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HomeMy WebLinkAbout06-16-15 w Neil W.Yahri,Esquire C— M rn C0 Attorney LD:No. 82278 m JSDC Law Offices r...._ rn ► n P.O.Box 650 ' Hershey,PA 17033 ;'✓ --r, Attorneys for Petitioner r-, C r :3 rn M IN RE: CALENE M. CLOUSE, ) IN THE COURT OF COMMON PLEAS CD an alleged incapacitated person ) CUMBERLAND COUNTY, PENNSYLVANIA -' ORPHANS' COURT DIVISION On the Petition of ) J. Edward Clouse ) NO. 21-15-93 MOTION FOR HEARING AND EVALUATION AND NOW comes the Petitioner, J. Edward'Clouse (herein"Edward" or"Petitioner"), by and through his attorney,Neil Warner Yahn, Esquire, of JSDC LAW OFFICES, who upon valid information and belief hereby submits the below Motion for Hearing and Evaluation: 1. On or about Wednesday, May 27, 2015, a status conference was held in chambers with the Honorable Judge Masland following the Petition to Adjudicate Incapacitated and Appoint Plenary Guardian of the Person and Estate for the alleged incapacitated person, namely Calene M. Clouse (herein"Calene").' 2. At the status conference, Attorney Saidis represented that Calene signed new testamentary documents including the execution of a Power of Attorney naming Attorney Tricia D. Naylor as agent for Calene. 3. The execution of said estate planning documents was wholly inconsistent with maintaining the status quo as the parties vetted out a series of issues related not only to certain businesses,but also production of records related thereto. 1 Petitioner hereby incorporates all facts,averments,references and exhibits from his Petition to Adjudicate Incapacitated and Appoint Plenary Guardian of the Person and Estate(herein the"Petition")and Motion for Status Conference("Motion")submitted before this Honorable Court as if fully set forth in full herein. 4. Remarkably, Attorney Saidis appears to have relied upon a one page precis drafted by Dr. Jagadeesh K. Moola, MD, dated April 9, 2015 (marked as Exhibit"A") in concluding that Calene had testamentary capacity to sign new estate planning documents. 5. Dr. Robert Howse, MD, completed a separate medical evaluation on Calene on or about October 23, 2014 and memorialized on June 12, 2015 as set forth in the attached Exhibit «g» 6. Dr. Howse concluded a diagnosis of Dementia of Alzheimer's Type without behaviors. Calene clinically lacks the necessary capacity for decision making,rendering her unable to appreciate the consequences of designating an agent under a power of attorney instrument as well as unable to comprehend the contractual nature of changing'her estate planning documents (see Exhibit`B"). 7. In light of Dr. Howse's most recent evaluation of Calene, it reasonably follows that the report provided by Dr. Moola on April 9, 2015 is unreliable and subject to scrutiny. 8. At the status conference, the parties also addressed an independent evaluation of Calene and it was agreed each would exchange names of psychiatrists to then present,to this Honorable Court for consideration. 9. As of today's date, Petitioner has presented two psychiatrists, Dr. Stefan Kruszewski, MD and Dr. Diane Angstadts, MD, specializing in the field of geriatric psychiatry and elder matters,but counsel for Calene has failed to provide any individuals to perform the same (see attached Exhibit"C") despite affording Attorney Saidis ample deferment. 10. Petitioner believes and therefore avers that this matter will not be resolved absent adjudication from this Honorable Court regarding Calene's capacity, and Petitioner wishes to move forward with the July 8, 2015 date that has been set aside with regard to this matter and in the interim, order an independent evaluation utilizing either of the psychiatrists so named. 11. The undersigned hereby certifies that counsel for the alleged incapacitated person, Daniel L. Sullivan/Robert C. Saidis, Esquire,have been provided a true and correct copy of the Motion contained herein, as well as a copy of the Proposed Order, and said counsel does not concur in Petitioner's Motion for Hearing and Evaluation. WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order setting forth July 8, 2015 for a hearing on the matter, including the testimony of Dr. Robert Howse, and also scheduling one of the above named psychiatrists to perform an independent evaluation of Calene in the interim. Respectfully submitted, JS C LAW OFFICES Date: c /14- ' By: Neil W. squire AttoY.D.N'. 8227 8 134 1pe Avenu H elstown, A 17036 (717) 533-3280 Aft ey for titioner VERIFICATION I verify that the statements made in this Motion 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. ^EdwardClouse - ' Date: "a Neil W.Yahn,Esquire Attorney I.D.No. 82278 JSDC Law Offices P.O.Box 650 Hershey,PA 17033 Attorneys for Petitioner IN RE: CALENE M. CLOUSE, ) IN THE COURT OF COMMON PLEAS an alleged incapacitated person ) CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION On the Petition of ) J. Edward Clouse ) NO. 21-15-93 CERTIFICATE OF NON-CONCURRENCE Pursuant to the Cumberland County Local Rules,the undersigned hereby certifies that counsel for the alleged incapacitated person,Daniel L. Sullivan/Robert C. Saidis, Esquire,have been provided a true and correct copy of the Motion contained herein, as well as a copy of the Proposed Order, and said counsel does not concur in Petitioner's Motion for Hearing and Evaluation. Respectfully submitted, JSDC LAW OFFICES Date: '4 � By: UHummelsto ,Esquire No. 82278 nue n, PA 17036 0 etitioner a HOLY SPIRIT A GEISINGER AFFILIATE April 9,2015 Robert C.Saidis, Esquire � SaidIs,Sullivan,and Rogers 26 W. High St, Carlisle, PA 17013 . i Re: Calene M.Clouse I'I DOB: 12/29/39 1 Dear Mr,Saidis: I had a regularly scheduled appointment with Calene M,Clouse on April 3,20U for a medication checkup visit. Her current diagni osissis Dipolar I Disorder,most recent episode depressed, Based on my examination on April 3,2015,it is my opinion that Calene M.Clouse is not in a manic state and when not in a manic state she is capable of making decisions affecting her everyday life including financial matters, I Upon examination,she had a clear knowledge of the general composition of the properties she owns and discussed the financial arrangements being made,.including the trusts, At the time of my April,3,2015 examination,Calene was, In my opinion,capable of determining the disposition of her estate and making other financial decisions, I ' If you need additional Information,please do not,hesitate to contact me. Sincerely, Jagadeesh K. Moola,M.D. Psychiatrist Behavioral NealthServices: 503 North 21st Street,Camp Hill, PA 17011-2288 www.hsh.org EXHIBIT B Lancaster General Health Fax Date:6112115 To: Neil Yahn Fax:533-7771 From: Geriatrics Willow Lakes Office Pages: 12 Message: Geriatrics 212 Willow Valley Lakes Drive Suite 101 Willow Street, Pa. 17584 �' (717) 464-0286 ' (717) 464-0617 Fax Me dopfmrnt N arcow#atg/V thff tar v+w*dwt t aWn k*melon nom Lamav&nwWRw0 nW be coaafwtt*q*p V* blbrrnsli&n tr&stevdrar only for thea.of Me bd4ki�uf or enNyn>roed on�frafan�Rdon sheet The wfhotfted of dss b/ohmNon�prohb/1sd from &daft M&ImbmwM,n ro any oMarpwp�Nfthwr the wtlhadt.Nwr oft&nnrAer Qenaaf ite&kla pyov&m trot the brenaled neo(ok�you ax hereby rmh6ed rhn any afrdbtuap�Pla Im datrtbrtdon a the bMng of any setter in n4mce on the confer&of fhh bbtmMm tt&hddgr prolkblbd Ayow hair tecened 0*by pwatnhrbn b emr,phase nodi ea by mtpbmw bmm*jteyn the&how ft*honr aweber m Met rm wn wraw for dw orhwn nr detauabn afthew dotmeo t ELI 1, SLOZ-et-90 -w-dZE:WCO [1909941�L Lancaster General Health Physicians Geriatrics Neil Warner Yahn James, Smith, Dietterick s1<Connelly PO Box 650 Hershey, PA 17033 Email: NYahn@jsdc.com Fax:717-533-7771 cc:Robert Howse MD Rear Mr.Yahn, Thank you for the opportunity to evaluate Calene M Clouse of 4 East linden Drive,Carlisle PA 17015 at the same address on 10/2312014.This is her home.1, her husband Ed Clouse,and Calene M Clouse were present. She is a left handed 74 year old with a date of birth of 1212911939. She completed 12 years of education.The client was cooperative.There was not Interference from anyone with the evaluation. Informed consent was offered. She did not understand and did not remember the consent for the duration of the interview. No medical or psychiatric records were available for my review.The Montreal Cognitive Assessment Score was 18 of 30 consistent with her presentation of moderate dementia.The PHQ-9 score for depression was zero.The AUDIT score for alcohol use was zero.The interview was 3 hours in duration. No particular formal testing protocol is recognized as the gold-standard for capacity evaluation.These tests were evaluated In conjunction with the interview, collaborative information and medical information in order to form and an opinion about this client's capacity for self-direction with a commitment to the preservation of the personal dignity that is achieved by the least restrictive level of supervision.These opinions are rendered with a reasonable degree of medical certainty. There Is not evidence of physical abuse. There is not evidence of sexual abuse. There Is not evidence of emotional abuse. There is not evidence of financial exploitation. There is evidence of physical neglect. It is self-neglect. There is not evidence of financial neglect. Calene M Clouse's diagnosis Is most consistent with a diagnosis of Dementia of Alzhelmees Type without behaviors.There are multiple cognitive deficits manifested by memory Impairment,and aphasia,apraxia, agnosia,,and disturbance in executive function showing problems with planning,organization,sequencing and abstracting.These deficits are insidious, progressive and have decremanted this person's social and occupational functioning. She may have, and is certainly at risk for, Lithium Induced Encephalopathy as a cause of Dementla Not Otherwise Specified without Behaviors.This diagnosis should be considered given her gait disorder, incontinence and long term lithium use. Magnetic Resonance Imaging Non-Contrast brain and potentially subsequent PET scanning should be pursued to assist with diagnostic accuracy.A review of her records to search for episodes of laboratory confirmed 2112 Hertisburg Pace,Sutte 312 Lancaster PA 17601 0 717-544-3022 • 717-544.3021 Fax www.L.G"eatthPhysidans.org ZLft SLOZ-ZL-90 'W'd1E:LE:ZO 11,901+WU Calene M Clouse DOB: 12/29/1939 Page 2 of 11 toxicity,or long lapses in lithium level laboratory testing may yield clues to this diagnosis. However,this level of accuracy Is not needed for the determination of her decision making incapacity. The syndrome of irreversible lithium effectuated neurotoxicity(SILENT)consists of prolonged neurologic and neuropsychiatric symptoms following lithium toxicity. In typical cases of SILENT, neurologic toxicity develops along with an elevated Iithium concentration,but symptoms persist despite successful removal of the drug. Cerebellar dysfunction,extrapyramidal symptoms, brainstem dysfunction,and dementia can develop as part of SILENT.tither neurologic sequelae may include nystagmus, choreoathetoid movements, myopathy,and blindness.A review of 90 published cases identified cerebellar dysfunction as the most common sequelae, and proposed that demyelination at multiple sites in the central nervous system may be the cause, SILENT can continue for months and in rare cases effects persist for years. I understand from you that her functional status has declined since my evaluation on 10/23/2014. 1 would be happy to re-evaluate her if you desire. However, a decline in functional status would not be consistent with recovery of decision making capacity. I am unable to provide you with the names of other persons who perform capacity evaluations, as I do not know of any. Her ability to make a choice is impaired. Her understanding is poor. Her appreciation Is nearly absent. Her reasoning is variable, unreliable, easily swayed,inconsistent, idiosyncratic and sometimes delusional. Calene M Clouse lacks capacity for decision making permanently on the basis of this diagnosis. I recommend the appointment of a plenary guardian of her person,finances, and level of care. Calene M Clouse will not recover decision making capacity in the future. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 0812014 psychiatric admission. Her functional status has not completely recovered since this time. I do not have the exact date of her admission. Calene M Clouse Is able to appear in court I recommend a routinely scheduled guardianship. Calene M Clouse Is not at high risk for irreversible disability or death in her present circumstances. Stabilization of the situation can be expected with ongoing supervisiori by a guardian. Her husband is ill,and has an uncertain prognosis from prostate cancer,and may not be the best choice of guardian for this reason. Other capable family members or a thirst party guardian could be considered. Calene M Clouse was not able to answer the following questions regarding finances,a financial agent and power of attorney. Which bank do your use?She has no idea. Which accounts to you have there?She has no Idea. Do you have an Income?She has no idea. How much income to you have?She has no idea. Is this enough for you to live on?She has no idea. What are your income sources?She has no idea. 2112 Harrisburg Pica.Suite 312 i anmeter PA 17601 . 717.544,3022 , 717.544-3021 Fax www.LGHeaWhys!ctans.org ZVE SLOE-21-90 w,dOS:i£:to LL90091rLIL Calene M Clouse DOB: 12/29/1939 Page 3 of 11 Do you balance your checkbook?She rambles. Do you need help balancing your checkbook?She has no idea. Who helps you manage your checkbook?She has no idea. What do they do to help you manage your checkbook?She has no idea. How do you balance you checkbook?She has no idea. Do you have savings?She has no idea. How much do you have in savings?She has no idea. Do you'have investments?"I have three million dollars I think."This is inserted In other rambling. How do you manage your investments?She has no idea. Do you have bills?She has no idea. Which bills do you have?She has no idea. How much are your bills?She has no idea. Do you have debts?She has no idea. Which debts do.you have?She has no idea. How much debt do you have?She has no idea. Do you own your home?"Yes."Is there a mortgage?"No, I own it. It is mine." Do you own a car?"Yes. I drive all the time. Or someone drives me. I don't drive so much anymore. But I can if I want to. I am a good driver. I don't always want to drive." Is anyone misusing your money?"No. I manage all my money without help." Are you giving money to anyone?She has no idea. Do you play the lottery?She has no idea. Are you making donations to charities?She has no idea. Do you have a power of attorney for your financial decisions?This had to be explained several ways. "No.] can do that all by myself."What about when you are sick?"No, I can always do it. arts not sick that much. If I am, l can tell someone to do it."And who would that be. "Whoever I ask, because i don't need help.They will do what 1 say."How would they have access to your accounts?"I would tell what to do and they would do it" Do you have any agreements with the bank or your investment companies that allow other people to withdraw money or pay bills for you?"I don't need that"Did you ever create paperwork or documents that allow someone to help with your accounts and bills?"No, I never did that I don't need to. They will do what I say." Who might you name as someone to make decisions about your finances if you are too ill to do so yourself?There was a long silence.Then there was rambling. I repeat the question. "Maybe my husband." Do you trust him to act In your best interests?"Yes." Why do you believe this person to be trustworthy?"Yes" Do you trust this person to make decisions you would have made for yourself if you were able to do so?"Yes." Have you discussed your wishes with your surrogate decision maker?"No." When was the last time your discussed your wishes with your surrogate decision maker?"We never discussed it" Later in the interview she expresses distrust of her husband handling her affairs because she believes he sold property of hers and put it in his name. Power of attorney documents were not available for my review.She did not explain the creation or absence of the documents. Calene M Clouse is not able to designate an agent and make a power of attorney nor can 2112 Harrisburg Me,Svb 312 Lancaster PA 17801 . 717-544-3022 • 717-5443021 Fax www.LGHeafthP*1cia ns.org ZLIO SIDE-EL-90 ,w'd VO:ZE:ZO LL900901LL Calene M Clouse DOB: 12/29/1939 Page 4 of I I she change an agent or power of attorney.She is not able to choose between disparate, potential courses of action.She is not able to understand their financial obligations and opportunities. She is not able to appreciate the consequences of designating an agent and the import of the power of attorney instrument. Her reasoning is not intact, She is not able to apply her long term personal goals and values to these choices regarding an agent and a power of attorney. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 0812014 psychiatric admission. Her functional status has not completely recovered since this time. I do not have the exact date of her admission. Calene M Clouse was not able to adequately answer these questions regarding a testamentary will: Do you have a testamentary will?"Yes." What are the legal ramifications of your will?"The people I want will get my things when idle." Who are your heirs?"My two daughters." Why did you choose them as heirs?"They are my daughters.Who else would I choose?" What are your assets?"About 3 million dollars,and the house and the car."So what would that add up to?She has no idea. Who created and filed your documents?She has no idea. How are the assets to be divided?"Well, now that one died, equally between the others. I may have some other small parts to given to some charities or other people"Who would they be?"I don't remember. Its been a long time since I looked at it." Who is the executor?"My husband." Why did you choose them as executor?"He is a businessman," There is no collaborative information for me to review. Calene M Clouse has a weakened intellect and is prey to designing individuals. Testamentary will documents were not available for my review. She did not entirely explain the creation or absence of documents. Calene M Clouse Is not able to make and change a testamentary will.She is perhaps able to correctly identify her assets,suis Juris heirs, and comprehend the contractual nature of the instrument, but has a weakened intellect and is prey to designing individuals. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric admission. Her functional status has not completely recovered since this time. I do not have the exact date of her admission. Calene M Clouse is not able to handle small sums of money.Alternative arrangements include the supervised use of small sums of money,supervised use of a debit card, unsupervised use of non-essential income which can be misspent or lost, pre-payment of regularly used personal items. It Is my opinion that she lost this ability by the time of her 08/2014 psychiatric admission. Her functional status has not completely recovered since this time. i do not have the exact date of her admission. Calene M Clouse was not able to answer the following questions about their role as the agent for another person. ' Are you the representative payee,executor, power of attorney or guardian for anyone?"I don't know." 2112 Harrisburg Pike,Suite 312 Lancaster PA 17601 . 717.544.3022 • 717-544-3021 Fax www.LGHeakhPhyslclans.org 2115 SLOZ-ZL-90 'w'd 9t.Z6:zo Lt9099DL1L Calene M Clause DOE: 12/29/1939 Page S of 11 Can you state the duties of an appointment?She has no idea. What does it mean for you as an agent to act In the best interests of the principal?She has no Idea. - - - What does it mean for you as an agent to not mix your accounts with the principal's accounts? She has no idea. What does it mean for the agreement to be legally binding?She has no idea. What are the legal penalties if you fail to abide by the agreement?She has no idea. Calene M Clouse does not have the capacity to act as an agent or surrogate for another on the basis of this diagnosis.She is not able to make choices as an agent. She is not able to understand the duties of an agent. She is not able to appreciate the duties of an agent.She is not able to reason as an agent. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric admission. Her functional status has not cpmpteteiy recovered since this time. I do not have the exact date of her admission. Calene M Clouse was not able to answer the following questions regarding their medical care. Who is your doctor?"Dr. Molla does my psychiatric care once a month. Dr.Harris at Grand Medical in Newville." When did you last see your doctor?"Often.When I am sick. Recently." For which medical problems does your doctor treat you?"Bipolar.You can see my messy house"The home is cluttered, hoarded, and mainly not functional. I only saw three of the many rooms.There is too much clutter to effectively clean.A chair had to be cleared off for me to sit through the interview. Which medications are you on?"Lithium one daily at night."How many milligrams?She has no idea. "Cymbaita 30 mg in the morning."i was not able to look at her medication bottles. How do you get your medication?She has no idea. How do you take your medication?She has no Idea. Are you allergic to any medications?Denies. Do you take over the counter medications?"No," Do you take vitamins?"Over fifty vitamins." What do your medications do for your health?She has no idea. What would happen to you if you did not take your medications?"My bipolar."How long have you had bipolar disease?She has no Idea. What do your medical problems mean for your overall health?She has no idea. Tell me about your hospitalization from August 2014. "My husband thought l was a danger to him. He had me arrested and taken in handcuffs to Reading. t almost liked the place. I could help people. I opened someone's milk for them"She continued for 10 more minutes of uninterrupted and uninterruptible rambling well off the point of our discussion, progressively becoming more verbally and physically agitated during this monologue. Calene M Clouse is not able to direct her medical decision making.She is not able to choose between disparate potential courses of action.She is not able to understand her medical diagnoses and treatment options.She Is not able to reliably participate in informed consent for medical procedures and decision making. She is not able to appreciate the consequences of these diagnoses and treatments or their refusal. She is not able to demonstrate intact reasoning with which to apply her long term personal goals and values to these choices. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric admission. Her functional status has not completely recovered since 2112 HBrrtsburg Pike,5uTo 312 Lancaster PA 17601 + 717-544-3422 • 717-544-3021 FaX wsw.LGHealthPhyslcdans.org 2119 S10Z-21-90 Wd ZEIVE0 L190096L1L Calene M Clouse DOB: 12/29/1939 Page 6 of 11 this time. i do not have the exact date of her admission. Calene M Clouse was not able to able to answer the following questions regarding an advanced directive: Do you have a living will or advanced directive?"No." What are your wishes regarding cardiopulmonary resuscitation if you are obviously at the end of your Ilfe?"1 don't want that." What are your wishes regarding antibiotics if you are obviously at the end of your life?"1 don't want that." What are your wishes regarding intravenous fluids if you are obviously at the end of your life?"i don"t want that." What are your wishes regarding artificial feeding if you are obviously at the end of your life?"I don't want that." What are your wishes regarding renal dialysis if you are obviously at the end of your life?"I _ don't want that.' What does your advanced directive say?"I don't want that." Did you name someone to make decisions about your health care if you are too ill to do so yourself?"No." Who did you name as your decision maker?"I don't know. Maybe my husband. I trust him..He would make decisions for me just like I make them myself." Have you discussed your wishes with your surrogate decision maker?"No." When was the last time your discussed your wishes with your surrogate decision maker or family?"I don't think I ever did." Living will, advanced directives and PaOLST documents were not available for my review. She did not explain the creation'or absence of such documents. Calene lib Clouse is not able to make a living will or make changes to their living will.She is not able to choose between disparate potential courses of action. She is not able to understand her medical diagnoses and treatment options. She Is not able to reliably evaluate and choose an agent who will act in a surrogate fashion on her behalf. She Is not able to appreciate the consequences of these diagnoses and treatments or their refusal. She is not able to demonstrate intact reasoning with which to apply their long term personal goals and values to these choices. It is my opinion that she lost this ability by the time of her 0812014 psychiatric admission.Her functional status has not completely recovered since this time. 1 do not have the exact date of her admission. Calene M Clouse can no longer drive a motor vehicle. Do you drive?"Yes"Have you had any accidents?"No."Do you get fast?"No."Has anyone ever told you not to drive?"No."Her husband feels she should not be driving.She leaves the house, gets lost, calls him and he has to go find her.She says she has a valid drivers license.I recommend immediate driving cessation. I have filed the appropriate paperwork with PennDOT.Alternative private and public transportation should be arranged for her.A Pennsylvania Photo Identification Card can be obtained if necessary for proof of identity within Pennsylvania.A valid United States Passport is another alternate means of personal identification. Calene M Clouse was not able to answer these questions regarding voting privilege: Do you vote?'Tlo"Why not?'"I'd vote for the wrong guy. It didn't matter which one I voted for. It 2112 Harrisburg Pike,Sufte 312 t arecamer PA 17601 . 717.644-3022 - 717-5443021 Fax wwmLGHeakhPhyx)dans.arg ZItL SIoZ-ZR-90 wdLV:ZE;Zo Lt9DO9 IL Calene M Clouse DOR: 12/29/1939 Page 7 of 1.1 would be the wrong guy." What will happen on the next election day?She has no idea. What will you do on the next election day?She has no Idea_ How will a decision be made on the next election day. She has no idea. Would you vote for more taxes and more services or less taxes and less services?Why?She has no idea, Calene M Clouse does not retain the capacity to vote.She is not able to distinguish between candidates and parties. She is not able to choose between opposing candidates and ideas.She does not understand nature of voting and the effect of voting. She is not able to correctly use voting privileges without cuing. She is prey to designing persons because of her inability to resist coercion and suasion and voter fraud is possible. In my best medical opinion, Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric admission. Her functional status has not completely recovered since this time. I do not have the exact date of her admission. Supporting Data: Problem List Diagnosis * Health maintenance examination 10123/2014 Hearing:mild loss clinically,she denies this. She should be evaluated by her audiologist'wlthln 90 days.She will not benefit from augmentation. Her canals are free of cerumen. Debrox 5 drops each ear twice a weep should keep them cerumen free. Vision:glasses.She should be evaluated by her ophthalmologist within 90 days. Driving: Without accidents or citations. Husband says she gets lost and calls him to come flnd her. He feels she should not drive. Dental:Yearly recommended. Dentures to be evaluated at least yearly. Exercise: none Diet:Ad lib. Fails: denies, but family says recurrent. Incontinence:denies urinary and fecal incontinence Screening Cognition: Montreal Cognitive Assessment See attached scan for detailed findings. MOCA total score:18 Screening Depression: PH09 Screening Stool Occult Blood x 3:this is overdue Screening Colonoscopy: this Is overdue Screening Mammogram:this is overdue Screening DEXA:this is overdue. Immunizations:There is no immunization history on file for this patient. Immunizations may not be up to date. I recommend DtaP 0.5 ml Intramuscular, Prevnar immunization not in the same year as the also recommended adult pneumococcal vaccine 0.5 ml intramuscular,yearly influenza vaccine,and a single Zoster vaccine live 0.65 ml intracutaneously administered not within 30 days of iinfiuenza vaccine. Multifactorial gait disorder 10123/2014 Strength 315 in bilateral legs and thighs. Unstable gait,turns and transfers. Sedentary. Physical therapy, occupational therapy recommended. 21*2 Hardsburg Pike,SuRe 312 Lancaster PA 17801 • 717-5443(22 • 717-544-3021 Fox www.LGHeafthPhyslclans.org V/8 SiOz-ei-90 W'd 10:66:Zo Li9069dLU Calene M Clouse DOB: 12/29/1939 Page 8 of 11 • Patient incapable of making informed decisions 10/23/2014 Lacks decision making capacity. • Urinary incontinence, mixed 10123/2014 Has urge symptoms during the day,stress and functional symptoms at night.There is a bedside commode.A urology referral is recommended. • Bipolar disorder o Wears dentures 10/23/2014 Upper Dentures.She has dentures.They are several years old.They do seem fit well with without adhesive.They do not cause oral pain.They are cleaned routinely. They are due to be evaluated for It and should be replaced If necessary. Dentures routinely improve nutrition, social confidence and communication. Dentures usually have a 2 year life span. Loss of fit occurs from recession of the alveolar ridge from aging and tooth loss and cannot be compensated for by adhesive,which works well only with well-fitting dentures. Bilateral sensorineural hearing loss 10/23!2014 She denies this, but it is clinically evident. She should be evaluated by her audiologist within 90 days. She will benefit from augmentation. Her canals are free of cerumen. Debrox 5 drops each ear twice a week should keep them cerumen free. • Xerostomia 10/23/2014 Medication induced • History of blood transfusion Review of systems: She is unable to give a reliable review of systems because of her dementia. No headache, earache,visual loss,hearing loss,nasal congestion or discharge, sore throat, dysphagia,dysphonia, dysarthria. No neck pain or lymphadenopathy. No cough, hemoptysis, dyspnea, shortness of breath at rest or exercise. No chest pain, diaphoresis,palpitations, syncope or dizziness. No nausea,vomiting,diarrhea, hematemesis, melena or bright red blood per rectum. No constipation. No indigestion or reflux.Appetite intact. No hematUda, pyuria, dysuria, hesitancy, urgency or retention. No joint pain or gait disorder. No conceming skin lesion. No memory loss, sleep disorder,depression, anxiety, hallucinations or delusions. Allergies: She has No Known Allergies. Durnent Medications: "Lithium one daily at night."How many milligrams?She has no idea. "Cymbalta 30 mg in the morning."I was not permitted to inspect her medication bottles.l have no collaborative medical history. Past Medical History: She has a past medical history of Psychiatric problem (08/2014). Past Surgical History: She has past surgical history that includes ovarian cyst removal (Bilateral); appendectomy;and knee replacement(Bilateral). Social History: She reports that she has never smoked. She has never used smokeless tobacco.She reports that she does not drink alcohol or use illicit drugs. Family History; Her family history includes Coronary Heart Disease,early onset in her father and mother. Immunizations: There is no immunization history on file for this patient, 2112 Harrisburg Pace,SwIe 312 Lancaster PA 17801 717.644-3022 • 717544.3021 Fax www.LGHealthPhysidans.org ZLl6 SLOE-Zt-go *w,d91:EE:Zo L190V99LLL Calene M Clouse DOB: 12/29/1939 Page 9 of 11 Physical Examination: Head, Ears, Nose and Throat: Normocephalic,atraumatic, pupils equal, round reactive to light, extraocular movements intact. Sclera anicteric. Conjunctiva pink and moist.Tympanic membranes peariy and mobile without occluding cerumen. Nares without erythema purulence or discharge. Dentition intact. Pharynx without erythema purulence or discharge. Neck supple without lymphadenopathy. Carotid pulses 2+without bruit. Hearing loss is clinically evident, but did not interfere with the evaluation. She wears glasses and has clinically adequate visual acuity to participate In formal testing. Chest: Normal excursion, resonant,without kyphosis,clear to auscultation and percussion. Heart:Without heaves or thrills, rate and rhythm regular without murmurs, rubs or gallops. S1 and 82 normal. No 83, no S4. Abdomen: Obese, soft, non-tender,without hepatosplenomegaly. Extremities: Without cyanosis, clubbing or edema. Peripheral pulses absent. Skin: Intact Lymph:No cervical, supradavicular, or axillary lymphadenopathy. No femoral or popliteal lymphadenopathy. Neuro: Cranial II-XII intact. Finger-to-nose intact. Sensory intact to light touch and proprioception. Motor 415 throughout except in the bilateral thighs and legs where it is only 3/5. Her gait is unstable,transfers are unstable,turning is unstable. There is not evidence of Parkinsonian features. Judgement is not intact. Insight is not intact.Anosognosia is present. Orientation:To person is intact. To place is intact.To time is not intact. Concentration is not intact. Delusions are present. Do you remember what happened before you went to the psychiatric hospital recently?"Ed sold a property of one of my babies and put it in his own name."Ed denies this. "i went to the movies,but was greeted by the police on the way out.Then I got back. I wanted powdered milk because my milk is always sour and I went to see those police to tell them to see the movie called,'You Wanna Be a CopT it was hilarious.And instead they arrested me aid took me to Reading. I had a shot.They told me if I didn't get it I would have to stay a month. There was a guy who dropped his pants and peed on the television. One fell in love with me and slept outside my door, but then he went into a rage like 1 have never seen and I stayed away from him. Mostly there were women abandoned by their husbands stuck there in limbo with no place to go. Hallucinations:Visual hallucinations are not present.Auditory hallucinations are not.Olfactory hallucinations are not present. Gustatory hallucinations are not present. Formication is not present. Derealization is not present. There is social disinhibition.There is not verbal disinhibition.There is not sexual disinhibition. There Is not urinary disinhibition, but there are functional elements to her urinary incontinence. There is not fecal disinhibition.There is not hyperorality. Eating:There is not polydipsia.There is not polyphagia.There is not anorexia. Sleeping: is not normal, is not excessive,is diminished,is interrupted. "My sleep is terrible. That's why I see Dr. Mullah, but the last two to three nights are better on the Cymbalta. I had been off it because it made me too high. But that was In the spring. Now 1 am sleepy.My energy level is low right now. In the spring and summer it is very high. I plant trees and flowers. I go on spending sprees in the spring and summer. My energy level changes overnight."Denies periods of sleeplessness. "Even when I am high I sleep at night." Mood is happy, is not elated, is not sad, is not depressed. 2112 Harrisburg Pike,8ulte 312 Lencaster PA 17601 • 717-644-3022 • 717.544-3021 Fax www.LGHealthPhyaicians.org CUM stoz—ZL-90 wd IE:EE:r0 L190Y9lrLtL Calene M Clouse DOB: 12/29/1939 Page 10 of 11 Affect is not happy,is not sad, is somewhat flat, is somewhat inappropriate. Motor agitation is not present. Motor retardation is present.Abnormal posturing is not present. SpeecKis not always fluent, is riot pressured, is not slow, is spontaneous,,-is not`slurred:There is paucity. There are word choice errors.There are word use errors.There are syntax errors. There are comprehension errors. Conversation is not always coherent, Is rambling, is tangential, is confabulatory, is not logical. Reading ability: Comprehension is not intact.Vocabulary is not intact. Fluency is not intact. Memory: Immediate is not intact.Short Term is not intact. long Term is not intact Procedural is not intact for[ADL. Calene M Clouse perceives herself to be Independent of ADL and independent of IADL. Calene M Clouse as evaluated by me is dependent of tolleting of AOL and dependent of transportation,finances, cleaning, chores, and personal safety of IADL. Life expectancy is estimated to be 12 years by actuarial and clinical means. Presently,actuarial data is considered to be the best means of estimating life expectancy except in clinical situations that are clearly mortal in character.These include various forrns of advanced cancer, heart failure, lung failure, kidney failure, liver failure and dementia. Calene M Clouse is appropriate for assisted living care. She requires assistance with instrumental activities of daily living and would benefit from the services provided by an assisted living facility.These services can be provided In the community with a combination of personal,family, private and community resources bearing in mind that this is often difficult for caretakers to manage,arrange,and routinely provide. Back-up systems are particularly difficult to arrange and manage. It is important to remember and consider that caretakers who are obligated to provide direct care beyond their personal abilities suffer an increased risk of morbidity and mortality after six weeks of over-extension. Caretakers who are over-extended are at increased risk for acute medical problems, hospitalization, depression and dementia. Underlying chronic medical issues, poor coping skills,a low perception of personal agency and depression further increase these risks and the risk of failure to provide adequate care. Respite care plans and a day off per week are minimally required for ongoing caregiver health. She is very likely to need skilled care within the next two years. She may have the monetary resources necessary to achieve this in her home, but this may not be the best choice for her well-being, and well-reasoned consideration of the options for skilled dementia care should be evaluated at the time a transition is made. Persons with dementia have a uniformly poor chance of meaningful long term recovery after cardiopulmonary resuscitation.Although published literature indicates a one In six or fifteen percent chane of immediate post-resuscitation survival,far fewer patients survive the next sixty day period. There is literature to indicate a less than 3%survival rate in elders with dementia.This time of hospital stay is invariably fraught with Indignity, pain, and suffering with Invasive procedures, intravenous lines, artificial feeding, mechanical ventilation and prolonged intensive care unit treatment. I recommend Do Not Resuscitate orders for patients with this terminal, progressive disease.Likewise, I do not recommend artificial feeding for dementia patients who are declining,spending greater than 18 hours a day in bed,who are eating and drinking poorly and losing weight. Percutaneous gastrointestinal artificial feedings do not improve weight, survival,or comfort in advanced dementia patients. They are invariably associated with multiple uncomfortable visits to the hospital for replacement of the device when 2112 Fhrrisburg Pike,Suite 312 Lancaster PA 17601 • 717-544-3022 - 7175443021 Fax www.LGHeathPhysicians.org ZL/LL SLOZ-EL-90 'w'dLti WE0 LL9090M Calene M Clouse DOB: 12/29/1939 Page 11 of 11 confused patients pull them out.They increase the risk of aspiration pneumonia in severely demented elderly patients.They are associated with an increased risk of death compared to comfort feeding regimens. Thank you for the opportunity to serve Calene M Clouse. I trust my recommendations will help her age with dignity and as much independence as possible. Sincerely, 4&-Vqh4�9 lu Robert Howse, M.D. 2112 Harrisburg Pike,Sufte 312 f amster PA 17601 • 717-544.3022 - 717-644-3021 Fax www.LGHeaRhPhysWns.oM UM SIOZ—Zl-90 'W'dEO.VE:ZO L190V9VLtL EXHIBIT C Tammy L. Frye From: Tammy L. Frye Sent: Friday, May 29, 2015 4:22 PM To: 'dsullivan@ssr-attorneys.com' Cc: Neil W. Yahn; Gregory A. Kogut Jr.; Karly E. Grace; 'tnaylor@baricscherer.com' Subject: Re: Calene M. Clouse- Psychiatrists Attachments: Ltr to Dan Sullivan 05292015 Names for Eval.pdf JSDICLAWOMC15, Jam +SSS w D>Fv l r'UKX• CorZqELLY &SP.ADE N!AHN+ SE MZ TONLASM Dear Attorney Sullivan: Attached please find correspondence from Attorney Grace.The original will follow via First Class Mail. Thank you for your time and attention to this matter. Tammy L. Frye—Legal Assistant JSDC LAw OFFICES P.O. Box 650 Hershey, PA 17033 Tel: 717.533.3280 DD Tel: 717.520.8074 DD Fax: 717.520.8075 SECURITY NOTICE-Because email messages sent between you and JSDC Law Offices("JSDC")and its employees are transmitted over the Internet,JSDC cannot assure that such messages are secure.You should be careful in transmitting information to JSDC that you consider confidential.If you are uncomfortable with such risks,you may decide not to use email to communicate with JSDC.Although you may be sending an email message to a specific JSDC employee,other JSDC employees may review such messages.Additionally,your email messages to JSDC may,consistent with JSDC's regulatory requirements and retention polices,be retained.You should also be aware that email messages may be delayed or undelivered. CONFIDENTIALITY NOTICE-This electronic mail transmission originates from JSDC.If there are any problems regarding reception of this transmission or any attachments indicated above,please call the signatory listed above.This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged,confidential and exempt from disclosure under applicable law.If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient,you are hereby notified that any dissemination,distribution or copying of this communication is strictly prohibited.If you have received this communication in error,please notify us immediately by telephone,and delete this transmission with any attachments from any computer and destroy all copies in any form.Thank you 1 JSDC LAW OFFKM JAMES SN•DTETTERKX•CENT snLy•(�RMAL•YjiM,•SEEM•TOMASKO Ned W.Yabn nyahn@jsdc.com P.O.Box 650 May 29,2015 H130CY,PA 17033 MAIN OFEM 134SPE kscx VIA FIRST CLASS MAIL&ELECTRONIC MAIL HUMMIRSTOM,PA 1M6 WEST SHORE UrAim Daniel L. Sullivan, Esquire M5 GErryiam PM SUMCAIM Saidis, Sullivan&Rogers MEOWIMBURG,PA 17055 26 West High Street TEL 717.533.3280 Carlisle,PA 17013 WWW.JSDC.COM Re: Calene M.Clouse—No.21-15-93 G*TY L At Es PsychiaMsts Specializing in Dementia MAX J.8,MffH,JR. AM J.calwaly,JR. Dear Attorney Sullivan: SOOTr A.DETTERICK WTTHEV CRQAL,III NELW,Y;,HN As a follow-up to the Status Conference earlier this week before Judge Masland,please BWOM P.samm find below the names and contact information for two(2)physicians which we believe RoNqD T Tawm ,WAES F SPAM are qualified to present to the court to provide an independent capacity evaluation for SUGM K K-"ZM Calene in the above referenced matter: CoLsmy K Pa;;at_ KARM N.C-VNEV CFMNE T.BR" 1. Dr. Stefan KruszewsK M.D. Jwsr,E.Sism 133 LingIcstown Road Harrisburg,PA 17110 GFE-OMY A KwAft,JR Tr,qE,A M.PUFcvm9 (717)234-2684 JAMES 0.YaPn Fee: $650.00/hour CAYIA B.AWBOM Agan K Wwmavw KATw.,N L Wsw 2. Dr.Diane Angstadt,M.D. OF 000WW Commonwealth Affiliates GREwy K RcKv9w 2215 Forest Hills Drive Harrisburg,PA 17112 KIMM A.BateR (717) 540-5353 ANDFav H,Bnw--,� Fee:unknown at this time JWA FREAMSDaM Thank you for your time and attention to this matter. Sincerely, JSDC LAW OFFICES e tKarly E. Gra KEG/tlf cc: J. Edward Clouse(via First Class Maio Tricia D.Naylor,Esquire(via First Class Maio Neil W. Yalm,Esquire(via Hand Delivery) P ' JSDC LkW 0FRCES JAN ES•SM[tH•DETrMCK•COrava a*GiABAL•YAHN R SEEm•TtowlAsKo Nee W.Yahn nyahn a�jsdc c= P.O.Box 650 June 4,2015 HERsmEY,PA 17033 MAIN OFI:. 134 SPE AVBQE VIA FIRST CLASS MAIL&ELECTRONIC MAIL RxAmazrw+ PA 17036 WEST SHORE LQ=W, Daniel L. Sullivan,Esquire 555 GEnTMSBURG Pei SurTE C400 Saidis,Sullivan&Rogers G,PA 17055 26 West High Street Carlisle,PA 17013 TEL 717.5M.3280 WWWisoc,COM Re; Calene M. Clouse—No.21-15-93 PsPsychiatrists Specializing in Dementia M`;". J.4 Y P g� Ma:J.SMrtw.JFK i0m J.00141am JR Dear Attorney Sullivan: S=A DEMI-M MAM EW QM4j-,III Nell W.YAwu On May 28,2015,correspondence was sent to you via electronic transmission regarding EDAPM a sEIMM the names and contact information for two( )physicians,2 7 a ysicians Dr. Stefan Kruszewski�M.D JAu��sPACE� and Dr.Diane Angstadt,M.D.,which we believe are qualified to present to the court to SUW M.KAM provide an independent capacity evaluation for Calene in the above referenced matter. °01RMK P01N°L A"SnaE T.aVMI As it follows,we have not received a response or further information from you. Kindly .FMcA E.SNTH advise if you have additional physicians qualified to present,or if the two(2)physicians GFEWRYA K«G1c A P Y TmjmA M,RBFsr ER we believe to be qualified are sufficient. JAM 0.YOUN3 cAYIA B.Jr&L8MVtZ ALBOS MLOSEWN Thank you for your prompt time and attention to this matter. KATwYM MAsoN OF r, Sincerely, GREGOw K RIC ww KeSsrr.YA.WNW JSD LAW OFFICES Amxv.'R Bmw DANA FwpFINN5DO71w Neil All ra cc: a First Class Mail]uire(via First Class Mail) Law Offices of SAIDIS, SULLIVAN & ROGERS A PROFESSIONAL CORPORATION 26 WEST IHG1I STREET ROBERT C.SAIDIS CARLISLE,PENNSYLVANIA 17013 LEM MYNE OFFICE DANIEL L SULLIVAN TELEPHONE:(717)243-6222—FACSIMILE:(717)243.6486 635 NORTH 12TH STREET,STE.400 ELYSE E.ROGERS EMAIL:aftorney@ssr-attorneys.com LEMOYNE,PA 17043 JOHN A.FEICHTHL www.gsr-attorneys.com TELEPHONE:(717)612-5800 MARYLOU MATAS FACSIMILE' (717)612-5805 ANNA BORRO HAYS TODD F.TRUNTZ Of Counsel SEAN M.SHULTZ STEPHEN L GROSE CHRISTOPHER E.FISHER HANNAH VAUTE-GIBSON REPLY TO,CARLISLE Email:dsullivan@ssr-attorney—s.com June 8,2015 Neil W. Yahn, Esq. Yz*a E-mail gLqha@jsde-com JSDC Law Office, P. O. Box 650 Hershey,PA 17033-0650 Re: J.Edward Clouse/Calene M.Clouse Dear Neil: I am in receipt of your June 4,2015 letter,which follows up the May 29,2015 letter from Karly Grace from your office. By way of correction,the letter from Karly Grace was sent by electronic transmission late on Friday afternoon,May 29,2015 (4:22 PM),not on May 28,2015. 1 acknowledged receipt of Ms. Grace's letter in an e-mail the next business day (Monday,June 2,2015)advising her that we would be in touch. Be advised that we are still in the process of reviewing the two physicians whom you identified, as well as conducting our own investigation to identify potential alternate candidates. Be assured we will contact you once this process is complete and we are able to respond in a substantive and meaningful way. Very truly yours, SAIDIS, SULLIVAN&ROGERS Daniel L. Sullivan DLS/pm cc: Tricia D.Naylor, Esq. Via E-Mail tn y1a,!Mariescherer.coin Neil W.Yahn,Esquire Attorney I.D.No. 82278 JSDC Law Offices P.O.Box 650 Hershey,PA 17033 Attorneys for Petitioner IN RE: CALENE M. CLOUSE, ) IN THE COURT OF COMMON PLEAS an alleged incapacitated person ) CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION On the Petition of ) J. Edward Clouse ) NO. 21-15-93 CERTIFICATE OF SERVICE AND NOW, this G+day of June, 2015, I,Neil W. Yahn, Esquire, do hereby certify that I served a true and correct copy of the foregoing Motion for Hearing and Evaluation upon the following below-named individuals by depositing the same in the U.S. Mail,postage pre-paid at Hershey,Dauphin County, Pennsylvania: SERVED UPON: Daniel L. Sullivan/Robert C. Saidis, Esquire Saidis, Sullivan &Rogers 26 West High Street Carlisle, PA 17013 Attorney for Calene Clouse NEI W ER YAHN, ESQUIRE At rney 1. #82278