing C~ Readin~ Video games ~.~ .Photography ~ollectin~l/Scrapbooks/Photo albu ms ,_% L..ei,.s.u..r.e_a..cti._v_ities generally initiated by self or others? S~TY,, . J COMMENTS: P~Se 13 of' 19 LEISURE INTERESTS Individual name: Jeanne Kelly Indicate individual's interest according to this scale: S - Strong or consistent interest C - Casual or intermittent interest . O - No interest N/A - Not assessed or not applicable ACTIVITIES (LIST OTHERS ON BACK IF NEC,E.,SSARY) YEA~: ~. YEAR: YEAR: Dancing ~ ............ Playin9 musical instrument: , Listening to music. F,a,v~:rite type(s): , Concerts ~/~ Movies.~ Favodte type(s): ~heater (Attending or Acting in plays) ~, Watching TV Favorite..show(s): (. .... Church/church activities Visiting .,m, useums ,,, Visiting library ~ .. Volunteer organization work £.. .... Walking/hiking ¢ .. Biking Swimming .... Watching ,sports ,, Playi_ng sports ..... Board/card gam e~. _,. C ... Arts and crafts .., ,C, Puzzles. Type: ,, " C Fishing ...... O Boating._ 0 ,,, Bowling Roller-skating Gardening Camping Metal or wood work /vfr Sewing Reading /V~' Video games Photography ...... Collecting/Scrapbooks/Photo albums Leisure activities generally initiated by self or others? '4 ~J% ' ' - COMMENTS: 0CT-17-2~02 10:14 EMPIRE MEDICARE SUS 717 565 34~6 P.~1/~2 · I ,;='Consistently completes taskJactivity independently 4= Independently completes tasWactivity, but not consistently 13-~ Requires verbal or gestural prompts to complete tasWactivity j 2= Requires physical prompts to complete tasks/activities 1= Currently does not demonstrate skill/s to complete task/activity N/A= Not applicable or not assessed (must include reason why) Il/C= Individual has chosen not to engage in task/activity SENSORY/MOTORSKILLS (OPTIONAL) YEAR ~-¢~'~ Holds h~ad up Maintains good posture Maintains balance while standing, sitting<or'walking alonewt,-e.~( Wa]ks..without assistance t ,._Sc)~,.4',~5. ~ ~' 'Wi ~/~s'.¢/~'' ~ ~P z',~?~ Walks/maneuvers independently with adaptive equipment p~.,.r_~ .:~h.,~, (Circle.: wheelchair, cane, walker,, electric wheelchair, other: ) ./~[ '7~ Walks .up and down stairs ~,/Y....'.. Runs Carries obiects ~ ... Bends to pick up objects from the floor Throws objects L~ . . Catches. o.bj.e.,cts B .. swimming: Maintains balance ~hile standing in water Walks in water ~'? ... Aware of the dangers(divin~l boards, deep water, etc.) ~r~ ........ Stays afloat in water /~. Propels self to safe area Swims well Swi.m.'.s in variOus conditions ([e. ocea._n., pool, lake) .' Manipulat.es fasteners: Zippers Snaps Buttons ....... Belts '~, " Velcro . Speci~ O. ther: __ Operates (Circle) knobs han~'dles pushbuttons "' USes pin. c.e.r grasp ' ' · Uses palm. er grasp Twists caps · ..Squeezes . .Opens containers (i.e. jars, cans, pots, etc) ti 0CT-17-2882 18:14 EMPIRE MEDIEP~E SUS 717 555 3436 P.32×32 ' Jeanne Kelly's STRENGT~S/N'EEDS Status of Need: C = Currently concentrating on this skill/area (either as a formal goal or informally) F = Individual may benefit from concentrating on this skill/area sometime in the future I/C = Individual chooses to not work on this skill/area F-- Strength .., Need Status Communication Personal LEe/Sexuality c Money Financial Self-Help - Motor(optional) -- TOTRL P.32 MAIN OFFICE 412 Erford Road Camp Hill, PA 17011 Stanley E. Schneider, Ed.D. Director EMP I RE MEDI CARE SUS ~GUIDANCE II · i' ~1 ASSOCIATES pSYCHOLOGICAL EVALUATION ?17 565 3436 P.03/12 Camp Hill: (717) 732-2917 Hershey: (717) 533-4312 Carlisle: (717) 245-2289 Ch~_mbersburz: (717) 263-9392 JUN -6 NAME: AGE: BIRTHDATE: EDUCATION: OCCUPATION: EVALUATION DATE: REFERRING AGENCY: CASE MANAGER: Jeanne Kelley 37 11/21/57 Intermediate Unit CIT 5/27/94 Cumberland Perry MH/MR Julie Castelluccio REFERRAL INFORMATION: A previous evaluation of Jeanne was completed by these offices on 2/5/93. A diagnosis of mild mental retardation was suggested along with some additional minimal brain impairment. The current evaluation is being requested because Jeanne's mother as well .as MR staff have become .concerned about unusual and withdrawn behaviors, and suggestions for appropriate interventions are sought. INTERVIEW DATA & OBSERVATIONS' Jeanne was minimally interactive on her own initiative, but smiled, responded when spoken to, and cooperated fully with the tasks presented. She was positively responsive with her mother and case manager who were also present for the evaluation. At times as the other adults talked, Jeanne would move her lips and make motions and smile as if she were talking to an invisible person or entity. This was not done in an unpleasant way, and only positive emotion seemed to be associated with the activity. Jeanne was self-conscious about it, however, mildly attempting to hide the activity from the rest of us. Jeanne's personal care seemed to be quite good, and she didnot present herself in a disorganized or inappropriate way. It is my understanding that Jeanne was recently taken to Holy Spirit Hospital to receive counseling services. Although the diagnostic impression was depression, a psychiatrist has requested a geriatric assessment to rule out dimentia. Services cannot continue until the evaluations have been completed. Apparently during her 'initial contacts at the hospital, Jeanne commumcated loneliness and feeling badly about her disability. Jeanne's mother, Rosemary Kelley, was present and reported concerns about Jeanne's loss of interest in past activities (latch hook, puzzles, cards), no longer ~Comprehensive Psychological Services Drug and Alcohol Treatment-~ SEP-26-2~02 16:40 EMP !RE MEDICARE SUS PSYCHOLOGICAL E¥~UAT~ON RE: Jeanne Kelley Page 2 ?17 565 ~436 P.04/12 · · dance and sing, withdrawal behavior in the form of just o~ng into her room to ...... ~g;**..,,,, o~,,~ ~,~t t~lk;nn r~,f,,sinn to talk when spoken to, and talking to some.one o~-,¥ ................ ~ ..... = i OWn who ~s not present. Mother. has s.een Jeanne take_a Iow and act as if she is explaining it to someone WhO ~s no: ~nere. been willing to say who this inwsible someone is. Mother has also noticed that Jeanne is no longer afraid of the dark. Initial concerns began some months ago when Jeanne was crying, confused, wa.nd.erln9 around, a.nd re!king to. her.self at work. Cryin9 and disrupted eating ane s~eep~ng were a~so ooserve(~ at nome. Jeanne is do~ng better at work now and helps with food service at the Embers which has an off site program for CIT. Jeanne says that her best friend is Phyllis, who is also her boss at work. Other social contacts for Jeanne include church attendance every Sunday, daily chats with a neighbor, Mrs Clark, and brief visits, perhaps twice a week, from Susie who lives close by and is a fellow CIT worker. Mother reports that Jeanne's judgment remains good with regard to safety matters. Mother reports that Jeanne seems happy "only sometimes" at home, and she interprets Jeanne's quietness a~d .withdraw_al. as.being i~.up.s, et"; S.h.e !n,~c_ate_._d~t.h_a_t this was not everyday. Jeanne s orotl~er, ~'a~, stays w~tn tne Tamely ~nree week. Mother said, "He took care of her like her dad would". When presenteo with several choices of feelings, Jeanne told me that she was happy at home and wanted to live with her mot]~er, and she is happy when Pat is there. Mother reports that there are no changes in Jeanne's indepen, dent self-c.ar.e, a. nd there continues to never be a problem with aggressiveness or (~estructive oenawors. TEST IMPRESSIONS: ..... WECHSLER ADULT INTELLIGENCE SCALE - REVISED VERBAL TESTS SCALED SCORE Information 1 (2) Digit Span 1 Vocabulary I (2) Arithmetic 2 Comprehension 1 Similarities I PERFORMANCE TESTS Picture Completion Picture Arrangement Block Design Object Assembly Digit Symbol SCALED SCORE 3 1 (2) 4 5 (6) 3 (4) VERBAL IQ 51 (54) PERFORMANCE IQ 66 (70) FULL SCALE IQ 54 (58) The parenthetical numbers represent scores from the 2/93 testing. The overall pattern remains the same. Jeanne was somewhat more disorganized during this testing, but it would be difficult to say that the drop was significant. As compared to last time, she was unable to tell the purpose of a thermometer (information), was less able to retrieve word meanings (Vocabulary), could not arrange three simple pictures in proper social order (Picture Arrangement), and had 5EP-26-2002 16:40 EHP ! RE PiED ICIqRE SUS PSYCHOLOGICAL E~,-,-UATION RE: Jeanne Kelley Page 3 mild deficits in visual organization and speed (Object Assembly, Digit Symbol). If there has been any nervous system deterioration, it apparently has not shown up in the work visual abilities, significant deficits remain in the areas of auditory procession/comprehension and retrieval of meanings and language expression. Hands-on manipulation of materials remains Jeanne's strength. Jeanne drew the .Bender figures with considerable crowding on the page and with the Gestalt evident only in the broad sense of the word. She was able to make basic circles, angles, wave lines, squares, and so forth, and the different parts of the drawings are in correct proximity to each other, Short term visual memory is quite poor with one figure recalled. Jeanne's performance is consistent with intellectual limitations. Jeanne's H. uman...Fiqgre DrawiJ3c[s are child like in appearance and are drawn in 13 appropriately related parts. She drew her brother first ' choice feelings Jeanne said that she and herself second. When ~ven a of was "happy" about "work". Aga,n, the drawings are consistent with intellectual limitations and life adjustment. DIAGNOSTIC IMPRESSIONS: I will here repeat the diagnoses made in 2/93 of mild mental retardation (DSM III-R: 31 7.00) with additional significant brain dysfunction suggested in the area of auditory .processing/.expression (Organic mental disorder, NOS, DSM III-R 294.80). A major depressive episode may have been experienced in recent months; symptomatology is not currently present with the exception that Jeanne has not regained some past interests. The behavior of talking with an invisible person or entity may be an outgrowth of felt language/communication limitations in conjunction with loneliness, or it might be eviden_c.e.of a mild psychotic process perhaps associated with depr~s-sion; 'or it c~u'l'~i be a function of an organic process that is slowly impeding ability, or maybe Jeanne is just bored and this makes life more interesting. Perhaps Jeanne thinks of this "person" as protecting her since she no longer seems to be afraid of the dark and positive emotions are associated with the activity. While remaining open to the possibility of psychotic/organic processes, I am going to choose the other possibilities as the source of the behavior for the time being. However, a check needs to be placed on concurrent withdrawal behavior to keep Jeanne reality oriented. RECOMMENDATIONS: 2' Group therapy and social support, Social activities through the county MR program. 31 A companion who vis,ts and takes Jeanne somewhere once or twice a week. 4. Provide mother/daughter relationship building activities, to take the emphasis off verbal exchanges and understanding. 5. Help mother to not interpret Jeanne's behavior from a totally negative context. Eugehe H. Ste'cher, Psychologist IN RE: JEANNE R. KELLY IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. STATEMENT OF PROPOSED GUARDIAN/CONSENT TO SERVE AS PLENARY GUARDIAN FOR JEANNE R. KELLY~ AN INCAPACITATED PERSON 1. My name is Kathleen M. Cleveland and I am an adult individual residing at 2231 North Third Street, Harrisburg, Pennsylvania 17110. 2. My date of birth is April 15, 1953 and I am the only sister of Jeanne R. Kelly. 3. I am a citizen of the United States of America and I am able to speak, read and write the English language. 4. I have no interest adverse to Jeanne R. Kelly. 5. I am currently serving as the Executrix for the Estate of Rosemary C. Kelly, my deceased Mother. Myself, my brother Patrick M. Kelly, and my sister Jeanne R. Kelly are the three equal residuary beneficiaries of the Estate. 6. I consent to serve as Plenary Guardian of the Estate and Person of my sister, Jeanne R. Kelly. Dated: ' "' Kathleen M. Cleve'l~nd IN RE: JEANNE R. KELLY IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. CONSENT FOR KATHLEEN M. CLEVELAND TO SERVE AS PLENARY GUARDIAN FOR JEANNE R. KELLY~ AN INCAPACITATED PERSON 1. My name is Patrick M. Kelly and I am an adult individual residing at 218 Swarthmore Drive, Lititz, Pennsylvania 17543. 2. My date of birth is July 16, 1954 and I am the only brother of Jeanne R. Kelly and Kathleen M. Cleveland. 3. I am a citizen of the United States of America and I am able to speak, read and write the English language. 4. I have no opposition to my sister, Kathleen M. Cleveland being appointed the Plenary Guardian of the Person and Estate for my sister, Jeanne R. Kelly. Patrick M. K~lly ~ VERIFICATION I verify that the statements made in the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. IN RE: ' JEANNE R. KELLY, an incapacitated person IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION · NO. 21-2003-0057 AFFIDAVIT OF SERVICE I, Jill M. Wineka, Esquire, being duly sworn, depose and say that true and correct copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the Preliminary Decree scheduling a Hearing for February 13, 2003 at 11:00 a.m. in Court Room 2 and a Citation and Notice were served upon the following next of kin by depositing same in the United States Mail, First Class Mail, postage prepaid at the address listed below· Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 A copy of the cover letter dated January 27, 2003 to Patrick M. Kelly and the postmarked Certificate of Service are attached hereto. Sworn to and subscribed to before me this 'i'~'~', day of ' ~., .,,; . ,2003· Notary Public My Commission Expires: (clients\cleveland\afl of serv on Patrick) Oill~. Wineka, Esquire NOTARIAL SEAL :"i~rdsb~g. Dauphi~ Cour~j EXHIBIT HOXWARD B. KRUG LEON P. HALLER JOHN XW'. PURCELL, JR. JILL M. XgrlNEKA BRIAN J. TYLER NICHOLE M. STALEY O'GOI~MAN LAX~ OFFICES 1719 NORTH FRONT STREET HARRISBURG. PENNSYLVANIA 17102-2392 TELEPHONE (717) 234-4178 FAX (717) January 27, 2003 JOSEPH NISSL£Y (1910-19B2! JOHN W. PURCELL VALERIE A. GUNN OF COUNSEL Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 In Re: Jeanne R. Kelly No. 21-2003-0057 Dear Mr. Kelly: Enclosed for your records is a date-stamped copy of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person. I am also enclosing a copy of the Preliminary Decree and the Citation with Notice issued by the Orphans' Court of Cumberland County. The Citation is directed to Jeanne. A Hearing has been scheduled for February 13, 2003 at 11:00 a.m. in Court Room No. 2 in the Cumberland County Court House regarding the Petition to Adjudge Jeanne incapacitated and to appoint Kathe the Guardian of Jeanne's Person and Estate. You are not required to be present. However, as next of kin, I am obligated to forward the date-stamped Petition to you, along with the Preliminary Decree and Citation with Notice. Please do not hesitate to contact me if you have any questions. Sincerely, JMW/bas Enclosure cc: Kathleen M. Cleveland w/o enc. (clients\cleveland\01-27-03 Itr to Patrick) Jill M. Wineka Re: In Re: Jeanne R. Kelly No. 21-2003-0057 Notice of Hearing and Petition to Adjudge Jeanne R. Kelly an Incapacitated and to Appoint a Plenary Guardian for her Estate and Person U. S. POSTAL SERVICE CERTIFICATE OF MAILING (In compliance with Postal Service Received from: Purcell, Krug & Hailer 1719 North Front Street Harrisburg, PA 17102 One piece of ordinary mail addressed to: Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 Postmark: IN RE: JEANNE R. KELLY, · an incapacitated person · IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2003-0057 AFFIDAVIT OF SERVICE I, Jill M. Wineka, Esquire, being duly sworn, depose and say that true and correct copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the Preliminary Decree scheduling a Hearing for February 13, 2003 at 11:00 a.m. in Court Room 2 and a Citation and Notice were served upon the following next of kin by depositing same in the United States Mail, First Class Mail, postage prepaid at the address listed below. Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 A copy of the cover letter dated January 27, 2003 to Patrick M. Kelly and the postmarked Certificate of Service are attached hereto. Sworn to and subscribed to before me this ,;~¢~... day of "/"'~'~'~ ~ ~1 , 2003· Notary Public My Commission Expires: (clients\cleveland\afl of serv on Patrick) Jill{~. Wineka, Esquire ~'--~ NOTARIAL SEAL BARBARA ^. SHADEL, Notary ~,.'~y Commission Expires March 17, 2003 HOWARD B. KRUG LEON P. HALLER JOHN W. PUI~CELL. JR. JILL M. WINEKA BRIAN d. TYLER NICHOLE M. STALEY O'GORMAN L A~,Y/' OFFICES 1710 NORTH FRONT STREET HARRISBURG. PENNSYLVANIA 1710,9.-~392 TELEPHONE (717) 234-4178 FAX (717) 233-1149 Januaw 27,2003 JOSEPH NISSLEY (1910-198~,) JOHN W. PURCELL VALERIE A. GUNN OF COUNSEL Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 In Re: Jeanne R. Kelly No. 21-2003-0057 Dear Mr. Kelly: Enclosed for your records is a date-stamped copy of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person. I am also enclosing a copy of the Preliminary Decree and the Citation with Notice issued by the Orphans' Court of Cumberland County. The Citation is directed to Jeanne. A Hearing has been scheduled for February 13, 2003 at 11:00 a.m. in Court Room No. 2 in the Cumberland County Court House regarding the Petition to Adjudge Jeanne incapacitated and to appoint Kathe the Guardian of Jeanne's Person and Estate. You are not required to be present. However, as next of kin, I am obligated to forward the date-stamped Petition to you, along with the Preliminary Decree and Citation with Notice. Please do not hesitate to contact me if you have any questions. Sincerely, JMW/bas Enclosure cc: Kathleen M Cleveland w/o enc. Jill M. Wineka (clients\cleveland\01-27-03 Itr to Patrick) Re: In Re: Jeanne R. Kelly No. 21-2003-0057 Notice of Hearinq and Petition to Adjudge Jeanne R. Kelly an Incapacitated and to Appoint a Plenary Guardian for her Estate and Person U. S. POSTAL SERVICE CERTIFICATE OF MAILING (In compliance with Postal Service F,- Received from: Purcell, Krug & Hailer 1719 North Front Street Harrisburg, PA 17102 One piece of ordinary mail addressed to: Patrick M. Kelly 218 Swarthmore Drive Lititz, PA 17543 Postmark: IN RE: JEANNE R. KELLY, an Incapacitated Person IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2003-0057 AFFIDAVIT OF SERVICE PETITION~ PRELIMINARY ORDER OF COURTT AND CITATION WITH NOTICE I, Jill M. Wineka, Esquire, being duly sworn according to law, depose and state that service of certified copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the January 23, 2003 Preliminary Decree and the Coud's Citation with Notice was made on Jeanne R. Kelly, by handing copies of the documents to her on Friday, January 30, 2003 at 3:00 p.m. at her residence located at Keystone Residence, 6 South Road, Mechanicsburg, Pennsylvania 17050. I explained the documents to Jeanne, to the maximum extent possible, in language and terms she was likely to understand. Sworn to and subscribed before me this ~ day of r/~'~.~ / / Notary Pub/ic ,2003. (~[lill M. Wineka, Esquire I verify that the statements made in this Affidavit of Service are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. {}4904, relating to unsworn falsification to authorities. Dated: Z/~/03 (clients\cleveland\afl of serv on Jeanne) 'Jill M. Wineka, Esquire IN RE: JEANNE R. KELLY, an incapacitated person : IN THE COURT OF COMMON PLEAS : CUMBERLAND CO., PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-2003-0057 AFFIDAVIT OF SERVICE OF PETITION~ PRELIMINARY ORDER OF COURT~ AND CITATION WITH NOTICE I, Jill M. Wineka, Esquire, being duly sworn according to law, depose and state that service of copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the January 23, 2003 Preliminary Decree and the Court's Citation with Notice was made on the Keystone Residence, by personally handing copies of the documents to Cindy Stuck, Program Director for Keystone Residence on Thursday, January 30, 2003 at 2:55 p.m. at Keystone Residence, 6 South Road, Mechanicsburg, Pennsylvania 17050. Sworn to and subscribed before me ~; " ' 2003. this . ~" day of ~ -,'~,. ~.. ~ ; , Notary Public Jill M. Wineka, Esquire NOTARIAL SEAL ~,~,~ARA . SHADEL, Notary PL,~L'~ Harrisburg, Dauphin C_.,our~, ?.Cor~mission Expire~ M~rch 17, 2c~3 I verify that the statements made in this Affidavit of Service are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Dated: ~ [ ~ /~.~ (clients\cleveland\afl of serv on Keystone) ll M. Wineka, Esquire IN RE: JEANNE R. KELLY, an incapacitated person · IN THE COURT OF COMMON PLEAS : CUMBERLAND CO., PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-2003-0057 AFFIDAVIT OF SERVICE OF PETITION, PRELIMINARY ORDER OF COURT, AND CITATION WITH NOTICE I, Jill M. Wineka, Esquire, being duly sworn according to law, depose and state that service of copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the January 23, 2003 Preliminary Decree and the Court's Citation with Notice was made on the Keystone Residence, by personally handing copies of the documents to Cindy Stuck, Program Director for Keystone Residence on Thursday, January 30, 2003 at 2:55 p.m. at Keystone Residence, 6 South Road, Mechanicsburg, Pennsylvania 17050. /lill M. Wineka, Esquire Sworn to and subscribed before me this ~'~'/~ day of ,~(~/5/~F4/Z~' ,2003. I / Notary Public NOTARIAL SEAL Comrni~ Expires March 17, 2003 I verify that the statements made in this Affidavit of Service are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Dated: z i ,:'-', /~11 M. Wineka, Esquire (clienLs\cleveland\aff of serv on Keystone) IN RE: JEANNE R. KELLY, an Incapacitated Person IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2003-0057 AFFIDAVIT OF SERVICE PETITION~ PRELIMINARY ORDER OF COURT~ AND CITATION WITH NOTICE I, Jill M. Wineka, Esquire, being duly sworn according to law, depose and state that service of certified copies of the Petition to Adjudge Jeanne R. Kelly an Incapacitated Person and to Appoint a Plenary Guardian for her Estate and Person, the January 23, 2003 Preliminary Decree and the Court's Citation with Notice was made on Jeanne R. Kelly, by handing copies of the documents to her on Friday, January 30, 2003 at 3:00 p.m. at her residence located at Keystone Residence, 6 South Road, Mechanicsburg, Pennsylvania 17050. I explained the documents to Jeanne, to the maximum extent possible, in language and terms she was likely to understand. Sworn to and subscribed before me / '?~i this ,.h day of/~;~., ! Notary Public ,2003. (~Jill M. Wineka, Esquire NOTARIAL SEAL !.~ARBARA A. SHADEL, hk:~mj Public Harrisburg, Dauphin Cour~ Cern~ E~r~ ~ 17, ~3 I verify that the statements made in this Affidavit of Service are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Dated: Z / ~o/0.3 (clients\cleveland\afl of serv on Jeanne) JJill M. Wineka, Esquire IN RE: JEANNE R. KELLY IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 21-03-0057 ORPHANS' COURT ORDER OF COURT AND NOW, this ~ day of February, 2003, following a hearing, and finding that Jeanne R. Kelly, born November 21, 1957, is an incapacitated person, her sister, Kathleen M. Cleveland, is appointed plenary guardian of the person and estate of Jeanne R. Kelly. The guardian shall serve without posting bond. Edgar B. Bayl~,,J. Jill M. Wineka, Esquire For Petitioner :sal INTERNISTS of Central Pa. LTD.: Peter M. Brier, M.D. Michael L. Gluck, M.D. James A. Tyndall, M.D. Ira J. Packman, M.D. Richard Schreiber, M.D., F.A.C.P. L. Lynne Britton, M.D. Lawrence B. Zimmerman, M.D. Michael A. DeMichele, M.D. Carla J. Dente, M.D. Dominic Mirarchi, D.O. Wendy Schaenen, M.D. Patrick Ratnasamy, M.D. Andrzel R. Walker, M.D. V. Martha Kapoor, M.D. Victoriya K. Abramova, M.D. Dean L. Lehman, PA-C Beth M. Rabedeau, PA-C Mlchelle L. Latsha, PA-C HARRISVIEW PROFESSIONAL CENTER * 108 LOWTHER ST. * P.O. BOX 107 * LEMOYNE, PA 17043-0107 * (717) 774-1366 FAX (717) 774-4232 February l0,2003 Re: Jeanne Kelly To Whom It May Concern: Jeanne Kelly is a long time patient at Internists of Central PA (ICP). This patient is followed by ICP for severe Down syndrome with a history of hallucinations, elevated cholesterol, obesity, irritable bowel depression, and hypothyroidism, history of sciatica and DJD of the spine. Her medications are prozac, synthroid and multivitamins and a low dose of aspirin. It is in my professional medical opinion that Jeanne Kelly suffers from a mental impairment, such that she is unable to receive and evaluate information effectively and to communicate her decisions. She is unable to manage her financial resources or to meet the essential requirements for her physical health and safety. Regards, Carla J. Dente, M.D. CO14~O~TH OF PENNSYLVANIA COUNTY OF: I 'EX ~HIBIT '1 Before me, the undersigned notary public, this day, personally, appeared ~ ' ~'~3 to me knowt}/who being duly sworn according to Ia., deposes the followixtg: ~ ~) Subscribed and sworn to before me this Janice L Morrow, Notary Public Lemoyne Bom, Cumber and County My Commission Expires Feb. 22, 2003 "!ember, Pennsylvania Association ot Notaries dayof ~-~~ 2003 Notary Public IN RE: JEANNE R. KELLY : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-2003-0057 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including our right to manage money and property and to make decisions. A copy of the petition which has been filed by Kathleen M. Cleveland is attached. You are hereby ordered to appear at a hearing to be held in Court Room No. 2, Cumberland County Courthouse, Carlisle, Pennsylvania, on February 13 ,2003, at 11:00 A.M. to tell the Court why is should not find you to be an incapacitated Person and appoint a Guardian to act on your behalf. To be an incapacitated Person means that you are not able to receive and effectively evaluate information and communicate decisions and that you are unable to manage your money and/or other property, or to make necessary decisions about where you will live, what medical care you will get, or how your money will be spent. At the hearing, you have the right to appear, to be represented by an attorney, and to request a jury trial. If you do not have an attorney, you have the right to request the Court to appoint an attorney to represent you and to have the attorney's fees paid for you if you cannot afford to pay them yourself. You also have the right to request that the Court order that an independent evaluation as to your alleged incapacity. If the Court decides that you are an Incapacitated person, the Court may appoint a Guardian for you, based on the nature of any condition or disability and your capacity to make and communicate decisions. The Guardian will be of your person and/or your money and other property and will have either limited of full powers to act for you. If the court finds you are totally incapacitated, your legal tights will be affected and you will not be able to make a contract or gift of your money to other property. If the court finds that you are partially incapacitated, your legal rights will also be limited as directed by the Court. If you do not appear at the heating (either in person or by an attorney representing you) the court will still hold the heating in your absence and may appoint the Guardian requested. Cumberland County, Carlisle, PA My Commission Expires 1~t Monday, January, 2006 IN RE: JEANNE R. KELLY, An Incapacitated Person 2003 : IN THE COURT OF COMMON PLEAS : CUMBERLAND CO., PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-03-0057 ORDER AND NOW, this t\ day of , 2003, upon review of the Petition for Court Approval to Fund OBRA Trust for an Incapacitated Person, IT IS HEREBY ORDERED that the Petition is GRANTED and that Kathleen M. Cleveland, as the Court-appointed Plenary Guardian of the Person and Estate for her incapacitated sister, Jeanne R. Kelly, is authorized to place into the Jeanne OBRA Trust the $20,364.15 Jeanne received as an inheritance from the Estate of Rosemary C. Kelly, along with any other assets Kathleen M. Cleveland deems advisable to protect Jeanne's financial interests. IN RE: JEANNE R. KELLY, An Incapacitated Person IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-03-0057 PETITION FOR COURT APPROVAL TO FUND OBRA TRUST FOR AN INCAPACITATED PERSON AND NOW, comes the Petitioner, Kathleen M. Cleveland, through her attorneys, Purcell, Krug & Hailer and files this Petition for Court Approval to Fund OBRA Trust for an Incapacitated Person and avers as follows: 1. Petitioner is Kathleen M. Cleveland, an adult individual with a current address of 2231 North Third Street, Harrisburg, Pennsylvania 17110. 2. By Order of Court dated February 13, 2003, Judge Bayley found that Petitioner's sister, Jeanne R. Kelly, born November 21, 1957, was an incapacitated person and appointed Petitioner to be Jeanne's Plenary Guardian of the Person and Estate and waived the posting of Bond. A true and correct copy of the February 13, 2003 Order is attached hereto and marked Exhibit "A". 3. Jeanne has been diagnosed with mild mental retardation/Down's Syndrome, with additional significant brain dysfunction in the area of auditory processing and expression and has a full scale IQ of 54. 4. Jeanne currently resides at Keystone Residence located at 6 South Road, Mechanicsburg, Pennsylvania 17057 and her sole source of income is approximately $620.00 she receives monthly from Supplemental Social Security. 5. The Petitioner, Jeanne and their only brother, Patrick M. Kelly are the only beneficiaries of their Mother's Estate, the Estate of Rosemary C. Kelly. 6. On June 24, 2003, a Family Settlement Agreement and Final Release was filed of record in the Estate of Rosemary C. Kelly, docketed to No. 2002-00387 in Cumberland County, whereby distributions were made equally to Petitioner, Jeanne and Patrick M. Kelly in the amount of $20,364.15 each. A true and correct copy of the Family Settlement Agreement and Final Release is attached hereto and marked Exhibit "13". 7. In an effort to preserve Jeanne's assets, Petitioner subsequently retained counsel in York County who prepared a Trust Agreement titled "Jeanne OBRA Trust", which established a Trust for Jeanne R. Kelly dated August 4, 2003. A true and correct copy of the Jeanne OBRA Trust is attached hereto and marked Exhibit "C". 8. Owning the aforesaid distribution of $20,364.15 from the Estate of Rosemary C. Kelly will render Jeanne ineligible for prospective benefits, including but not limited to, Medical Assistance and Supplemental Social Security Benefits, if such assets are not consumed or protected. 9. Petitioner proposes to protect the aforesaid assets by placing them in the Jeanne OBRA Trust, along with any other assets necessary to insure Jeanne's qualification for all available governmental benefits. 10. The purpose of the Jeanne OBRA Trust is to set aside a fund which may be used for purposes which are not for the primary support of Jeanne, but will supplement any governmental benefits to which Jeanne may otherwise be entitled. 11. Federal law permits a disabled person under the age of sixty-five to deposit her own money into a Trust which is not intended to be used for her primary support, and such a Trust would not be considered the be a resource of such person so as not to adversely affect such person's eligibility for any governmental benefit to which she may otherwise be entitled, so long as such Trust (a) is established by parent, grandparent, legal guardian or court; and (b) provided that all amounts remaining in the Trust, upon the death of the Beneficiary, will be distributed to the State up to the amount of all Medical Assistance paid by the State on behalf of the Beneficiary. 42 U.S.C. §1396p(d)(4)(A). A copy of the entire subsection (d) is attached hereto and marked Exhibit "D". 12. The corpus of the Jeanne OBRA Trust will be the aforesaid inheritance and such portion of Jeanne's Supplemental Social Security Benefits, and any other assets of Jeanne, that Petitioner, as the representative payee, may deem advisable in the unlikely event that at any time a balance should remain from such benefits after paying for Jeanne's usual and necessary expenses. 13. Placing the funds in the Jeanne OBRA Trust meets the Federal law in that it is a nonsupport Trust and Paragraph 3 of the Trust requires that upon Jeanne's death, the Trust remainder is to be distributed to the State, up to the amount of all Medical Assistance paid by the State on behalf of Jeanne, thereby protecting these funds from being considered as a resource of Jeanne in determining her eligibility for various governmental benefits. WHEREFORE, Petitioner respectfully requests this Honorable Court to grant the Petition and to authorize Petitioner, as the Plenary Guardian of the Estate and Person for Jeanne R. Kelly, an Incapacitated Person, to place into the Jeanne OBRA Trust the aforesaid inheritance and all other assets Petitioner may deem advisable. Respectfully submitted, Jill ~. Wineka, Esquire Att~Cney ID# 58802 Purcell, Krug & Hailer 1719 North Front Street Harrisburg, PA 17102 (717) 234-4178 Attorneys for Petitioner (clients\cleveland\petition re OBRA Trust) 3 IN RE: JEANNE R. KELLY IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 21-03-0057 ORPHANS' COURT AND NQW, this ORDER OF COURT /~'- day of Februaw, 2003, following a hearing, and finding that Jeanne R. Kelly, born November 21, 1957, is an incapacitated person, her sister, Kathleen M. Cleveland, is appointed plenary guardian of the person and estate of Jeanne R. Kelly. The guardian shall serve without posting bond. By the Court,'~./ Edgar B. Bayle~y...r.O. Jill M. Wineka, Esquire For Petitioner :sal IN RE: ESTATE OF ROSEMARY C. KELLY : IN THE COURT OF COMMON PLEAS : CUMBERLAND CO., PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 2002-00387 .' PA No.: 21-02-0387 FAMILY SETTLEMENT AGREEMENT AND FINAL RELEASF IN ESTATE OF ROSEMARY C. KELLY~ DECEASED KNOW ALL MEN BY THESE PRESENTS, that: WHEREAS, Rosemary C. Kelly, late of Lower Allen Township, Camp Hill, Cumberland County, Pennsylvania, deceased, died testate on March 24, 2002; WHEREAS, Letters Testamentary on the Estate of the Decedent were duly issued by Mary C. Lewis, the Register of Wills of Cumberland County to the Executrix, Kathleen M. Cleveland on April 15, 2002; WHEREAS, the Executrix has gathered the assets of the Estate of the Decedent and the assets consist of real and personal property with a total value of $90,680.28, as set forth in the Statement of Account which is attached hereto and marked Exhibit "A"; WHEREAS, the Executrix has paid the debts of the Estate in the amount of $28,964.53, as set forth in the Statement of Account; WHEREAS, the present balance for distribution, after taking into account the unliquidated value of the MetLife stock, is in the amount of $61,092.45, which will be distributed in accordance with the Statement of Distribution which is attached hereto and marked Exhibit "B"; NOW, THEREFORE, WE, KATHLEEN M. CLEVELAND, individually and as the Court-appointed Guardian for her sister and residual beneficiary, JEANNE R. KELLY, an Incapacitated Person, and PATRICK M. KELLY, being the only residuary beneficiaries of the assets of the Estate of Rosemary C. Kelly, do hereby acknowledge that we have this day received all sums of money which are given to each of us, by virtue of the Decedent's Last Will and Testament, with the exception of the liquidation value of the Met Life Stock, which is in the process of being sold. .AND, we do hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, we agree that no account is necessary and we agree that we consent to distribution being made without the formal filing of an account and schedule of distribution, the same to be with the same force and effect as if the documents had been filed and confirmed by the Orphans' Court Division of the Court of Cumberland County. THEREFORE, we do hereby release and forever discharge the Executrix, Kathleen M. Cleveland, Jill M. Wineka, Esquire and the law firm of Purcell, Krug & Hailer, the Attorneys for the Estate, their assigns, executors and administrators, from all actions, suits, payments, accounts, and claims whatsoever, touching upon the Estate of the Decedent. We do also agree that should any liability come due to the Estate of the Decedent after the signing of this Agreement, each of us do covenant and agree that, after the escrowed funds identified in the Statement of Distribution have been exhausted, we will contribute equally our share of the Estate which we each have received in order to satisfy any and all taxes, liabilities, claims, demands, suits or causes of action which may be successfully prosecuted or assessed against the said Estate or the aforesaid Executrix after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. The parties acknowledge that this Family Settlement Agreement and Final Release will be signed and notarized separately by each of the three beneficiaries. The three original signatures will be attached to the original Family Settlement Agreement and Final Release and filed of record with the Cumberland County Orphans' Court. IN WITNESS WHEREOF, I have set my hand and seal to the Family Settlement Agreement and Final Release on the date as indicated below. WITNESS: KATFILEEN M. CLEVELAND COMMONWEALTH OF COUNTY OF ~':) ~; g~ · SS: i.'~ ~::~ da ' ' , On this, the .. ~ -, y or ..?,,:.~>.,';? 2003, before me, a Notary Public, the undersigned officer, personally appeared KATHLEEN M. CLEVELAND, known to me (or satisfactorily proven) to be the person who name is subscribed to the within instrument, and acknowledged that she executed this Family Settlement Agreement for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal· (SEAL) NOTARIAL SEAL BARBARA A.'SHADEL, Notary Public City of Harrisburg, Dauphin County ~y. _C_ommission Expires March 19, 2007J IN WITNESS WHEREOF, I have set my hand and seal to the Family Settlement Agreement and Final Release on the date as indicated below· WITNESS: / KATHLEEN M. CLEVELAND, Guardian for JEANNE R· KELLY, an Incapacitated Person COMMONWEALTH COUNTY OF · SS: On this, the / :~W'~day of - ? "-',~-,' ,:? ,2003, before me, a Notary Public, the undersigned officer, personally appeared KATHLEEN M· CLEVELAND, Guardian for Jeanne R. Kelly, an Incapacitated Person, known to me (or satisfactorily proven) to be the person who name is subscribed to the within instrument, and acknowledged that she executed this Family Settlement Agreement for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. Notary Public NOTARIAL SEAL .... BARBARA A. SHADEL, Notary Public City of Harrisburg, Dauphin County My Commission Expires March 19, 2007J IN WITNESS WHEREOF, I have set my hand and seal to the Family Settlement Agreement and Final Release on the date as indicated below. PATRICK M. KELLY COMMONWEALTH OF COUNTY OF On this, the day of · SS: ,2003, before me, a Notary Public, the undersigned officer, personally appeared PATRICK M. KELLY, known to me (or satisfactorily proven) to be the person who name is subscribed to the within instrument, and acknowledged that he executed this Family Settlement Agreement for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and offiCial seal· ~-r~o~/Pub~i~'7/' ~' - Tara Jane Pisser, Notary Public Lititz Boro, Lancaster County My Commission Expires Nov. 10, 2003 Member, Pennsylvania Association et Notarie~ (SEAL) Register of Wills - fee to file PA Inheritance Tax Return Register of Wills - fee to file Inventory Allfirst Bank - fee to order Estate checks AIIfirst Bank - stop payment fee Lower Allen Township - real estate taxes Lower Allen Township - personal tax Lower Allen Township - sewer and refuse services UGI ~ gas services PP&L - electric services Verizon - phone services PA Water Company - water services PP&L - electric services Comcast - cable services UGI - gas services AT&T - phone services PP&L - electric services Verizon - phone services PA Water Company - water services UGI - gas services PA Water Company - water services Verizon - phone services PA Water Company - water services UGI - gas services PP&L - electric services Verizon - phone services Ladies Home Journal - outstanding subscription invoice Comcast - cable services 15.00 13.00 13.O0 30.00 910.13 9.80 74.25 71.35 61.45 39.99 31.64 45.67 56.79 64.00 7.51 75.83 31.99 52.23 64.00 15.73 6.70 32.69 64.00 29.77 51.75 25.46 56.79 R.T. Wagner - homeowner's insurance Sears - credit card AT&T- phone services UGI - gas services Comcast - cable services PP&L - electric services Verizon - phone services Real estate settlement costs assessed against the Estate as the Seller - eleven twelfths of costs PA Water Company - water services Lower Allen Township - sewer and refuse services AT&T - phone services Comcast - cable services PA Water Company-- water services UGI - gas services PP&L - electric services Charlie Knipe - lawn care services Register of Wills - additional probate fees Register of Wills - PA Inheritance Taxes Kathleen Cleveland - personal representative commission Purcell, Krug & Hailer - attorney's fees Register of Wills - fee to file Family Settlement Agreement and Final Release Register of Wills - Short Certificate 269.00 293.30 13.03 64.00 56.79 32.59 30.06 7,855.84 11.10 74.25 6.78 17.63 2.47 16.55 15.77 50.00 85.00 4,300.00 4,500.00 2,662.50 17.00 3.00 TOTAL DEBTS '03 ,JLIN 24 !N~_, © :56 TRUST AGREF.~ENT JEANNE OBI~ TRUST THIS AGREEMENT OF TRUST is made on ~:'/~'~ ~ , , 2003, by and between Kathleen M. Cleveland, of Dauphin County, Pennsylvania, plenary guardian of the person and estate of the hereinafter named Beneficiary, hereinafter referred to as "Settlor", and Kathleen M. Cleveland, of Dauphin County, Pennsylvania, hereinafter referred to as "Trustee", who, in consideration of the mutual agreements hereinafter contained, and intending to be legally bound hereby, do hereby agree as follows, to wit: WHEREAS, Settlor desires to establish this Trust for the purposes hereinafter set forth and not as a Trust for the primary support of the hereinafter named Beneficiary; NOW, THEREFORE, Settlor does hereby establish this Trust with Trustee and does hereby grant and convey unto Trustee the sum of One ($1.00) Dollar, receipt of which is hereby acknowledged by Trustee, in trust, to hold, administer and distribute the same, and any other property, real or personal, that may be added to the Trust (such sum, additions and any accumulation of income thereon being hereinafter called principal), and any income thereon or proceeds therefrom, in trust, as follows: FIRST: The beneficiary of this Trust is Jeanne R. Kelly, a person who has been determined to be disabled under the regulations of the Social Security Administration, herein referred to as ,'Beneficiary." SECOND: A. For the duration of the life of Beneficiary, the Trustee may pay or apply for her benefit such amounts from the net income and principal of this Trust as the Trustee in the exercise of the Trustee's absolute discretion deems advisable for the welfare of Beneficiary as hereinafter set forth. In making such distributions to or for the benefit of Beneficiary, and as the Trust principal and income are not to be used in place of any statutory benefits, the Trustee shall take into consideration all other resources available to Beneficiary, including any benefits to which Beneficiary is, or may be, entitled through public assistance, medical assistance, or from any other governmental or other resources° The Trustee may hold, withhold and retain any or all of the income and principal of this Trust as the Trustee, in the exercise of the Trustee's absolute discretion, shall deem advisable for the uses and purposes herein set forth. B. In exercising the discretionary powers herein conferred on the Trustee, the Trustee shall be guided by the following statement of Settlor's purposes and intentions. It is Settlor's expectation that the Trust income and principal will not be made available to provide primary support for Beneficiary. Therefore, the Trustee is directed to investigate other sources of support available to Beneficiary and to take whatever steps necessary to enroll her for such benefits or assistance. The Trust principal and income may be used only as a supplement to, and shall not replace, any statutory or other governmental benefits to or for which Beneficiary is, may be or may become eligible, including, but not limited to, medical assistance, public assistance, supplemental security income, or the like. The Trustee is authorized to make Trust distributions to or on Beneficiary's behalf to increase her quality of life, to assist in the treatment of Beneficiary's disability, to pay or provide for Beneficiary's health, safety, welfare, education and treatment when such items, products or services are not provided by a public agency or government program, and to pay or provide for Beneficiary's special needs. Special needs shall include, but not be limited to, medical expenses, dental expenses, nursing and custodial care, psychiatric/psychological services, recreational therapy, occupational therapy, physical therapy, vocational therapy, durable medical needs, prosthetic devices, special rehabilitative services or equipment, programs of training, education, transportation and required travel expenses, dietary needs and supplements, and related insurance. The Trustee is authorized to expend the Trust estate to procure more sophisticated medical, dental, ophthalmological and other similar treatment than may otherwise be available to Beneficiary and to seek private rehabilitative and educational training; however, the Trust principal and income may not be used in any manner to provide for basic medical care and is not to be used to replace medical assistance or similar statutory or other governmental benefits to or for which Beneficiary is or may become eligible. The Trustee is authorized to expend such amounts of income and principal as shall enable Beneficiary to 3 achieve her maximum potential and to lead as comfortable a life as possible. To that end, it is Settlor's desire, without it being legally binding, that the Trustee may expend the income and principal of this Trust in ways that shall protect, enforce and expand the rights of Beneficiary. Furthermore, expenditures from the Trust must have a reasonable relationship to the disability of Beneficiary. Settlor desires the Trustee to exercise the discretionary power conferred on the Trustee hereunder in a manner which will provide flexibility in the administration of the Trust under conditions from time to time existing, and in exercising such powers, the discretion of the Trustee shall be conclusive as to the advisability of any distribution of income or principal, and as to the person to or for whom such distribution is to be made, and the same shall not be subject to judicial review. Therefore, the Trustee may not and shall not be compelled in any manner by any person, court or governmental agency to expend any of the Trust income or principal for the replacement or reimbursement of any statutory or other governmental benefits, or any support or other assistance, to or for which Beneficiary is, may be or may become eligible, nor may the Trustee be compelled to exercise the Trustee's discretionary powers in favor of any beneficiary of such statutory or other governmental benefits, or any support or ~ther assistance. Furthermore, the Trustee is authorized to expend such amounts of income and principal for the benefit of Beneficiary as shall best provide for her comfort and happiness without regard to the effect that such distributions might have upon the interest of 4 the takers of the remainder of this Trust. THIRD: This Trust shall terminate upon the death of Beneficiary. Upon such termination, the Trustee shall distribute pro-rata all remaining principal and accrued income to any state which had provided medicaid, also known as medical assistance, to or on behalf of Beneficiary under any such state's plan under Title 42 of the United States Code or any similar federal law up to the total of all such medicaid paid to or on her behalf. If any funds remain in this Trust after such distribution to a state or states, such remainder shall be distributed to Settlor, if Settlor is living at the time of such distribution; and if Settlor is not living at the time of such distribution, the Trustee shall distribute all remaining principal and accrued income to Settlor's heirs as named in her Will if she dies testate or to her intestate heirs if she dies without a Will. FOURTH: The Trustee named herein, Kathleen M. Cleveland, may appoint in writing a natural person or a corporate fiduciary with trust facilities to succeed her as the Trustee of the Trust. FIFTH: This Trust shall not be subject to anticipation or to voluntary or involuntary alienation. SIXTH: Trustee shall have the following powers in addition to those vested in it by law and by other provisions of Trust, applicable to all property, whether principal or income, exercisable without court approval, and effective until actual distribution of all property: A. To hold and retain any or all of the assets of this Trust, real or personal, without regard to any principle of diversification or risk. B. To sell at public or private sale, to exchange, or to lease for any period of time, any real or personal property, and to give options for sales, exchanges or leases, for such prices and upon such terms or conditions as Trustee deems proper. C. To allocate receipts and expenses to principal or income or partly to each as Trustee from time to time thinks proper in Trustee's sole discretion. D. To compromise any claim or controversy. E. To invest in all forms of property including, but not limited to, all types of stocks, bonds, notes and other securities including those of a corporate trustee or of a company controlling such corporate trustee, insurance policies upon any life as deemed appropriate by the Trustee, shares of investment companies, common trust funds, mutual funds, mortgage investment funds, real estate, or any variety of real or personal property, without being confined to legal investments and without regard to any principle of risk, diversification or productivity. ~ SEVENTH: Settlor has had explained to Settlor the consequences of an irrevocable trust, and Settlor does hereby declare that Settlor intends this Trust to be and the same shall be irrevocable EIGHT~: Subject to the approval of Trustee, anyone may add 6 property, real or personal, to the principal of this Trust by Deed, Will or otherwise. In the event the same should be or include life insurance proceeds payable to this Trust or the applicable Trustee of this Trust under the terms of any life insurance policy, said proceeds shall be paid, in trust, to the then serving Trustee hereof by the applicable life insurance company without liability responsibility on the part of such life insurance or further company. NINTH: The Trustee shall be entitled to receive compensation for service hereunder, which compensation shall be charged against or payable from both principal and income of this Trust, at such rates as may be reasonable and customary. TENTH: The situs of this Trust for administrative and accounting purposes shall be in the County of Cumberland and Commonwealth of Pennsylvania, and all questions pertaining to the construction or validity of the provisions of this instrument shall be governed by the laws of that Commonwealth. IN WITNESS WHEREOF, the parties hereto do hereby execute this instrument on the date and year first above written. WITNESS: as Settlor and Trustee 42 U$CS § 1396p PuaLIC HEALTH AND WELFARE resources for less Ihan /'air markel value exccpl in accordance wilh this ~ub~cction. of a Irun~l~r by Ih~ s~u~c ~f aa individual which re~ul[~ in a ~ri~ of ineligihili~. I~)r medi- cal as~islance under a Slale plan fi~r ~uch iudividual, u Slu[~ ~hull, u~ing a re~unuble ogy {u~ ~cilicd by Utc SccrcI~). up~nion ~uch ~d~ of incligibilJly (ur uny ~nJon of such ~H{~) among Ibc individual and ghc individual's ~)us¢ il' Ibc ~us¢ olll~is¢ becomes eligible I~r medical ~istuncc under Ihc Slal¢ plan. { ~) I Unchungcdl id) Trealmen[ of l~l amoun~ (I) For pu~scs of dcle~ining un individual's eligibility l~r. or amoum or'. ~nc/ils under a Slale pl~ under Ihis 61lc [42 USCS ~ 1390 ¢~ seq. I. p~ugraph (4). Ibc roles s~cili~d in p~ugruph (3) shall apply [o a [msl established b~ such individual. (2)lA) For pu~ses o[ Ihis subseclJon, an individual shall ~ considered Io have eslublish~d a Irusl if asscls uf Ihe individual w~re u~d .) Ibm~ all or pa~ of Ihe ~o~us al' Ibc ~st and if uny of Ihe following individuals cslabllshed ~u~h I~1 u~hcr [haa by will: (il ~e individual. (ii) ~e individual's s~use. (iii) R ~non. including a court or adminis~adve ~y, with legal au~oHty place of or on ~half o~ ~e individual or ~e individu~'s s~use. (iv) A ~on. including any court or adminislrative ~y. acting at ~e direction or u~n · e request u~ ~e individu~ or ~e individu~'s s~u~. lB) In ~e case of a ~st ~e co~us o1' which includes ~se[s o[ an individual (~ under subp~agraph (Al) and usseu of any od(er ~mon ~r ~rsons. Ibc pmvision~ of Ibis subsection shall apply m ~c ~nion of ~ ~s[ a[~bmable m the ~s~u of the individual lC) Subjccl [o p~agraph (4). I~s subscc[ion shall apply wi~om reg~d t~ (il ~e pu~ses for which a ~s~ is (ii) wh~r ~c ~mslces have or exc~cisc ~y disc~don under ~e (iii) ~y re~cdons on when or wh~cr dis~butions ~y ~ mad~ /~om the ImsL or (iv) any rc~cdons on thc u~ of dist~sbudons [rom ~e ~s~. (3)(Al In ~e c~e of a rev~able (il ~e co~us of ~e ~t sh~l ~ considered resoles syllable [o ~e individual. (ii) paymcn~ from dm ~s[ [o or ~or U~e ~n~li[ of U~e individu~ shall ~ considered income of ~e individual, and (iii) ~y other puymenU from ~e ~t shall ~ considered ~seu disused of by ~e individual for pu~sc~ of subsection lB) In ~e ca~ of ~ inev~able (il if there ~e ~y circumst~ces under w~ch payment from ~e ~[ could or Ibr the ~nelit of [he individu~, ~e ~nJon of the co~us from which, or Ihe income on the co~us from which, payment [o Ih~ Jn~vidu~ could ~ made shall be considered resources syllabic lo ~e individual. ~d payments from d~u[ ~on of die co~u~ or income-- (1) [o or for the ~ne~l o[ thc individual, shall be considered income of ibc individual. and (11) tot ~y oihcr pu~sc, shall be considered a ~s[cr of ~sc~ by ~c individu~ subjcc[ lo subscclion lc); and (ii) any ~nion o[ thc ~sl [rom which, or any income.on ~c co~us [rom which, no p~ymcm could under any circumstances bc made [o dic individual shall ~ considered ~ of thc date of c~[abli~hmcnl al' thc ~msl {or. if later, dm dare on which puymcm to the individual w~ [orccloscd) [o ~ asscls dish,cd by mc individu~ IBr pu~scs of subsec- tion (cl. and ~e value uf thc [msl ~hall ~ dc[e~incd l~r pu~scs o[ such subscc[io~ by'including thc ~oum o[ any payments inad~ from such potion og Ih: ~usI aJlcr such dale. (4) ~is subscclion shall nor apply ~o uny o[ Ihc following Imsu: (Al A ~st conlaining ~c us~c~ of an individu~ under age 65 who is disabled (as dclincd in section 1614(a}(3) [42 USCS ~ 1382c(a)(3)1) and which is established I~r thc ~nc~l such individual by a purcm, grandparcm, legal gu~di:m of ~c in~viduul, ur u cue, if thc S~tc will receive all ~iounls remaining in Ibc lmsl u~n Ihc dca[ll of such individual up an amoum equal ~o ~c lural medical ~sisluncc paid un ~huJ[ of Iht individual under S~a~g plus under diis lUIc [42 USC~ ~ 1~9b cl (~) A ~sl established in a S[u~c IBr [hc bcnclil of an individu~ (il thc [ms~ is core,sod only of ~nsion. S~iul SccuH[y. ~d other income to ~c individual (and accumulated income in the (ii) ~hc Sm[c will receive all umoums remaining in ~he lmsl u~n die dcafl~ of such 178 SOCIAL SECURITY ACT 42 USCS § 1396p individual up lo an amounl equal Itl Ihe Iolal medical assistance paid on behalf of the individual under a Slulc plan under Ibis lille [42 USCS §§ 1396 el seq. I. and IiSi) Ibc SluI¢ IllUk~ medical assistaflcc available ~u individuals descried in ~CClion 1902tall 10ffAffli~lV) 142 USCS ~ 1396alaR 10)(ARii)(VjJ. bm d~s nu~ muk~ such sis[ustc available Io individuals I~r nursing l~cili{y se~i~es und¢r ~c~lion 1902(aR 142 USCS ~ 1396aiul(10~lC)J. lC) A Ims~ uonlainmg Ihe assets of an individual who is disabled t~ defined in ~ciion 1614(a)(3)) 142 USCS ~ 1382clu~13)1 mat mee(s the Ibllowing condinons: ~i) The ~ms[ is established and managed by a non-profit ass~ia6on. (iii A scp~u[~ acuuum is maimaincd Ibr each benclici~ of ~h¢ [msL but. for O~' iflv¢slln~lll a~d fll~ag¢fll¢fi[ of funds, the I~Sl pooJ~ Ihcs¢ (iii) Aucoums in ~¢ ~m~ ~e ~stablishud sulcly Ibr ibc bcncfil of individuals who ~ disabled las detined in section Ibl41aJl3)) 142 USCS ~ 1382clu~(3)J by ~he grandp~em, ur legal gu~diun of such individuuls, by such individuals, or by a court. {iv) To ~ ext~m Ihul umounls remaining in the ~ncficiu~'s accounl u~n thc dcu~ of the bcnclici~ are SOl retained by (he [~sI. Ibc [~Sl pays [o thc Slalc front such remain- ing amounts in Ihe acCounl ~ ~oum uqu~ io ~e lois] ~oum of medic~ paid on ~hall' of ~c ~n~dci~ under thc Sta[~ plan under ~is title [42 USCS ~ 1396 et seq. I. ~5) ~e S~ate agency shall establish pre,dares {in accordance wi~ st~d~ds s~cified by Secret~) under which ~ agency wmves ihe application of Ibis subsection with res~cl ~o an individual if ~e individual establishes ~at such application would work ~ undua h~dship on me individual ~s delermincd on the basis of cntcna established by ~he i6) The ~enn "lmsl" includes any legal instrument or device that is simil~ to a Imsl but includes an anno,y only m such ext~m ~d in such manner as thc Secrel~ s~cifics. lc) Deflations. In ~is section. ~e l~llowln~ d~initions shall apply: (I) ~e Ic~ "assels". wi~ res~c~ Io ~ individu~, includes all income ~d resources of ~e individual and of the individu~'s s~pse, including may income or resources winch ~c individu~ or such individu~'s s~use is cmill~d to bo{ d~s not receive ~cause of aciion~ {Al by lh~ individual or such individual's spouse. lB) by a ~on. including a court or adminisuadve ~y. with legal au~omy io act in place of or on ~halt' of ~e individu~ or such indiwdual's s~use, or lC) by ~y ~rson. including ~y court or administrative b~y. acting at ~e direction or u~n ~he request of the individual or such individu~'s spouse. (2) The [cnn "income" h~ the racing given such tem~ in section 1612 [42 USCS ~ 1382aJ. (3) ~e tcm~ "instim6on~ized individu~" m~ans an individual who is an inpatient in a nurs- ing 13cility. who is an inpatiem in a medical inslimtion ~d with res~c~ lo whom payment is mad~ based on a level of c~e provided in a nursing facility, or who is descried in section 1902{a)(10){A)(ii)(Vl) [42 USCS ~ 139ba~a)( 10}{A)tii)(VljJ. (4) ~e lerm "noninstimtion~ized individual" means an individual receiving any of ~e settees s~cified in subsection loll)lC){ii). (5) The [crm "resources" has mc meaning given such te~ in sec6on 1613 [42 USCS ~ 13826J. without rcg~d {in ~e cas~ of an institution~izcd individual.) ~o ~e exclusion descried an subsection (a)(I) of such suction. ~As amended Aug. 10. 1993. P. L. 103-66. Tille XI[I. Ch ~ Subch B. P~ 11. ~ 1361I(a~c). 13612(aH{cL 107 Stat. '~n 627.) IIISTORY; ~NCIL~RY LAWS AND DI~IV~ Amendment: 19~3. Act Aug. 10. 1~3 (applicable ~ provided by ~ 13611(c) or' such AcL which ap~a~ as a note ol this section), in sub~c, icl subtUlulcd p~a. (I) for one which read: "~1} In order Io mee~ Use reqmrcm~nss of Ibis subs~clion (for pu~ses of 1~2(a)(51 )(U)). Ihe S~asc plan mom provide lot u ~d~ of ineligibility fur nursing facdily ~sccs ~ld Ibr services under section 1915(O in thc CaS¢O[ an inaihulionalized individual ' (~s detiucd in p~agraph (jj) wh~. ur whose ~use. a~ ~,y [hnc during or at(ct ~c 30-mou~ ~ in,nedia~ely belbre thc date Ihe individual ~comcs an inalitulionahzcd individual ~C indivldUdJ it clnnlcd io medical assistance under Ihc Stutc pl~ on such da(c) or, if thc insli[ulionaJizcd individual disposed of rcsou~co for Ic~ d~an fair markc( value. ~sc of incligibihly shall ~gm ~uh thc inondl in which such resources were [r~s~cncd and dsc number of momh~ m such ~rs~ shall be cqu~l IO d~e lesser "lA) 30 ninnlhs, or "lB) Ill {he Iol~l uncom~nsuled value nf Ihe ~sourc~s so ~rans~ened, divided by Iii) VERIFICATION I vedfy that the statements made in the foregoing Petition for Court Approval to Fund OBRA Trust for an Incapacitated Person are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: · .,,1 Kathleen M. Cleveland q ::: d 6- di'! :-_'0,