HomeMy WebLinkAbout01-10-12IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
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ESTATE OF RAYMOND CLARK, c
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AN ALLEGED INCAPACITATED PERSON `~' ~'` c_. ~ .
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PETITION UNDER §5511 OF THE PROBATE, ~ _~ A*,e, ~ ':
ESTATES AND FIDUCIARIES CODE TO ADJUDGE ~' --- `~' a
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RAYMOND CLARK TO BE TOTALLY INCAPACITATED AND `~~
APPOINT A GUARDIAN FOR HIS ESTATE AND HIS PERSON
TO THE HONORABLE JUDGES OF SAID COURT:
Golden Living Center -West Shore ("Petitioner") respectfully represents that:
1. Petitioner is a skilled nursing facility wherein resides Raymond Clark, an alleged
incapacitated person.
2. Raymond Clark was born on March 1, 1942 and is currently 69 years of age.
3. Raymond Clark resides in a private nursing facility in Cumberland County, whose
address is:
Golden Living Center -West Shore
770 Poplar Church Road
Camp Hill, PA 17011
4. Because Raymond Clark resides in Cumberland County, this Court has
jurisdiction pursuant to § 711 (10) of the Probate, Estates and Fiduciary Code and § 5512(a).
5. To the extent of Petitioner's knowledge, Raymond Clark has the following living
relative
Name:
Diteasha Daniels
Address:
620 Ross Street
Harrisburg, PA 17110
Relationship:
Daughter
6. To the extent that your Petitioner has knowledge thereof, Raymond Clark owns
no assets of significant value.
7. Raymond Clark receives a monthly income stream consisting of Social Security
in the amount of $1,344.00 and a pension in the approximate amount of $819.00.
8. To Petitioner's knowledge, Raymond Clark was not a member of the Armed
Services of the United States and therefore is not receiving any benefits from the United States
Veterans' Administration.
9. An application for Medical Assistance benefits was filed on Raymond Clark's
behalf; however, this application was denied on October 13, 2011 due to the failure to provide
requested financial verifications to the Cumberland County Assistance Office. (See a copy of
Notice dated October 13, 2011 attached hereto as Exhibit A.)
10. Petitioner attempted to contact Raymond Clark's daughter, Diteasha Daniels, by
telephone on several occasions requesting assistance with Raymond Clark's Medical Assistance
application; however, to date, Diteasha Daniels has not provided all financial verifications
requested by the Cumberland CAO.
11. To Petitioner's knowledge, Raymond Clark has not appointed an agent to act on
his behalf under power or attorney, nor has a guardian been appointed to act on Raymond
Clark's behalf.
12. Raymond Clark's treating physician is:
Dr. Edward Lamarque
2920 Market Street
Camp Hill, PA 17011
13. Dr. Lamarque diagnosed Raymond Clark as suffering from dementia, a condition
which causes incapacity and requires that he receive 24-hour-a-day care.
14. Because of the lack of a representative willing to act on Raymond Clark's behalf,
and due to the onset of Raymond Clark's dementia, there may be no less restrictive alternatives
to the appointment of a Guardian of the estate and person of Raymond Clark.
15. Because of Raymond Clark's dementia, he is totally unable to manage or even
appreciate the significance of his financial affairs, property and business and to make and
communicate any decisions relating thereto, including the ability to communicate his need for
assistance in these areas.
16. Because of Raymond Clark's dementia, he lacks the capacity to make or
communicate any responsible'decisions concerning his person and is unable to attend to his
personal hygiene or to keep himself properly nourished and hydrated or communicate to others
his need for assistance in these areas.
17. Because of the severity of Raymond Clark's dementia, the assistance of other
persons or services would not enable Raymond Clark to participate in the making of any
decisions concerning his estate or person.
18. The severity of Raymond Clark's dementia requires that a plenary guardian be
appointed to manage his estate. Said guardian should be appointed to manage and handle all
aspects of his estate, specifically including, but not limited to: all issues relating to his cash,
checks in any bank or savings account held in his name, his stocks and bonds, his personal
property, his real estate, his life and other insurance of which he is a beneficiary, his entitlement
to any government ornon-government benefit plans, federal, state, local taxes, trust accounts of
which he is the beneficiary, claims made or to be made on his behalf or against him, the
execution of documents, the entry into contracts affecting him and the payment of reasonable
compensation or costs to provide services for him.
19. The severity of Raymond Clark's dementia mandates that a plenary guardian of
his person be appointed to handle all issues relating to the person of Raymond Clark, specifically
including but not limited to: his living arrangements, his medical and psychiatric care, the
administration of medication to him and the employment and discharge of physicians,
psychiatrists, dentists, nurses, therapists, and other professionals for his physical and mental
treatment and care.
20. The proposed guardian of the person and estate of Raymond Clark is:
Keystone Guardianship Services
P.O. Box 804
Elizabethtown, PA 17023
717-674-5 75 7
21. The proposed guardian, Keystone Guardianship Services, does not have any
adverse interests to the person or estate of Raymond Clark, and an acceptance to serve as
guardian of the person and estate is attached hereto as Exhibit B.
22. Keystone Guardianship Services has been suggested as guardian of the person and
estate of Raymond Clark because they have extensive experience in handling such matters.
23. To Petitioner's knowledge, no other Court has ever assumed jurisdiction in any
proceeding to determine the capacity of Raymond Clark.
24. Due to the limited resources of Raymond Clark, Petitioner requests the fees of
court-appointed counsel for Raymond Clark be paid by Cumberland County.
WHEREFORE, Petitioner prays that a Citation be issued directed to Raymond Clark to
show cause why he should not be judged a totally incapacitated person and Keystone
Guardianship Services be appointed permanent plenary guardian of his person and his estate,
with notice by personal service to Raymond Clark.
Respectfully Submitted,
Date: ~~ ~ fl %1 By:
A~ofney LD. No.!68278
Benjamin J. Glatfelter, Esquire
Attorney I.D. No.: 203935
KENNEDY, PCLAW UFFICES
P.O. Box 5100
Harrisburg, PA 17110-0100
(717)233-7100
Attorneys for
Golden Living Center -West Shore
ExHis~T A
2819-11
CONSENT OF PROPOSED GUARDIAN
Keystone Guardianship Services does hereby certify they are willing to act as
permanent plenary guardian of the person and estate of Raymond Clark, an alleged
incapacitated person, if the Court shall so appoint.
Further, Keystone Guardianship Services hereby certifies they are not a fiduciary
of any estate in which Raymond Clark has an interest nor do they have any other interest
currently adverse to Raymond Clark's person or estate.
Dated: /a~ ~~//
Signature
Print: l,C7NSTAnIG~' ~ erjt~NF ,~U~ ~
Title: ~R e S ~ D 6 n17"
Keystone Guardianship Services
EXHIBIT B
OCT-24-~D11 1~:?t~ From:i1r76~~85C~ Faee:4~16
Notice ID: 9005863316
CUMBERlANO CAO
33 WESTMINSTER DRIVE
CARUS~E, PA 17013-9976
M3;1 oats, 1a13~2o11
RAYMOND CLARK
,~• Pennsylvania
DEPAATMEN7 OE pU9LtC WELFARE
OFFICE Of WCOME Ma1NtENaHCE
Record ID' 21/0162532 Telephone: 1-800-2fi9-0173
Notice 10; 90058&3316
_XXQ RQ- .~.- COMPAcS~~fhgfasrarrd~asyw~ta`~spty-for Genefils - _.
- CAAAP HILL, PA 17011-0000 ~ v1IVVW Co~Y1RdSS.state.pa.us
DEAR RAYMOND CLARK,
We received your request for the following benefits. If you have a question, please call the
number fisted above.
Which benefit?
r
>~~ ~ Medical Assistance
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® Long Term Care
d
This is a summary of your benefits.
You can find more information inside, this letter.
Your eligiblity for benefits has been reviewed and you do not
qualify for Medical Assistance because you did not give us the
infomlation we asked for. Read this letter for more
information.
If you do not agree with this decision, read the flier that came
with this fetter called "Your Right to Appeal and to a Fair
Hearing."
Fill out the Fair Hearing form, then mail it or give it to your
caseworker by November 12, 2011. _ _ _ , _ _
•You do not qualify for payment of services in a Long Term
Care facility because you did not give us the information
we asked for. Read this letter for more information.
If you do not agree with this decision, read the flier that came
Your benefit information is continued on the next page..
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if you have a disability and need this letter in large print or ono#ter format, ~w
`please call our helpline at 1-80~-692-7462. TDD Services are available at
01-800-451-5886.
If you do not agree with our decision, you have the right to a Fair Hearing. To learn more about Fair s
Hearings, read Your Right to Appeal and to a Fair Hearing.
Do you need legal help? You can get free legal help by visiting:
MIDPENN LEGAL SERVtCES
at 401-d05 LOUTHER STREET, CARLISLE:, PA 17013 or by calling (717) 243-9400.
~...
OrT-24-2N11 15:36 From:7177637C5[
Which benefit?
F'aue:5~16
Notice tD~ 9005$63316
This is a summary of your benefits.
Yqu can find more infgrmation inside this letter.
with this fetter called "Your Right to Appeal and to a Fair '
Hearing."
' Fill out the Fair Hearing form, then mail it or give it to your
caseworker by November 12, 2011.
_~ .____.~..._.._.,.___. ~..._:H.,.
.:._. _.~,., . ,_M.._.. _~_,.._. __~_~ _ . ~
GCT-c4-2~111 1~:?t. From: f177537G5C~ F'aGe:6. 1E
Notice 10: 5005863316.
Your Medical Assistance Benefits
- -- -
Who does not qualify?
Who? When? 9
RAYMOND ~ ~ ~ -__-i October 12, 2011
._
;This is the law we used to make this
decision: 55 Pa. Code §§ 125.1(d), 155.2,
181.1 (d ), 201,1, 201.3, 201.4, 257.24
"_ ~ _....-_ e
RAYMOND' (Starting 1011212011) You do not qualify for this benefit because you failed to provide
s information needed to decide if you qualify. The following information was not received: ":
;;
i S
;Name(s): Items(s): i
RAYMOND CLARK -VERIFICATION Of PENSION AND GROSS AMOUNT
s - VERIFIGATION OF BANK ACCOUNTS :i
-ALL RESOURCES 1
a
N
This information was due by 10112/11.
If you do not agree with this decision, read the flier that came with this letter called "Your Right to
Appeal and to a Fair Hearing."
L
~' Fill out the Fair Hearin fo~,,rm, then mail it or ive it to fur caseworker b~November 12, 2011.
t ._~._._-__~..~.~..~..~.._.__. ~. -
Long Term Care
Who does not qualify?
who?
RAYMOND
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tltrher,?
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October 12, 2011
.
This is the law we used tv make this decision:
55 Pa. Code §§ 125.1(d), 1552, 181.1(d),
201.1, 201.3, 201.4, 257'.24
RAYMOND: (Starting 10/12/2011) You do not qualify for payment of services in a Long Term Care
facility because you do not qualify for Medical Assistance.
i
If you do not agree with this decision, read the flier that came with this letter called "Your Right to
Appea! and to a Fair Hearing."
Fill out the Fair Hearing form, then mail it or yi_ve it to your caseworker b~Novernber 12, 2011. _ _
t ..._ __..~.~____,~....__ _...... .------_. _ _ _._.....
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