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HomeMy WebLinkAbout04-01-13 David R. Galloway Attorney I.D. No. 87326 rn 54 E. Main Street © ca Mechanicsburg, PA 17055 f'`' Telephone: 717-697-4650 rn r-� rn rn Facsimile: 717-697-9395 " C, C� IN THE COURT OF COMMON PLEAS OF CUMBERLAND C PE1SNIA .. c.� €. m c- Cn Q IN RE: ) ORPHANS' COURT DIVON ESTATE OF FLORENCE M. FASICK ) ESTATE NO.: 21-12-0271 BENEFICIARY PETER MONTGOMERY'S RESPONSE TO PETITION OF APPEAL BY ELIZABETHTOWN COLLEGE FROM PROBATE OF DECEDENT'S AUGUST 5,2011 WILL AND NOW, comes Peter Montgomery, by and through his counsel, David R. Galloway, Esquire, and responds to the Petition of Appeal by Elizabethtown College as follows: 1. Admitted. 2. The allegation contained herein is a conclusion of the law to which no response is necessary. 3-5. Respondent admits Bethesda Mission and Nursing Foundation are beneficiaries under the probated Will. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the remaining allegations contained herein. 6-9. Admitted. 10. The allegations contained in this Paragraph are admitted except for Marcia M. Montgomery's address. Ms. Montgomery's address is 660 Bamberger Road, Etters, PA 17339. 11. The allegation contained herein is a conclusion of law to which no response is necessary. 12. Without admission or denial as the allegations contained this Paragraph refers to a written document which speaks for itself. 13. Respondent admits Nancy L. Grady was Mrs. Fasick's only daughter. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the remaining allegations contained herein. 14. Admitted. 15. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the allegations contained herein. 16. Admitted. 17. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the allegations contained herein. 18. Admitted. 19-22. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the allegations contained herein. 23. Without admission or denial as the allegation contained herein refers to a written document which speaks for itself. 24. Admitted. Respondent has produced a copy of the power of attorney acknowledged on January 4, 2011, copy attached hereto as Exhibit "A." Respondent has produced an agency accounting; upon agreement of Petitioner and concurrence of the Office of Attorney General, said accounting was not filed with the Register of Wills. 25. After reasonable investigation, Respondent is without sufficient information or belief as to the truth or falsity of the allegations related to Ms. Dahmus' "periodic"visits. To the extent a response can be formulated, Ms. Dahmus' visits were no more than once per month or once every other month. All allegations regarding Mrs. Fasick's deteriorating health are specifically denied. To the contrary, Mrs. Fasick remained intellectually sharp and attentive until a few weeks before her death. 26. Respondent admits, in November 2010, Mrs. Fasick was using a wheelchair due to a back injury she suffered while being moved from a dental chair during a recent dental visit to have several teeth extracted. 27. In December, 2010, Respondent admits Mrs. Fasick, due to her back injury, would not be returning to her apartment in the independent living section of the Woods at Cedar Run but instead would remain in the assisted living section. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the remaining allegations. 28. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the allegation contained herein. To the extent a response is necessary, Mrs. Fasick remained intellectually sharp and attentive until a few weeks before her death. 29. Admitted in part and denied in part. Respondent admits after a fall while residing in her assisted living apartment at the Woods and a brief stay at the hospital, Mrs. Fasick was moved to the skilled nursing facility at Bethany Village at the end of April 2011. While there, she received rehabilitation therapy multiple times to get her walking again. In mid-August, Mrs. Fasick returned to an assisted living apartment. Respondent specifically denies Mrs. Fasick was bedridden. 30. Admitted in part and denied in part. Respondent specifically denies Mrs. Fasick suffered a heart attack at this time. Between June and September 2011, Mrs. Fasick resided at Bethany Village and was receiving rehabilitation therapy from her fall in April 2011. Respondent believes Mrs. Fasick fell in the bathroom in mid-April 2011 while at the Woods and was then transferred to the skilled nursing facility at Bethany Village for rehabilitation. During the first week of August, Mrs. Fasick moved into an assisted living apartment within Bethany Village as she no longer required skilled nursing care. It was in her assisted living apartment that the August 5, 2011, will was executed in the presence of James D. Bogar, Esquire. 31. Admitted. 32. After reasonable investigation, Respondent is without sufficient information to form a belief as to the truth or falsity of the allegations contained herein. In repeat conversations with Respondent and Attorney Bogar, Mrs. Fasick decided to revise her will not only to increase her initial bequest to Respondent but also to include the Nursing Foundation of Pennsylvania and others in her list of beneficiaries. 33-35. Without admission or denial as the allegations contained in these Paragraphs refer to a written document which speaks for itself. 36. Admitted. 37-38. Without admission or denial as the allegations contained in these Paragraphs refer to a written document which speaks for itself. 39. Respondent admits he was acting as Mrs. Fasick's power of attorney from January 4, 2011, through the date of her death. 40. The allegation contained herein is a legal conclusion to which no response is required. 41. Denied. To the contrary, Mrs. Fasick remained intellectually sharp and attentive until a few weeks before her death. 42. The allegations contained herein are specifically denied. Respondent, acting at the request of Mrs. Fasick, facilitated Mrs. Fasick's research of local nursing scholarship programs that eventually prompted revisions to her will. Mrs. Fasick conveyed her disappointment that Petitioner did not offer a nursing scholarship program and that she wanted to start a nursing scholarship fund. Any increase in the bequest to Respondent was at Mrs. Fasick's specific request to Attorney Bogar. 43-45. Denied. The allegations contained in these Paragraphs are conclusions of law to which no response is necessary. To the extent a response is necessary, Mrs. Fasick revoked the 2009 Will when she executed the 2011 Will. Furthermore, Mrs. Fasick remained intellectually sharp and attentive until a few weeks before her death. See Support Plan dated September 3, 2011, and December 22, 2011, attached hereto as Exhibits "A" and "B," respectively, which shows that neither cognitive nor mental health services were needed. 46. Admitted. WHEREFORE, Respondent, Peter Montgomery, respectfully requests this Honorable Court deny Elizabethtown College's Appeal From Probate of Decedent's August 5, 2011 Will. submitted, David R. Galloway# 326 Counsel for Respo ent ASSISTED LIVING RESIDENTAL LICENSING RESIDENT SUPPORT PLAN FORM §2800.224(c), 2800.27 - (Preliminary support Plan-to be completed within 30 days prior to admission or within 15 days after admission if certain conditions apply. Final Support Plan to be completed within 30 days after admission;revised annually or if significant change in resident needs.) 1.Name: Florence Fasick 2. Birthdate: 06/30/1910 3. Rm/Apt#: 333 4.Type of Plan: 5. Date of Support Plan Developed: 09/03/2011 ❑ Preliminary X Final 6. Date of Admission: 07/30/2011 ❑ Annual ❑.Significant Change 7..Medical 7 Service Needs 1. Florence sees Hampden Physician Associates for her medical needs. ID ; 2. �t�a.�.+e 1f- .D ; c 3. p ir'v► t,�l�,�.� 4. A I e! i e� ��. �- go-(Ac-f• e. , -S pa-P-1-vu< C! , � s Plan/Activity Frequency or Schedule Position Responsible Schedule appts Yearl /PRN Doctor 8 Ab" `of:the =` m i.... Y. es del ,toel : :r�,t AAed� ral [ �d� r, r,tdr � WItlo Service Needs 1. Florence requires the nurse to administer medications &4M/-r) , 2. 1" vi+r' v G n Plan/A&Avity Frequency or Schedule P06ition Responsible Cv*, Or Administer medications As ordered Nurse Service Needs 1. Florence is independent with oral hygiene 2. 3. Plan/Activity Frequency or Schedule Position Responsible Brush teeth Daily Self 10,; alre Services! . #ivt� �f t Service Needs , 1. Florence requires assistance with securing and managing health care. 2. Florence requires assist with securing transportation. 3. Plan/Activity Frequency or Schedule Position Responsible Secure and mange healthcare As needed Nurse, BV Secure transportation As needed Nurse, BV 11. Personal:Hygiene k Service Needs 1. Florence requires assist with weekly whirlpool, but independent with daily hygiene. 2. Florence is independent with dressing and grooming 3. Plan/Activity Frequency or Schedule Position Responsible Weekly whirlpool Weekly RA Independent with dressing and Daily Self roomin 12.. Mobil it r Service Needs 1. Florence is independently mobile with walker. Wheelchair for distance. 2. PTIOT eval-- 3X week both therapy. Eval 08/05/2011 P p1G q� 3. Plan/Activity Frequency or Schedule Position Responsible Use walker Daily Self 13!.;Vision v t f J r r Service Needs 1. Florence is legally blind 2. 3. Plan/Activity Frequency or Schedule Position Responsible Assist where needed per resident As needed All staff -request 14.-Hearin y T y JS f i M Y £F k: J 4 ft Service Needs 1. Florence has bilateral hearing aids, but is able to hear without them as well 2. 3. Plan/Activity Frequency or Schedule Position Responsible Wear hearing aids As desired Self 15 D�eta FY 4- Service Needs 1. Florence requests breakfast tray at 9am. 2 3. Plan/Activity Frequency or Schedule Position Responsible Breakfast tray at 9am Dail RA 46 Gcmu.ncatonr/Uclearstandin Service Needs 1. Florence is able to communicate and no difficulty with understanding instructions 2. 3. Plan/Activity Frequency or Schedule Position Responsible : t Service Needs 1. No cognitive service needs at this time 2. Plan/Activi y Frequency or Schedule Position Responsible 183• etit10e1� h' Service Needs 1. No mental health service needs at this time 2. Florence has been assessed for the dangers of poisons and is aware not to ingest poisonous materials. 3. 14ao :1b,1,Aj tIj(,*,rr4.j.,,r* rj; i-h Anea� /And;.Ig rt L P/ 6. '64) Plan/Acti Fr qu or Schedule Position Responsible 19�Q►ther ehsv`�d t Cie: r `► yes .. .,.,. :..J le..r.rt k r Service Needs 1. Florence has no behavioral care services needs at this time. 2. 3, Plan/Activity Frequency or Schedule Position Responsible < o VR the"T. "{TAY' e5'"�T '.R•!wiF .tLe>i•.- �X`N :x_SL .aY..�'. Y .9: '�.➢ .,c+.ih a.� .1.F`}- Service Needs 1. Florence is independent with bowel and bladder function 2. Florence is independent with transfers and mobility 3. Plan/Activity Frequency or Schedule Position Responsible Encourage independence Ongoing , All staff i 21. Social/Recreational Service Needs 1. Florence enjoys pla 'n bin o n playingthe piano. 2. oc L � ,:Qn�e 3. Plan/Activity Frequency or Schedule Position Responsible Inform of activities Ongoing All staff Encourage activities of choice Ongoing All staff rn L6AAhd -4-P.0" 22 Other=services a Service Needs 1. 2. Plan/Activity Frequency or Schedule Position Responsible 23:.Referrats to.Qua isle 5 Service Needs 1. No referrals to outside services needed. 2. Plan/Activity Frequency or Schedule Position Responsible 24 ..Strate yes<t a ?rs�m: # :Inter:.actwe �.c unic lion he Part a�f}and�e eei;.Rire Q eP a .: h o� min :� tvv c at #a# xrd �--_ .: :ti :-: r f !!'._:. '' ! 6 :E.} .5�'k y c•.7' `�. Indwid Z: es t_ F ;J]Q y■ �.>g;A. r r .a� -', '\ 1: , f r.:!r f 3Ar ...t •p 7 :?�' y_ - •'; S'4. 4 ! t ��� { .i `et• .s, ia. . -�i, 4. i. s s« r t t r ... - t, t.. -fit .':.':. c,4 �-� � i �*,X•c f;t�t. ar ?xfst,:� �,T .•,7, -�'.,'r+�. yatFc� .�� rt;a£i ,ir i . 1. 2. 3. 25 is the Resident Ab1e'tohSafeJ a:ratk�e 1ck�n ;Dev�ces'� X Yep CI`N/� r T i r `- 2f, Is t e eside ble Q of I Use Rotsbn s Pe- n'a Q: re a`nd TQilet Items? rtt & �! ■M ?' '..t .•4 f S �"�j�'.5 '' ` {i'. �. .. x }.�..: 4:...s•f :,_�S .._ a rr:. -Q4•gc r.if� It.` :1 7v... :.¢- >afi?�`i, �f. : Y•..�„y '.r'w' s-;[; �h!� .w.. ::_�4 A sue •{.N i 'Y;- E t}S E `,;r T.i. 11-W: J esid.ent:Abl ao-S, f,el Use'O,t .,;r�Po:�sc� such ae qle ntn � l,�es . :` �C1�e y. 4rxt{(,}��xu :.�'�,jX _ Y:� _� R N'.r.i ::lt:'e it --/7 k {AJ!'.dt3'S •t 27 _Vl►asra,gn. ���f .1. n., Iv���•to t�q c��ldentldest ,�ted..,s ers,Qr�? �� �;Y�s D �Q �, �r��r�-� �,�. � }' 18;'.WVho_as'ist4d i i color .letin $u oa Ian:; .check all a 'I cable Signature: Date: � [Resident U; lnable to sign ❑ Refused to sign Name: .f_ Chi►' er Address: Lp�av� z-�d �'G'' c� ❑ Resident's family �� 1 `� ��--- member Telephone: Signature: Date: (if participated in the development) ❑ Unable to sign ❑ Refused to sign Names: Caren Tyrrell, Social Services; Dixie Brown, Activities Coordinator Signatures: ❑ Other _ J3 AC Names: Diana Reigart, LPN: Melody Workman, LPN: Ruth Burkholder, RN Signatures: ❑ Assisted Living Residence Staff Completing Form* P 9 J *RN, or LPN (under the supervision of RN)who Name: Kathleen Bolden, RN reviewed and approved the support plan. - Title: Administrator *required only if the person who ,�+0-', � completed the support plan is not an Signature: y`' Date: RN or an LPN under the supervision of an RN. 29,:Quartert ®uivy.of �l nor Pla Ls.� Date of review: Reviewed by: (print name and title) Signature: Date of review: Reviewed by:'(print name and title) Signature: Date of review: Reviewed by: (print name and title) Signature: ASSISTED LIVING RESIDENTIAL LICENSING RESIDENT SUPPORT PLAN FORM §2800.224(c), 2800,27 (Preliminary Support Plan-to be completed within 30 days prior to admission or within 15 days after admission if certain conditions apply. Final Support Plan to be completed within 30 days after admission;revised annually or if significant change In resident needs.) 1.Name: Florence Fasick 2. Birthdate: 06/30/1910 3. Rm/Apt#: 333 4.Type of Plan: 5. Date of Support Plan Developed: 12/22/2011 ❑ Preliminary ❑ Final 6. Date of Admission: 07/30/2011 ❑ Annual X Significant Change 'i•1'C-`Ft ,ia,` +.,.1. Fs ..,r��.s..!-" -�r:a i ?a•^- .:h� 'x. /,�, N.. 'yY', ab .t. rx ...�t i,r.xAf .,�J.;s*•. 'i? 'WY .F: R 1 a .t� �w'r h s.L 6Y 5�.1',j`r. '7'" sV -} t k` r-.. � ���.."1` c.�i-�S� a �i3�?�}r 't. YF '.. �i. `- M1 Sry.T:.�:�7�> K.r",i�...•{I}� �r; .i':f aFl r� - Service Needs 1. Florence sees Hampden Physician Associates for her medical needs. 2. DX: Constipation, Diabetes, GERD, Edema, Osteoporosis, (End stage CHF), CAD, Hypothyroidism 3. Allergies: Codiene Sulfate, K+sparing Diaretics 4. Odyssey Hospice patient—Appts scheduled per need as decided by Hospice staff 5. Plan/Activity Frequency or Schedule Position Responsible Schedule appts Yearl /PRN Doctor _ .,.: �;;,: <'. /t:' -:� :.;:Gt�'rv:D:�rt; ;pko3r :�Ar!' s 'y ^.,:.:,` t d d-'k,' s f'?t' :,� ,4 ,.!•� s�k'�„y' s7' ,.:. .....7r. :s e 3 � .r 1 ..�-. :t.c• .t `.-�i2. �" t t ! fi er a -a o / Lf r e i t i I t - , • t t .:,5'� .,Ad.. :I•� st IVI: Via. t� n ���. .4_ R . � .� s �� t ��: �Q -;. Service Needs 1. Florence requires the nurse to administer medications 2. Florence requires the nurse to do Accu4s twice weekly 3. Plan/Activity Frequency or Schedule Position Responsible Administer medications As ordered Nurse AccuT Twice weekly Nurse 3. iii". i�-.» „�`-. ?,#.. �v�+ 3>- ,� s .w ,�i •:z.,t+ .+�%: K'x. :'.Y 't .fit.:'. .e1.•�.....,y d�'i 9+e.j-.SS.'rli✓ E .,� 4 ...[�}a�E.if f ..'�ar} �4t. s -i:..,t 14t: •,a t c �s?"�K,- � a.<:L=f pY �i�s`� .a �-,k t }' �Y: <:����f:. ,}. -i � '.i {•.h'.k:i, ,.y,if •� :d Fv � �.. ?;-. �..}a3 l�..l �.::Y .(.L 45:K`t_..F ..�T �:?_. ...�'4 ,..l. 1. Service Needs 1. Florence is independent with oral hygiene 2. 3. Plan/Activity Frequency or Schedule Position Responsible Brush teeth Daily Self .t�.(t •�;,. .'.: :',' -. _ ..':...,: ..'ry .F'• r.'::d ai .. -,. :-.t.,. s.- - rr 1 ik z; �i,..J���^77 .:y4 L!'t a�,s ?7- a�, ii '-'� -:l-.C'}� a�- r.'..��,il��' Yw„ ! i r � 'FS:..>r �r �ti�J l' �•. �M1�T ]? -,��/y g 7r"ti _ ,1 i SA 3{ G.:' ,�A J� T ':..� J Y+1; `.`^y:. :..�!- •K'.. .� '�,i ,;�! .: f -�'-a.Fsi-:.�St C,.an,ryn .:7. .".T,`T. '.?r,t y Service Needs 1. Florence requires assistance with securing and managing health care. 2. Florence requires assist with securing transportation. 3. Plan/Activity Frequency or Schedule Position Responsible Secure and mange healthcare As needed Nurse, BV Secure transportation As needed Nurse, BV "(," i "'F c...:�lrY.-:� 7r.,x;-� �� "iN,�.. .--.:s;, r'.# �':b',,-q F�j. a�zr t r i.s.- �.; :.9 y x,j•,.vi t'•. ,...z 4t r.' -�, ,,•-`.�- !Cf �..c'j}'V! { :x '�� a t afi I,x ,v s .r..t 'z.. j.. �e- r R - : .Al..:.a..: - ...rr .r.h v:.. 1 ...,..._.r�..rza...•:-y.n,. ,r.-..:.,y�n:. -.;, .....- a� h...�e� .�� v.`.� ;.Y:S. ..I Service Needs 1. Florence requires assist with weekly whirlpool and daily hygiene. 2. Florence is independent with dressing and grooming 3. Florence requires assist with pa nts and undergarments in AM Plan/Activity Frequency or Schedule Position Responsible Weekly whirlpool Weekly RA Assist with dressing and grooming Daily RA �..�„- .y �" .� :,,> s };`''?r ,-";e: `.�,„—, M�.•. �.. 53,:x= a +f.Y;s_ ,� 1t3� �,� icy'" 3 .�+'etF y,„�"sy.. 'rrar .>t � ��' .sa 3�iihMr4 i. it ..s• .{T�� .}�`.fb :'�>' � -4'aa.:.>r't:v >rb a3':.:;. �€i-@_�a:�.ai M�f{ �[� :'Sii.i a'} �r'S' •P!�4i, c_' ..,. ..,...+1:. a. ' '-��,+ v�'� ;v:)s� �}" �. .. '���.. ;. .t:rb. :�t'_ $�..57.� rf 'P' ,rc....`f�z..r .x .�✓.r..f-.... .n-Y ...A:it�_s. � 'T'°'E,J<... orC. Service Needs 1. Florence is independently mobile with walker. Wheelchair for distance. 2. MOT eval-- 3X week both therapy. Eval 08/05/2011 3. Plan/Activity Frequency or Schedule Position Responsible Use walker . Daily Assist .:i_te:'7' r�•` t 't...i=.v: � f g� '{: a+' .� �.� 4,v.. l .1:'� Y '9r;. �y�: t S.4::'<k` i.:f:�� .�!-:. �:j .,��, �it^,x.'?.=f- - .t ..44 4. Yi`. �'.F.� rtii'.'t!L.—t', Y'-. �f:. S� Y'.^ �. ,�f. .?'.),Y 1:k7.:t:, J i. al'�d�y: } •� f' r� .0 r.��. .,\..'M•le '�-. t R +7x�'ti.,;.J 1... � ,�'� a ,u. �.-�,.*” ,✓ .:�s'3�4� i_ y t#�i }. �Y .�??'-.�_r: s< ��i:�:�^s m;.:.n s,. tZ, �s .t Ie,F�'�`:r d'.5,; 'y�.�.:`�fS� � � 4. ?Y`, s4��'+ 4. 3•.t :.; ..r a;'if.;, [- :*,...,. S�°' y� x"_ __ r S 'k l':�'- �� - • s::+...,`t r i r. `1 x ..,.->, aa4.-.- ,:.y, i s :is.'c.r. .h: 'r :.s> 'r. , 'rt•`acd,,. Service Needs 1, Florence is legally blind 2. 3. Plan/Activity Frequency or Schedule Position Responsible Assist where needed per resident As needed All staff request ���..fix: 3...,...�.r rvf'a -i.'.yy,t�3-'�'j'°a� v.. ;�,..�c�..,�.. �� ��-t�� Ta_4,'x'S,v, �,.a'S ..r.s ";"T�.:.>� i ,y�:Y��' r'cy.:.i .'l�:lA•.T!<�s4 r. ''r` ��'s -x�tyy S ,�,.:<'-,y..2'"�f':'Y ?;',�-_ {'"`�. •;ZYS,. - .z� Nt`. ..s,4i`.�.41t yn.F - .�;, �w''" � '..:c���i `'�M.3+ryp �.5�$.,'�` ;'? �.��hy�.�.r y,'. i ,?� .c3iJi� °� x.�. ��. ,.{, �^n s• -a�'���*:.�Y...�.�'i�i;,y ,# ^*.,• s -- s'r- 'r. L§I! �'.+sni'.N��i'.;r.:u�. `1•b,!r•�?,s .e RF'i�. .,a Service Needs 1. Florence has bilateral hearing aids, but is able to hear without them as well 2. 3. Plan/Activity Frequency or Schedule Position Responsible Wear hearing aids As desired Self ... :.:.T.. i .:...>_c: r .::... r. .fir.;- �� ,_':+ ac�'.r_r:2•s � :,:;rte >sti. y uS``5, S r 1::tY`, C�'.g� -v': .K rt t �:;t'S`( '� ih.Ck tcq "t= t1 �.:•' � y.:c�::..�.,,`r=f,'.'i.! -r.';:..'3,.:�£P: �..> -rfG�3y,;u+`�',cs:?' .,,?:, .l���4 'x-Y"� x 7 � R =z x tr'�4 r' v �... ..:-' �. r... TF-}Pk'.x".f... ,>^.'.'cv!•4trSr1_, .N.�X.T:I... .."i`�., {, ...>:.;.i. kaxrra x^ ;t1}r!Rt `v_",'f'3'.��"t^3..FR:::a3,?'r, :`.'rY:_.tr3.. it��...YF<s t�"w �'%.,�rV..: .n7,�.'f;`F .4 al,t'h.._y J.:,'- �..a`,dt�d((��jG�.r�.z'}�Kht 7i ',iYj4ic.?AU Service Needs 1. Florence requests tray to room for all meals, due to difficulty with walking. 2. 3. Plan/Activity Frequency or Schedule Position Responsible Breakfast tray at 9am Dail RA y�, fiAb, -r' +•:, "ir- y v *i .is t'^,1t� t Fah M?�v ,:.km..� r t i vi i.�l4 ?',i �1 i 1 '� �s �L -x Service Needs 1. Florence is able to communicate and no difficulty with understanding instructions 2. 3. Plan/Activq Frequency or Schedule Position Responsible :::.. ­C Y. ,...i ■ ''+' .v:. -:.s.. {•. .is•..: i `ii, : • z .�,.• ..�..,;c ,,17:c'�+ry�:'�°:. a_y'° ! :-N: fi r.; LiXr; .�i..i '�-� 4;,';,�•r Y �AV �}`�.'" -i..t.: '+ '._ J... {•t F r,'t' ..kt. �`� � �� :.?, _k..�.+-1,-�T 5, s,.:..::3-a '. 1. � {t .r is 1. .4 Pl S a,,.. : .+•' �>. {. 4;.:d:9� J ��^�4�' Service Needs 1. No cognitive service needs at this time 2. Plan/Activity Frequency or Schedule Position Responsible w'm ♦y„ .... .':^:n i['Y �. :6' :� y,..2 :..'fl-y1h :,J.,: .'•-.Y.3 '.Z w .3 fi ; ��t{ ,�- .1•f r 1�' s3r 4'i�d �Y:'"� .w '` �, r c �,� f,a.-.`;...•[3i F,i:�.ter.; � r�,.''",,i *,?.:'�: �� ,:.+. ` '1.' lri. e 4r.':f�.�.:-.5° ,t..:..Y..., :4�i 9r:t�r.t - `"•a" a•R...!o-yla�a. ]-}"':�, s[r'!T"�:�'C.. )'a'.' _ ::�._.`�iJ.�a.. �ly. h .::1.;:. ...7°.1°i .6:ik.M .rs.�'?: Service Needs 1. No mental health service needs at this time 2. Florence has been assessed for the dangers of poisons and is aware not to ingest poisonous materials. 3. Has friend "Virginia" who visits frequently/assists Florence with individual activities 4. Plan/Activity Frequency or Schedule Position Responsible iS �, cP,i.r�a s�-. _s:.. �• �`'+Y.•i•i i d .,k�r'"1$`a r:�.�j r� � '3� dV'��. � iy�Ar_�.a' .:.� 'IF .: t_C:•. .��. � .� � ��� ��:R^„5.:. 1..•:t.__Y_5'..-_..'t.f'. } .:Si2S:.�"'si fr..,yY�.'i _._'7.,. i;''t r.::?.L't'i.i.�'s'fi...� - i.n.�r"L�.+1:'}- :._)Y;?�. �lid.. Service Needs 1. Florence has no behavioral care services needs at this time. 2.Piokr -f° . aA -c . a� '�- CrIC - "I .t► 4AJ V.,7" rk.ia��`. 3. Plan/Activity Frequency or Schedule Position Resp rnsible El A-r. 4-o jy yr' x:ii:� :s,:,f+ r itMEN I .1 W WIN '�t i�^" dct = .r■ yrA'S nJi+ ii .. .- .,_. Service Needs 1. Florence needs assist with bowel and bladder function . 2, Florence needs assist with transfers and mobility 3. Plan/Activity Frequency or Schedule Position Responsible -Encourage independence Ongoing All staff r �:, jiiir. 'r5) �.«L.tMs'*"yr�^l:, r3}t.��7+4Y�,fr�r'a'd •fi�t��,���?'i-��7"`�4X�''.s''k.. ir..�i( �''�.7?)k _'i'rt: "'.,R;,��}L`4� �•Lxt:t`�"',!'�; •i• ! �,y.p„fLJ,�.YSa;^ - iS,. •s�,.• �.;5• .':!.•� 'r�� �. -rY �:.'> �b� - k�n.l..• r. �"'�.'iS^` ;`5'y',:pT'-� )y ,..4-.•.�'�i f}:. . ., � r; �i��a�1;F � i �' ,>.� t, a s ;<TM F � F' i ..�"a•e'� w•snv. ,:,+b„ ,•..., ::. , -<.. . :..:a n..t.rte::?.. '�::f_✓.� er. -�:.. ..Y'!tsy.tt.) .t.: ..:)'f ..�i):•`�!. ,t:.. �:.Y,'�,w �+3:.�.Itk:4`d�.j`YA '�`'_3't�,+1�:F. +r c'� d ,x,1°�:.�e'`9 .;r,]�a l�t�y�y r.4 F�J. Service Needs 1. Florence enjoys playing bingo and playing the piano. 2. Has agency that spends lots of time with Florence doing special interest projects 3. Plan/Activity Frequency or Schedule Position Responsible Inform of activities Ongoing All staff Encourage activities of choice Ongoing All staff Provide opportunities for Bingo Ongoing All staff and Piano playing 1F• 'a l' fM `Y•(� :3'r.V F1 �' d,.. Y.�_. . .' : 1: �' A4)3 - �+:;t• 9V �W .!,/•;-'4i <i .Y -' iT. -y�•,} YF" 'i-; T"'• ''� `ue 'r�(��'w s£ 4u ��Ai:[� - �' -,y',�"�'rsi c`�•i'�9- < .t�ra.�(/._��YT ti yr.n '.`� ;Y+ t�?�r ,YtS'!. t f{ _ a; �• '.., '}° .'r; ': �+�+i./{r +L' t 'TS �!''i�-�a•§ r•°h�``A.rt�ta:rye.��S�'d�y �'. �?. .a *�` }P'� "+.n '«1� �P`� ��;a,.:�t, §,� .r .,t �'{s: Y�^i.�,f�+ r. A Service Needs 1. 2. Plan/Activity . Frequency or Schedule Position Responsible • :t.: •.- . -�.. yz. -..:.:,� r...�., f,...,ygh; ,r:� .. .� *rjl, _l'?;C."; *;a��....�YS� *i xk l.e.+.;r,'r-: :..#'' S! �.! uii4- -- ..:; ..s - '2- `. :.. ,. ;�. ... 1,4 k .�- <�r .•at_ �' N,/.};}'t�,•,t„'�''._v1'-s_ _s�. T` ..}r �f.�ti�'. '-�-'r 7' �Si;<,�:�`'�ii�a-•k:- ! sy.� ,} i7!�a.. ,;+' ^,s _ r d' ''-, '4't•:. 5 9' �t} ye, � •',� r�.,u:,.try ,.pt e±,; •�.�'� ,..f_:+,�:.' - '.° .��7"�..'t �'- ��• .�i': ` .. .�.. �x'�'&- '..X.::¢?S }P*�:4; "r,�•.� +�`J" �°� -ur ^��rt- �,s 3:Y'1' .� �R�•. �rgt.ti+e ... .•. •,sr .,•., -y��� f:.r.�. � .,..:t#�.t��f: Yx` 1,5,F1�,,.�� _i. �,�. ,.�':�-: Y� ,rr.. {•r.`. '� '�t ,,R S � �s{"4'-:.?_L �`� Service Needs 1. No referrals to outside services needed. 2. Referred to Odyssey Hospice Plan/Activity Frequency or Schedule Position Responsible '=1. r '�'ft?= .,).:.r J.7,f �..�, ri �";,�-. 'A,-...,'-,t r'!�"` .t, xs F2::.t�` - '.2t:#!u',y��1,�'�p' tr:',•y�.t x'�',:.:`,.tao .:,{ :-s ,.k.��Jy�� 44� 1,.:� 't! :.I L N� ..rQ �� t�- �4T �•� _1 �• }qy+b" +YY �>. ,�.5 4 n:��Trr�V.Y�' ��� � a i k ;� �.�'�Y,�.• t' t �ii3_.•� t � � � �ail T ^j�l'rt= ,'y yr. ;, .� y t ,s:. .u?x..�,. } 'tf}:. .t="'+�,}x�� sr'�� ''�# }y. 3 fS i f`d•'' .n:. 2s?. .y- •�T,.:l:: `FiW. Y5 �r{ rt 1. 2. 3. 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C��,` Q_� ' — Date: ' �.. ❑ Resident abl e to sign ❑ Refused to sign Name: Address: B'Resident's family , ' t1 member Telephone•. -D LA -L4 4 6 Signature: Date: p,�&t A (if participated in the development) ❑ Unable to sign ❑ Refused to sign Names: Car n Tyrrell, Social ervices: Dixie Brown Activities Coordinator Signatures: ❑ Other Names: Diana Reigart, LPN, Melody Workman, LPN: Ruth Burkholder, RN Signatures: i� ❑ Assisted Living �.-A 0• A C Residence Staff Completing Form *RN, or LPN (under the supervision of RN)who Name: Kathleen Bolden, RN reviewed and approved the support plan. Title: Administrator "required only if the person who completed the support plan is not an Signature: �' — ./�.�r V Date: RN or an LPN under the supervision of an RN. Date of review: Reviewed by: (print name and title) Signature: Date of review: Reviewed by: (print name and title) Signature: Date of review: Reviewed by: (print name and title) Signature: VERIFICATION I verify the facts set forth in this Response are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S § 4904, relating to unsworn falsification to authorities. Date: March 2013 By Peter Montgomery David R. Galloway Attorney I.D. No. 87326 54 E. Main Street Mechanicsburg, PA 17055 Telephone: (717) 697-4650 IN THE COURT OF COMMON PLEAS OFCUMBERLAND COUNTY, PENNSYLVANIA IN RE: ) ESTATE OF FLORENCE M. FASICK ) ESTATE NO.:21-12-0271 CERTIFICATE OF SERVICE I, David R. Galloway, certify I served a copy of the within Beneficiary Peter Montgomery's Response to Petition of Appeal on the below listed counsel this date via first-class mail,postage pre-paid, addressed as follows: Kendra D. McGuire, Esquire Marianna Davis McNEES, WALLACE &NURICK, LLC 2300 Dulaney Valley Rd. 570 Lausch Lane, Suite 200 Apt. C004 Lancaster, PA 17601-3057 Timonium, MD 21093 Michael T. Foerster, Esquire David R. Galloway, Esquire Sr. Deputy Attorney General 54 E. Main Street Pa. Office of Attorney General Mechanicsburg, PA 17055 14th Floor, Strawberry Square Harrisburg, PA 17120 James D. Bogar, Esquire Bethesda Mission One West Main Street 611 Reilly Street Shiremanstown, PA 17011 Harrisburg, PA 17102 Nursing Foundation of Pennsylvania Virginia Bone 2578 Interstate Drive, Suite 101 126 Clearview Drive Harrisburg, PA 17110 Camp Hill, PA 17011 Marcia Montgomery 660 Bamberger Road Etters,PA 17339 Res 1 submitted, By: Date: April ) , 2013 David R. Gallow