HomeMy WebLinkAbout9-15-15 � � � �
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Rhoads& Sinon LLP -- '- �
By: Scott Alan Mitchall � - _ � �'�
cn �
Attomey ID NaJ6�24 � . .
One. South Market Square. 12'" Floar _� �
P.O. Box 1146 - - _� �����
Harrisburg, PA 17108-1146 �-' . `�
Phone'. (717)231-6602 . �-�' -- r��
Facsimile Q17)260-0402 �' `O �
w -�
Email: smi�chell@rhoads-sinon.com
IN RE: : IN THE COURT OF COMMON PEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
SAMUELPOSSENTITALHELM .
: ORPHANS' COURT DIVISION
An Alleged Incapacitated Person .
: No. 21 - 15 - U� ��°
PETITION FOR APPOINTMENT OF PLENARY GUARDIANS
OF THE PERSON AND ESTATE OF SAMUEL POSSENTI TALHELM
TO THE HONORABLE JUDGES OF THE SAID COURT:
The Petition oF Michele Possenti by and through her counsel, Scott Alan Mitchell,
Esquire, of Rhoads & Sinon LLP, respectfully represents the following:
1. Petitioner is Michele Possenti, adult individual residing at 113 Woodview Drive,
Mount Holly Springs, PA 17065, who is the mother of Samuel Possenti Talhelm, the alleged
incapacitated person.
2. The alleged incapacitated person is Samuel Possenti Talhelm ("Sam"), who is
the son of Petitioner and primarily resides with Petitioner in her home at 113 Woodview
Drive, Mount Holly Springs, PA 17065.
3. Sam is 18 years of age, having been born September 15, 1997.
4. Sam suffers from Autism Spectrum Disorder (PDD) and Landau-Kleffner
Syndrome, which is a seizure disorder.
�
5. Sam is nonverbal and primarily communicates through physically pushing or
pulling an individual towards somelhing that he wants. He also communicates to some
degree through an iPad for purposes of basic communications and requests, but those
communications involve basic "wants," such as requests for various food, rather than
communicating a health issue, such as not feeling well.
6. Sam is completely dependent upon others for all activities of daily living. He is
unable to bathe himself, shave, get dressed, prepare food, brush his teeth, etc., and he is
not toilet trained.
7. Additionally, Sam has no awareness of safety and danger. For example, if there
is an item of food on a hot stove, he will simply reach for the food irrespective of the hoi
stove.
8. Sam is unable to attend to any aspects of personal and health care
management, nor does he have any concept of money, finances, and counting. In sum, he
is dependent upon others for his physical needs and activities of daily living, and he is
unable to manage independently or to be left unsupervised.
9. Sam is under the care and treatment of Holly C. Hoffman, M.D. of Carlisle
Pediatric Associates, 804 Belvedere Street, Carlisle, PA 17013.
10. Attached hereto as Exhibit"A" and incorporated herein by reference is a
Deposition of Individual Qualified in Evaluation of Incapacitated Person, which has been
completed and verifed by Dr. Hoffman. The deposition questionnaire is being presented to
ihe Court in lieu of a formal deposition transcript.
11. Sam currently is a student at Vista School, 1021 Spring Board Drive, Hershey,
PA 17033, which is a school devoted to students with Autism. Sam will remain a student at
Vista until he tums age 21. Sam currently has an IEP (Individualized Education Program)
and ISP (Individualized Service Program), both of which are attached hereto as Exhibit "B"
and incorporaled herein by reference.
12. Because of Sam's mental and physical condition, as outlined further in Exhibits
"A" and "B," it is believed and therefore averred by Petitioner that Sam is an incapacitated
person within the meaning of Chapter 55, Subchapler A, Section 5501 of the Probate,
Estates and Fiduciaries Code, in that his ability to receive and evaluate information
effectively and communicate decisions in any way is impaired to such a significant exlent
that he is totally unable to manage his financial resources or to meet essential requirements
for her physical health and safety.
13. Sam presently has no assets and income, but Petitioner is in the process of
applying for SSI (Supplemental Security Income) benefits for Sam.
14. Sam is unmarried and has no children. Apart from his mother (Petitioner) Sam
has the following next of kin:
a. Kevin Talhelm (father) - 1 Sheely Lane, Boiling Springs, PA 77007;
and
b. Paige Talhelm (sister— age 23) - 113 Woodview Drive, Mount Holly
Springs, PA 17065.
c. Jack Talhelm (brother— age 16) - 113 Woodview Drive, Mount Holly
Springs, PA 17065. �
15. Petitioner and her husband were divorced on December 14, 2004. Per
agreement belween Sam's parents, Sam stays with his father every olher weekend and
also on Mondays and Thursdays from 5:00 p.m. to 8:00 p.m. Othenvise, Sam lives with his
mother (the Petitioner).
16. Kevin Talhelm currently pays child support to Petitioner in the amount of$1,800
per month for both Sam and Jack Talhelm, which support has been agreed by the parties to
continue until Jack graduates from high school.
17. Sam has never been a member of the Armed Services of the United States and
is not receiving any benefits from the United States Veteran's Administration or its
successor.
18. Sam has not previously executed a General Power of Attorney, Advanced
Health Care Directive or Health Care Power of Attorney, and he currently lacks the capacity
to ezecute such documenis, which has led to Petitioner filing this Petition as a result of Sam
turning 18 years of age.
19. Due to the condition set forth above, Sam 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.
20. Due to the severity of the condition set forth above, Sam lacks the ability to
make or communicate any responsible decisions concerning his person and is unable lo
attend to his personal safety or to keep himself properly nourished, hydrated and
medicated, or to communicate to others his need for assistance in these areas.
21. Due to the severity of ihe diagnosed condition set forth above, the assistance of
other persons or services would not enable Sam to participate in the making of any
decisions concerning his estate or person.
22. The severity of the diagnosed condition of Sam requires that a plenary guardian
be appointed to manage the eslate of Sam. 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 an
owner or a beneficiary; his entitlement to any government or non-government benefit plans,
federal, state and local taxes, trust accounts of which he is a beneficiary, claims made or to
be made on his behalf or against his, the execution of documents, the entry into contracts
affecting his and the paymenl of reasonable compensation or costs to provide services to
him.
23. Less restrictive alternatives, other than the appointment of a plenary guardian
of his estate, have been considered but determined not to be viable alternalives. Petitioner
therefore believes that the best interests of Sam and his estate are not being provided for at
this time and will not be provided for absent the appointment of a guardian of his estate.
24. The severity of Sam's mental condition, as stated above, mandates that a
plenary guardian of his person be appointed to handle all issues relating to the person of
Samuel Possenti Talhelm, the alleged incapacitated person, specifically including, but not
limited to: his living arrangements, his medical and neurological care, the administration of
medication to him and the employment and discharge of physicians, neurologists, dentists,
nurses, therapists and other professionals for his physical and neurological treatment and
care.
25. Less restrictive alternatives, other than the appointment of a plenary guardian
of his person, have been attempted but determined not to be viable alternatives. Petitioner
therefore believe that the best interests of Sam and his person are not being provided for at
this time and will not be provided for absent the appointment of a guardian of his person.
26. The proposed guardians of the person and estate of Sam are his parenls,
Michele Possenti (the Petitioner) and Kevin Talhelm, and Sam's sister, Paige Talhelm, who
currently takes an active and loving role in Sam's care.
27. The proposed guardians are qualified individuals pursuant to 20 Pa.C.S.A. §
5511(� . The proposed guardians do not have any adverse interest to Sam and copies of
the ConseNs of Petitioner and Paige Talhelm to serve as guardians of Sam's estate and
person are attached hereto as Exhibit "C" and incorporated herein by reference. Petitioner
has not yet obiained a signed Consent from Kevin Talhelm at ihe time of filing this Petition.
28. No other Court has ever assumed jurisdiction in any proceeding to determine
the capacity of the alleged incapacitated person nor has a guardian already been appointed
for Sam
WHEREFORE, the Petitioner, Michele Possenti, prays that a Citation be issued and
directed to Samuel Possenti Talhelm, the alleged incapacitated person, to show cause why
he should noi be adjudged a totally incapacitated person and Michele Possenti, Kevin
Talhelm, and Paige Talhelm appointed permanent plenary guardians of his person and
estate.
Respectfully submitted,
Rhoads & Sinon LLP
Dated�. `�� ('f ��
By;
Scott Alan Mitchell
Atty. I.D. #76124
One South Market Sq., 12�" Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
(717) 231-6602
Attorneys for Petitioners
I� RF.: SAMUEL POSSENTI TAI.HELM
DSPOSI"I�IOt� I3Y INDNIDUAL QUAL1FiLD IN liVALUATION Oh'
I1�CAPACITATED PERSOV
Thc deposition of I lolly G I IofCman. M.D.. a witncss in this maucr, made on thc N
�
day ol'5.��,�. , 2015, at Cadisle. Pennsylvanic�. �
1. What is your nome and protessional hddress?
a. Mv namc is [lolly C. Hoffman, M.D., and my profcssional address is:
Carlisle Pedintric Associates
804 Belvedcre Stree[
Cadislc, PA 170L3
2_ Plense describe your cducation,trxining, and background wiih panicular cmphasis
on your expenise in evaluu[ing individuals with incapacities. If you pre(er to do
so, please attaeh et¢ciculum �ilae to those interrogatorics thal detail this
i�lorma[ion.
a (Ccoss out that Answer that docs not apply.)
�My c�n'iculum vitae dctailing this intormation is attachcd.
Or
ii. I received my college degrcc at _ _ _ ,_and
my post graduate training ¢t _ —
and I have practiced - �e�K�
medicine, psyehiaVy, psychology, geronmlogical social work ete.)
since
b. My speeial qualifieations and tcaining with cespect to evaluating persons with
incapacitie5 consists o�`. �
(^��,.oTh_i D� 1;tl�r�c r ;s,-�Ie,�c� _ —
� 1
� ��4.�£-_�r� �'� -
3. In what states arc you licensed to practice medicine?
a. I am licensed to practice medicine in the following states:
09(.U�J
\ �°V\ �N1�- . . .
4, In your capacity (e.g. physicixn. psychologist, social workcr, etc.) have yuu had
the opporiunity to meet with, csamine, spenk with and otherwise bccomc
acquaintcd with Samucl Posscnti Talhelm and if so, upon what occasions and in
what Tashion havc you been ablc to do so?
a. I first becomc acquainted with Samuel Possenti "Calhelm the month oC
�p o � �, when he was brought to my attention by means ol
y� I have sincc that time
(vis ted/spokcn wit examined/trea[e him on other occasiona
with an averagc frcqucncy o � _ �_ timcs per � .
(doylweelJmonth/year).
5. "Ib a reasonxblc degree of inedical certainty, do you havc an opinion as to whether
the ability of Samuel Possenti Talhelm to rcceive and cvaluate intormation
cifectively and lo communieate decisions is in any �+�ay impaired to such
si�nificant extent Ihat he is':
a. Partialty u�ablc to managc his fmancial resoumes,
or
t�f. �Potally unablc to manage his 6nancial resoumcs.
Ycs. my opinion is� � �� I . � >�^_�—
�.A ��� ��-., ._� � �_0_ _ r�S-_r �*�+T
6. 'Co a reasonable degrec oCmedical certainty, do you have an opinion as to whether
the ability of Samuel Possenti Talhclm to receive and cvaluatc information
eftectivcly and to communieate decisions is in any way impeired to sueh
sienificant estent that he is:
a Partially unable to meet essential rcquirements for his physical health and
sefet)',
or
UN. lbtally unable ro meet essentinl requircments for his physicol health and
safcty.
Ycs, my opinion is �I-.�a� 5�..�,,,-_ -z -1�.,--6.� -- "+�.
—�_ �- gSs¢..d,�.P .[� c .o.�fs -� 12;r �
���� 1,.s�+� � s� �
,�,�,�,� �
7. Please describe Ihe lype and severity oL any impxi�menls ol Samucl Possenti
"I'alhclm'?
a. The impairments of Samuel Posscnti �falhclm are as follows:
Lmpairmcnt (Circic one)
y) ��,� - � � nonc mild moderate severc
L �Sw r
b) � � none mil modcratc scvere
ar�a�
c) 5'��^�^'�"e none mild moderate severe
d) none mild moderate severe
c) none mild moderate sevcrc
t) none mild moderate sevcre
g) none mild modcrate severe
h) nonc mild moderate severe
R. �fo a reasonable degree of inedical certainty, can you cxpress an opinion ns to
whether Samucl Posscnti Talhelm is parti¢Ily or rotally unable to manage his
hnaneinl resources?
a. �I�he ability of Sanmcl Possenti Talhelm ro ntanager his li�ancial cesourecs is
impaired (not at all, partiall,� totnlly as lollows:
Yes. my opinion is -�i.-a.�F- S, ,-s _y�.��yo�I�,� ��I�E �
' _ �„ d 1n a c so_.e� c�„1, n.r.6,:e n�,' r,,.,�.�-
`7
5 .: 1-�. ?L...--F- �/�2 C�.v.��-�- ✓-w�n nc L l.<i s Uw`.. a ��r '�- (
9. "l�o a rcasonable degree of inedical eertamty, can youlexpress an op�nion as to' � -" �'
whether Sainuel Possenti Talhelm is able to mcct csscntial rcyuirements for his
physical hcalth and safety'?
a. �fhc abilit} of Samuel Possenti Talhclm ro meet essential requiremcnts Cor his
physical health and safety is impaired (no[ ut all, partially tota v as �olluws:
Yes, my opinion is. -��-{- 5, E, � ,�,-�- �. ,J -�
aw . L \...:, �,� �^e� l_'�--"�-5-" (���
o i
9ec i�i�
10. Can you please evaluate the present co�dition of Samucl Posscnti Talhclm with
respect to incapacities of the type 111eged in the Petitioa In particular, could you
please comment on the naturc a�d extent of the alleged incapacities and disability
hnd also, insofar as you arc nblc, thc mcntel, cmotional, and physical wndiiion of
tiamucl Posscnti �fnlhelm, his adaptive behavior, and his social skills?
a. 13ased upon my education, training and experience, as �vell as my
acquaintance with Samuel Possenti Talhelm, as stxted nbove, it is my opinion
that his incapacities and disabilities are:
._... �u,.'S �'. ��,. �'� Sa�.e..e_ 1 V:Y�M�Q�r�ia�.. L.n w.
G.�--�1 e-�e�.�.. V n. C�-�S—�`�� c�0 e�4�
hS�r�"'
b. His mental condition:
No.�.-.n..10 � 1.j ti.�,r1.. '�. � .-c.d G�q�rldiM--
/ � J
c�,,.z ���, �r > ���.c < �lls _ __
a His edm� o�tiio�n-al and physical conditinns are: �
/`�1,�'h� �P �3N C�.....o-I�ah�Q R�(�JC.BsidM � �/73.� SQIF�ns�.
�J:� �,5 — �q. � �d c�� c Y�s--� iP�: ��_
�! � _/� ni�. ,cblSu(�/-«Q�'fi-� "�4c1-
C ,J� S.A(�e-rl, i�V( in o�� «i�1� V"o��v!v�.�`��
Il. Is �hc co ition o�`Samuel PoYsenti 'Palhelm such as would make him suscept�ble
to be taken advantage of by unscrupulous or desig�ing penons?
a. His adaptivc bchavior is:
�k�e""1�.�, nT »`�_�d..ti__ .�J�.C,. V-�-vL�
�w.UG V'2C31 /�CS�J1��0 � L1 'Sa �.. D�S
�f��
b. l-lis social skills arc: `"1� � � � �� ����� .
vQ.(L� I ,w,-I-e�l --_ .L:iu res J -�_
� �.
�-1�' s� .. �,,,,,�� .�_ a��e-n �...0 1_.�. �--� �
b � a— �e_ l .� -� � �„�k:� � �n re�rs
< w� ,reG��— v-e�<.-l—�,uS� 10 �.Y`�-c:fi� ,
�voi�s i
12. What recomme�dations would you make conecrnin� services necessary to meet
thc esseotial requirements for thc physical health und safety of Samuel Possenti
Talhelm?
a. I would recommend that his physical health and safety be pcotected by
�„Jv��'t Q �+��I�-S�C ��µ��� �
J V
� 13. What rccommendations- would you make wnecming management of the finoncial
resoumes oC Samuel Possenti Talhelm?
a. I would recommend the following:
_ . U � ��..l:�ti� �n
14. What recom�nendations wo�id you make concerning the development or
regaining of physical or mental abilities oC Samucl Possenti 'I�alhelm?
¢. I would recommend the following:
� II q .�,(c�„ c H o
J
1�. What types ol assistanee do you think are required by Samuel Possenti Talhelm?
a. I bclicvc hc nccds assistuncc wilh thc following: ��,k� ��.��
�\w �� Cr�iY 54� Ch_. �{23Y�k1-�' A.iLYiY
[[q�� � /� /�
�1Z �SYaS�dti 1 . '��� —tllt4f�C-c� � _�i�a.Q G� 4(C � �iG�i6�j
16. hy is it no less xestr�ctrve alternatives wou d be appropriate?
a Lcss restrictive zlternatives woold not be appropriate because
5 w ��__ � v�c��o���n�, s�\�r� v-
Sc.�F —v..�,.nn�.,..�..1b
17. W'hat is thc probabiliry thaYthc extent of incapaciries of Samuel Possenti "Talhclm
may significantly change'?
a. In my judgntcnt, and based upon my cxperic�sc, training und acquaintancc
with Samuel Posscnti �I'alhclm, I belicve the probability that his incappcities
may significnntly lessen or change is:
�,��'3�.,�+_
�,�,��,� �
I8. Would the physical or mcntal condition of Samuel Puss-cnti �falhclm bc harmed
by his pxcscnce in opcn court?* �b
a. I belicvc that the presence of Samuel Posscnti '1'alhelm in open Court would
�not be harmful to his bccausc
1S�_1,��� 1,.� w.11 loz ��'I�uy
�O�i- w�+ ��f,���� a-fF�-�-t'4
*NOTC: Pennsylvania taw (20 Pa. CS. §�511(a)Q) requires that the alleged mcapac�tated
person must be present at the hea�ing unless a physician or licens-ed psychologist provides by
testimony or statemems, an opinion that hi�/her physicaL or mcntal condition would be harmcd
by his/her proscncc.
VERIFICA"IION
1. Holly C Hoffman, YI.D., veriCy [hat the statemeNs made in thc �bmgoing Deposition
arc tme and correcl to the best of my knowledge, information, and bdief. I understand that thc
stutements hercin are subject to [he penaltics of 18 Pa C.S. §4904 rclating to unsworn
talsi�ication to authori[ies.
Dated: � � 7� � � �—- —
Holly C. ti �� an, �4D.
ven i�s i
Curriculum Vitae
for
Holly C. Hoffman, MD, FAAP, MAMS
Home Address: 20 Arlington Drive
Carlisle PA 17015
Contact Information: Cell phone: 240357-1709
E-Mail: hollvmomna,earthlink.net
Business Address: Carlisle Pediatric Associates
804 Belvedere St.
Carlisle PA 17013
phone 717-243-1943 or717-243-1708
fax 717-243-6708
Personal: Born in Oakland, Maryland, USA April 18, 1959
Children: Ryan P. Hoffman-Smith, born 01-28-1984
Marie Annelise Hoffman (Bauer), born 05-17-1995
Education: Underqraduate
Lake-Sumter Community College, Leesburg, Florida
. Degree: Associate in Arts, June 1977
University of Florida, Gainesville, Florida
Major : Zoology
Degree : Bachelor of Science, March 1979
Medical School
University of South Florida College of Medicine, Tampa FL
Degree: Doctor of Medicine, June 1982
I nternshio/Residencv
Children's Hospital Medical Center, Cincinnati, Ohio
PL-I, PL-II, and PL-III June 28,1982 to August 1, 1985
Externship
Guy's Hospital, London, England
Pediatric Nephrology, April and May 1982
Practice Exoerience: Carlisle Pediatric Associates
804 Belvedere St.
Carlisle PA 17013
August 19, 1985 to present
Boards: American Board of Pediatrics
April 30, 1985 (permanent certification)
Honors and Awards: Phi Beta Kappa, University of Florida, 1979
Phi Kappa Phi, University of Florida, 1979
Alpha Omega Alpha Honors Medical Society
USF College of Medicine, 1982
Physician's Recognition Award of the AMA 1987, 1990,
1993, 1996, 1999, 2002, 2005, 2008, 2011
Staff A000intments: Carlisle Regional Medical Center
Carlisle PA
Active Staff
Additional Education: Lutheran Theological Seminary, Gettysburg PA
Master of Arts in Ministerial Studies May, 2009
Approved Diaconal Minister Candidate in ELCA
Called to St. Paul Lutheran Church, Carlisle June 1, 2010
Consecrated Sept.19, 2010
Current Medical Mission
Involvement:
a) Christ Lutheran Health Ministries, Harrisburg PA
Medical Director, one of hvo providers of low-risk prenatal
care
b) Emmitsburg Council of Churches Kenya Mission group-
co-organizer of inedical missions to Kitale/Kiminini Kenya
July of alternate years
http://ecckenvamission.webstarts com/index html
c)Living Water Dental Health Ministry, co-founder and
treasurer, volunteer administrator and translator
Print Individual Suppor[ PLan (Confidential) Pagc 1 of 29
Plan Admin > Print Plan
INDIVIDUAL SUPPORT PLAN
Commonwealth of Pennsylvania
Department of Public Welfare
Plan Summary
Consumer Name: TALHELM, SAMUEL
SSN: XXX-XX-9762
MQ: 680149566
BSU: 2120080518
MA; 6801495661
Date of Birth: 9/15/1997
Address: 113 WOODVIEW DR
MT HOLLY SPRINGS, PA - 170652002
Fiscai Year Begin Date: 7/1/2015
Fiscal Year End Date: 6/30/2016
Plan Status: Approved
AnnualReview Update Date: 3/17/2016
Plan Category: Fiscal Year Renewal
Annual Review Meeting Date:
Plan Last Updated Date: 04/21/ZO35
SC Entity: CUMBERLAND PERRY MH MR OFFICE AND BSU
Supports Coordinator: MISKE, JOSHUA
SC Supervisor: HOLLAND, THERESA
Waiver/Program Type: SC Servi[es Only
Waiver/Program Status: Enrolled
Waiver/Program Begin Date: 3/13/2015
Waiver/Program End Date:
Consent to share plan� ves
Reason for Abbreviated Plan:
Were lifesharing options considered for N/A
Residential Services:
Has the ISP signature sheet been completed:
Has the ISP Provider Choice information been
shared with the individual:
Consumer Demographics
https://www.hcsis.state.pa.us/HCSIS/pgm/asp/ISPPT.ASP 8/28/20I5
Print Individual Sttpport Plan (Confdentizl) Paee 2 of 29
Primary Demographics
First Name: SAMUEL
Last Name: TALHELM
Middle Initial: P
Suffix:
Last Name aF BirthQf different and known):
Preferred Name or Nickname:
Registration County/]oinder. Cumberland/Perry
Social Security Number: XXX-XX-9762
If Social Security Number not provided, specify
why:
Date Of Birth: 09/15/1997
Race: Other
If Race Other, Specify:
Ethnicity: Non-Hispanic
Gender: Male
School District:
6raduation Date: 06/O1/2019
Original Registration Date: 02/28/2001
Current Living situaFion: Relative's Home
Living situation Qualifier:
Prlmary Language: English
Primary Language in the Home: English
Ambulation: AMBULATORY CAN WALK INDEP WITHOUT
ASSISTANCE
Diagnosis: 318.1 Severe QCD-9)
County Of Residence: Cumberland
Are you a US Citizen?: Yes
Special Indicator:
Home Phone: 7172450903
Work Phone:
Mobile Phone:
OtherPhone:
Pager:
Confidential:
Confidential Details:
Status: Ac[ive
Reason Status: New Referral
Address
Address Type: Residential/Mailing
Address Linel: 113 WOODVIEW DR
Address Line2:
https://www.hcsisstate.pa.us/HCSIS/pgm/asp/ISPPT.ASP 8/28/2015
t'nnt Intl�vtdual Support Plan (Confidential) Page 3 of 29
Address Line3:
City: MT HOLLY SPRINGS
State: Pennsylvania
Z�P° 17065-2002
Email:
Additional Notes:
Effective Begin Date: Ol/11/2006
Effective End Date:
Alternate ID
Identifier Type: BSU
Identifier: 2120080518
Effective Begin Date: 02/28/2001
Effective End Date:
Identifier Type: MA
]dentifier: 6801495661
Effec[ive Begin Date: 02/28/2001
Effective End Date:
Identifier Type: MCI
Identifier: 680149566
Effective Begin Date: Ol/31/2004
Effective End Date:
Identifier Type: SSN
Identifier: XXX-XX-9762
Effective Begin Date: 02/28/2001
Effective End Date:
Insurance
Company: ACCESS
Insurance/Third Party Liability Type:
Policy Number: 6801495661
Policy Holder: SAM TALHELM
Policy Start Date: Ol/11/2006
Policy End Date:
Company: GATEWAY
Insurance/Third Party Liability Type:
Policy Number. 22273817
Policy Holder. SAM TALHELM
Policy Start Date: Ol/OS/2009
Policy End Date:
Company: capitol Blue Cross
Insurance/Third Party Liability Type: Major Medical Coverage
Policy Number: YWP80134438602
https://www.hcsis.state.pa.us/HCSIS/pgm/asp/ISPPT.ASP � 8/28l2015
P�int Individual Support PLan (Confidential) Yage v o[ty
Policy Holder: Kevin Talhelm
Policy Start Date: Ol/Ol/2012
Policy End Date:
Medicaid
Medicaid(MA) Number: 6801495661
Provider:
Provider Type:
Provider Policy Number:
Assistance was provided in applying for MA?: N
Medicaid Eligibility Effective Begln Da[e: 02/28/2001
Medicaid Eligibility Effective End Date:
Contacts
First Name: MICHELE
Last Name' POSSENTI
Middle Initial:
Suffix:
Relationship to Individual: Mother
Role: Caregiver
If Power of Attorney, is document on file at
agency?:
If Legal Guardian, is do�ument on file at
agency?:
If Living Will, is document on file at a9ency?:
If Caregiver indicate Date of Birth: 12/23/1963
Address Linel: 113 WOODVIEW DRIVE
Address Line2:
Address Line3:
CitY� MT HOLLY SPRINGS
State: Pennsylvania
ZiP 17065
Home Phone: 7174865092
Work Phone:
OtherPhone:
Email: michelep113@comcase.net
Preferred Contact Method: Home Phone
Best Time to Contact Morning (8:00 - 12:00)
Contact Notes:
Effective Begin Date: Ol/11/2006
Effective End Date:
First Name: Andrea
Last Name: Weber
Middle Initial:
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ermt lnarvidual Support Plzn (Confidential) Page 5 of 29
Suffix:
Relationship to Individual:
Role:
Support Team Member
If Power of Attorney, is document on file at
agency?:
If Legal Guardian, is document on file a[
agency?:
If Living Will, is document on file at agency?:
If Caregiver indi[ate Date of Birth:
Address Linel: vista school
Address Line2:
Address Line3:
City: hershey
Sta[e: Pennsylvania
Z�P' 17033
Home Phone:
Work Phone: 7ll5835102
Other Phone:
Email: aweber@thevistaschool.org
Preferred Contact Method: E-mail
Best Time to Contact:
Contact Notes: Andrea Is the Behavior Consultant at The Vista
School z1412 Best Time to contact: 7:30 AM
until 9:00 AM/2:00 PM until 3:30 PM
Effec[ive Begin Date: 02/21/2012
Effe[tive End Date:
First Name: paige
Last Name: Talhelm
Middle Initial:
Suffix:
Relationship to Individual: Sister
Roie: Support Team Member
If Power of A[[omey, is tlo[umen[ on file at
agency?:
If Legal Guardian, is document on file at
agency?:
If Living Will, is document on file at agency?:
If Caregiver indicate Date of Birth:
Address Linel: Away at college
Address Line2:
Address Line3:
City: Na
State: Pennsylvania
Zip: 99999
Home Phone:
Work Phone:
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Other Phone:
E mai I: olt1133@comcast.ne[
Preferred Contact Method: Mobile Phone
8est Time to Contact:
Contact Notes:
Effective Begin Date: 12/OS/2014
Effective End Date:
Referral
Name: SAMUELTALHELM
Relationship [o the individual: SELF
Address Linel: 113 WOODVIEW DR
Address Line2:
Address Line3:
City: MT HOLLY SPRINGS
State: Pennsylvania
Z�P; 17065-2002
Home Phone: 7172450903
Email Address:
Preferred Contact Method:
Referral Notes:
Best Time to Contact
Provider/Consumer Relation
Provider Name: CORNERSTONE AGENCY OF PA INC
Start Date: 7/1/2014
Stop Date: 6/30/2015
Provider Name: CORNERSTONE AGENCY OF PA INC
Start Date: 2/19/2015
Stop Date:
Individual Preference
Like and Admire
What do people like and admire about the
individual? :
SAMMY HAS AN INFECTIOUS SMILE. HE IS HAPPY MOST OF THE TIME. HE IS
AFFECTIONATE AND EASILY REDIRECTED. SAMMY IS MORE COMFORTABLE AROUND
FAMILIAR ADULTS. SAMMY IS VERY PROACTNE IN UTLIZING HIS COMMUNICATION DEVICE
TO MAKE HIS NEEDS AND WANTS KNOWN. SAMMY HAS A LOVE FOR 50 MANY DIFFERENT
TYPES OF MUSIC.
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Know and Do
What does the consumer/family think someone
needs to know to provide support?;
SAMMY LIVES WITH HIS MOTHER AND HIS BROTHER JACK. HE ATTENDS THE VISTA
SCHOOL DURING THE REGULAR SCHOO� YEAR AND EXTENDED SCHOOL YEAR. HE VISITS
HIS DAD EVERY OTHER WEEKEND. HE HAS AN OLDER SISTER, PAIGE, WHO IS VERY
ACTIVE IN HIS LIFE AS WELL. SHE IS CURRENTLY AWAY AT COLLEGE.
SAMMY RECEIVES PHYISCAL, OCCUPATIONAL, AND SPEECH THERAPY THROUGH HIS
SCHOOL. SAMMY HAS A VERY SHORT ATTENTION SPAN. WHEN SAMMY GETS AGITATED, HE
WILL NOT PARTICIPATE UNTIL HE IS CALMED DOWN.
SAMMY IS NON-VERBAL AND USES NO WORDS. HE CAN SHAKE HIS HEAD FOR YES WITH
LOTS OF PROMPTS. HE WILL PULL AND PUSH A PERSON TO GET WHAT HE WANTS. HE USES
AN I PAD.
HE HAS NO CONCEPT OF DANGER. SAMMY HAS A VERY HIGH PAIN TOLERANCE AND AN
INAPPROPRIATE RESPONSE TO PAIN WHICH IS USUALLY NO EFFECT. SAMMY WILL BITE
THE BACK OF HIS HAND WHEN HE 1S UPSET. HE USUALLY GETS UPSET BECAUSE HE
CANNOT COMMUNICATE HIS WANTS AND NEEDS OR DOES NOT WqNT TO DO SOMETHING
THAT HAS BEEN REQUESTED OF HIM. WHEN UPSET, HE MAY INADVERTANTLY PUSH OR
SCRATCH SOMEONE ELSE.
SAMMY DOES TAKE MEDICATIONS BUT DOES NOT SELF-MEDICATE HE TAKES HIS
MEDICATIONS WITH APPLESAUCE. HE KNOWS THAT THIS IS DONE IN THE MORNING AND
WILL GET HIS APPLESAUCE OUT AND WAIT FOR HIS MEDICATIONS. SINCE HIS SURGERY
IN 2013, HIS HEADACHES HAVE DEFINITELY DECREASED.
SAMMY IS NOT TOILET TRAINED AND STILL WEARS PULL-UPS. SAMMY TENDS TO NOT USE
THE RESTROOM AND HOLD IT AS LONG AS POSSIBLE AND AT WHICH TIME, HE HAS AN
ACCIDENT. HE [S NOW SITTING ON THE TOILET 6 TIMES PER DAY AND IS AVERAGING 1
VOID PER WEEK. HIS BEHAVIOR THERAPIST CONTIUES TO WORK WITH HIM ON
TOILETING AND INCREASING THE VOIDS. HE IS NOW ABLE TO PULL UP AND DOWN HIS
PANTS/PULL UPS BUTIS UNABLE TO UNBUTTON/UNZIP HIS PANTS. A PROGRAM WILL BE
IMPLEMENTED TO HELP WITH TOILET TRAINING.
SAMMY IS A PICKY EATER BUT THIS HAS IMPROVED. HE LOVES CHIPS AND ANYTHING
THAT iS SALTV, CHEESY AND OR CRUNCHY. MOM CONTINUES TO WORK WITH HIM TO TRY
DIFFERENT FOOD ITEMS. AT SCHOOL, FOOD IS USED AS A REINFORCEMENT, WHICH
WORKS WELL FOR SAMMY. HIS MOTHER STATES THAT THIS IS NOT AN ISSUE BECAUSE
HIS WEIGHT IS STABLE AND HEALTHY.
SAMMY IS AL50 DIAGNOSED WITH LANDAU-KLEFFNER SYNDROME, WHICH HAS CAUSED
HIM TO EXPERIENCE SEIZURES IN THE PAST. HE HAS NOT HAD A SEIZURE SINCE FALL
z01o, AT WHiCH rIME, HE ENDED UP IN THE EMERGENCY ROOM TWO TIMES. HIS MOTHER
STATES THAT IT IS BELIEVED THAT THIS WAS DUE TO SAMMY EXPERIENCING A GROWTH
SPURT AND HiS MEDICATIONS NOT BEING AD]USTED AS FAST AS HE WqS
GROWING. SAM'S MOTHER REPORTS THAT SHE CAN TELL WHEN HE IS ABOUT TO
EXPERIENCE A SEIZURE BECAUSE HE BECOMES VERY RIG[D AND STIFF BEFORE HAND. HE
CARRIES A DIASTAT RECTAL INJECTION WITH HIM AT ALL TIMES, IN CASE HE MAV
EXPERIENCE A SEIZURE. FAMILY MEMBERS AND SCHOOL ARE TRAINED AS TO HOW TO
ADMINISTER THEINJECTION,
SAM'S MOTHER ASSISTS HIM WITH ALL ASPECTS OF DAILY LIVING, EXCEPT FOR EATING,
WHICH HE IS ABLE TO DO WITH HIS HANDS OR SPOON. SAMMY DOES HELP HIMSELF
DRESSED, BUT IS RELIANT ON HIS MOTHER FOR MOST OF THIS AS WELL. SAMMY TAKES A
BATH, NOT A SHOWER. HIS MOTHER IS WITH HIM DURING THE WHOLE BATHING ROUTINE.
THERE HAS BEEN OCCASION WHERE SAMMY HAS TRIED TO GET INTO THE BATH FULLY
CLOTHED. SAM HAS LOW MUSCLE TONE AND IS NOT GOOD WITH MOTOR PLANNING AND
PROCESSING. HE GETS OUT OF THE VAN ON HIS OWN WITH SOME PROMPTING, ONCE HE
IS UNBUCKLED. ACCORDING TO HIS MOTHER, IT IS DIFFINLT FOR HIM TO KNOW WHERE
HIS BODY IS IN SPACE.
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SAM DOES NOT SLEEP FOR VERY LONG. THIS HAD IMPROVED, BUT S1NCE HIS SURGERY,
THIS HAS GOTTEN WORSE. AT TIMES HE DOES NOT FALL ASLEEP UNTIL 1:30/2AM, AND HE
GETS UP AT 7:45. HE WOULD SLEEP UNTIL NOON IF HE HAD THE CHOICE. AT NIGHT, HIS
MOTHER CLOSES AND LOCKS SAM'S DOOR, FOR FEAR THAT HE MAY ELOPE. THIS HAS
NEVER HAPPENED, IT IS JUST PRECAUTIONARY. SAMMY HOLDS HIS URINE FOR 50 LONG,
THAT HE FLOODS HIS DEPENDS CAUSING ACCIDENTS EVEN IF HE IS WEARING A NEW PAIR
OF DEPENDS. HE CONTINUES TO HAVE ACCIDENTS DURING THE NIGHT, WHICH AL50
DISTURBS Hi5 SLEEP, SINCE HIS SHEETS NEED TO BE CHANGED. HIS MOTHER SPENDS A
LARGE AMOUNT OF TIME AT NIGHT MONITORING SAMMY TO ENSURE THAT HE IS CLEAN
AND DRY.
SAMMY DOES NOT TOLERATE PHYSICAL PROMPTS AND DOES NOT IMITATE TO LEARN. THE
SCHOOL USES SHAPING TECHNIQUES FOR HIM TO LEARN SKILLS TO BE INDEPENDENT.
SAMMY MOVES AT HIS OWN PACE, WHICH IS PRETTY SLOW. SAM AL50 DOES EVERYTHING
FOORCESM IS MOTHER/SISTER WOEHAVE TOEL�AVEO WITHEHIM. IFEHEI DOESBNOTVIDO
SOMETHING, HE WILL DO ANYTHING TO PREVENT IT, INCLUDING DROPPING TO THE
FLOOR, IFNECESSARY.
THERE ARE AL50 SOME ADDITIONAL CONCERNS ABOUT SAM'S SAFEN AWARENESS: IF HE
IS THIRSN, HE WILL DRINK ANYTHING HE CAN FIND. HE WILL ALSO EAT OFF THE FLOOR
IF THERE IS SOMETHING DROPPED. HIS TEAM STATES THAT HE WILL EAT OFF OF ANY
SURFACE.
Desired Activities
Wha[ are the activities that the individual would
like [o participate in or explore? :
SAMMY LOVES MUSIC, CD PLAYERS, LISTENING TO THE RADIO IN THE CAR, AND MUSICAL
TOYS; HE EN]OYS BASICALLY ANYTHING THAT PLAYS MUSIC SUCH AS KEYBOARDS. SAM
LIKES TO REQUEST WALKS AT SCHOOL. SAMMY LIKES SPENDING TIME ON OUTINGS SUCH
AS TO HERSHEY CHOCOLATE WORLD. HE LIKES GOING ON WALKS AND BEING PUSHED IN
HIS JOGGER. SAMMY LIKES TO WALK AT Hi5 OWN PACE, HE DOES NOT LIKE TO WALK FOR
EXCERCISE OR WALKS AT OTHERS' PACE SAMMY AL50 VERY MUCH EN]OYS FOOD. SAMMY
AL50 ENJOYS ARTS AND CRAFfS.
SAM HAS A CELL PHONE AND IS ABLE TO UTILIZE THIS INDEPENDENTLY FOR TASKS SUCH
AS PUTTING HIS MUSIC ON.
SAMMY LIKES TO LOOK AT CARS AND MOTORCYCLES IN MAGAZINES DURING FREE TIME.
SAM RESI5T5 GETTING HIS PICTURE TAKEN.
Important To .
Important to Individual:
MUSIC IS VERY IMPORTANT TO SAMMY. HE RESPONDS MUCH BETTER WHEN MUSIC IS
INVOLVED.
Priority: Strongly Desired
Important to Individual:
IT IS IMPORTANTTO SAMMY TO CONTINUE HIS EDUCATION AT THE VISTA SCHOOL
Priority: Essential
Important to Individual:
IT IS IMPORTANT FOR SAMMY TO CONTINUE TO LIVE WITH HIS FAMILY
Priority: Essential
Important to Individual:
FOOD ITEMS SUCH AS CHIPS OR SNACKS ARE IMPORTANT TO SAMMY
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Priority: Strongly Desired
Important to Individual:
IT IS IMPORTANT FOR SAMMY TO RECEIVE POSITIVE REINFORCEMENT
Priority: Essen[ial
Important to Individual:
IT IS IMPORTANT TO SAMMY THAT HE IS ABLE TO COMMUNICATE AND GET HIS NEEDS AND
WANTS UNDERSTOOD
Priority: Essential
What makes sense
Whose Perspective: TEAM
What Makes Sense:
IT MAKES SENSE FOR SAMMY TO WORK ON BECOMING MORE INDEPENDENT WITH HIS
DAILY LIVING SKILLS INCLUDING TOILETIN6
What Does Not Make Sense:
IT DOES NOT MAKE SENSE FOR SAMMY NOT TO ATTEMPT TO BE MORE INDEPENDENT WITH
THE SKILLS IS DOES HAVE.
Whose Perspective: TEAM
What Makes Sense:
IT MAKES SENSE FOR SAMMY'S MOTHER TO RECEIVE RESPITE, SINCE SAMMY IS SO TIME
DEMANDING. IT ALSO MAKES SENSE THAT IT IS WITH SOMEONE HE KNOWS.
What Does Not Make Sense:
IT DOES NOT MAKE SENSE FOR SAM'S MOTHER NOT TO RECEIVE RESPITE.
Whose Perspective: SCHOOL TEACHER
What Makes Sense:
IT MAKES SENSE FOR SAMMY TO RECIEVE 1:1 HABILITATION SERVICES TO WORK ON
SKILL BUILDING
What Does Not Make Sense:
IT DOES NOT MAKE SENSE FOR SAMMY TO HAVE SERVICES IN A LARGE GROUP SETTING,
SINCE HE DOES NOT THRNE IN SUCH A SETTING
Whose Perspective: TEAM
What Makes Sense:
IT MAKES SENSE THAT SAMMY HAVE CONSTANT SUPERVISION DUE TO LACK OF SAFETY
AWARENESS.
What Does Not Make Sense:
IT DOES NOT MAKE SENSE FOR SAMMV'S HEALTH AND SAFETY TO BE IN IEOPARDY
Medical Information
Medications/Supplements
Diagnosis: RESTLESS LEG SYNDROME/SEIZURES
Medication/Supplement Name: TEGRETOL XR
Dosage: 400 MG
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Frequency: BID
Route: By Mouth
Blood Work Required?: Yes
[f Yes, How Frequentty?: QUARTERLY
Does the Person Self Medicate?: No
Name of Prescribing Doctor(Last, First): BARRON, TODD
Special Instructions/Precautions:
TAKE 1 TABLET IN THE MORNING, AND ONE TABLET BEFORE BED
Diagnosis: SEIZURE
Medication/Supplement Name: DIASTAT
. Dosage: PREMEASURED INJECTION
Frequency: PRN
Route: Rectally
Blood Work Required?: No
If Yes, How Frequently?:
Does the Person Self Medicate?: No
Name of Prescribing Doctor(Las[, First): BARRON, TODD
Special I nstructions/Precautions:
RECTAL INJECTION TO 8E USED ONLY IN CASE OF A SEIZURE. TO BE ADMINISTERED BY
FAMILY, SCHOOL STAFF, OR EMERGENCY MEDICAL PERSONEL
Diagnosis: VITAMIN SUPPLEMENT
Medication/Supplement Name: VITAMIN D
Dosage: ONE TABLET
Frequency: Q�
Route: By Mouth
Blood Work Required?: No
If Yes, How Frequently?:
Does the Person Self MedicaFe?: No
Name of Prescribing Doctor(�as[, Firs[):
5 pecia l Ins[ruc[ions/Precautions:
TAKE DAILY AS RECOMMENDED BY DOCTOR
Allergies
Known Allergy: AMOXICILLIAN
Reaction: HIVES
Required Response: REPORT TO MEDICAL PERSON ASAP IN CASE OF
RESPIRATORY RESPONSE DIFFICULTY
Known Allergy: SEASONAL
Reaction: ITCHY WATER EYES, RUNNY NOSE
Required Response: TREAT WITH PRN OTC
Health Evaluations
Type of Appraisal: Dental
Specialist Type: DENTIST
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Medical Contact:
DR. KEARNS AND ASHBY
Was Diabetes Management Considered?: N/q
If Yes, enter details:
Date of Appraisal (MM/DD/VYYY); 03/03/2014
Frequency of Appraisal: As needed
Person Responsible for Arranging/Completinq: Family
If Responsible Person is 'Other', Specify:
Type of Appraisal: Physical
Specialist Type: PEDIATRICIAN
Medi[al Contact:
DR. HOLLY HOFFMAN
Was Diabetes Management Considered?: N/A
If Yes, enter details:
Date of Appraisal (MM/DD/VYYY): 10/O1/2014
Frequency of Appraisal; Yearly
Person Responsible for Arranging/Completing: Family
If Responsible Person is 'Other', Specify:
Type of Appraisal: Other
If Type is "Other" Specify: NEUROLOGIST
Specialist Type: NEUROLOGV
Medical Contact:
TODD BARRON
Was Diabetes Management Considered?: N/A
If Yes, enter details:
Date ofAppraisal (MM/DD/YYYY); 08/O1/2014
Frequency of Appraisal: Every 6 Months
Person Responsible for Arranging/Completing: Family
If Responsible Persan is 'Other', Specify:
Medical Contacts �
First Name: BARRON
Last Name: TODD
Middle Name:
Clinir. WELLSPAN NEUROLOGY
Specialist Type: NEUROLOGY
Address Linel: 370 SL CHARLES WAY
Address Line2;
Address Line3:
City: YORK
State: Pennsylvania
Zip: ll402
Phone Number: 7178515503
First Name: HOLLY
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Last Name: HOFFMAN
Middle Name:
Clinic CARLISLE PEDIATRIC ASSOCIATES
Specialist Type: PEDIATRICIAN
Address Linel: 804 BE�VEDERE ST.
Address Line2:
Address Line3:
City: CARLISLE
State: Pennsylvania
ZiP ll013
Phone Number: 7172431943
First Name:
Last Name:
Middle Name:
Clini[: KEARNS AND ASHBY
Specialist Type: DENTIST
Address Linei: 4836 E. TRINDLE RD.
Address Line2:
Address Line3:
City: MECHANICSBURG
State: Pennsylvania
Z�P 17050
Phone Number: 7177375834
Current Health Status
Current Health Status :
SAM IS DIAGNOSED WITH PPD AUTISM SPECTRUM DISORDER,
iNTELLECTUAL/DEVELOPMENTAL DISABILITY, LOW MUSCLE TONE, RESTLESS LEG
SYNDROME, AND LANDAU-KLEFFNER SYNDROME WHICH IS THE GRADUAL OR SUDDEN
LOSS OF THE ABILIN TO UNDERSTAND AND USE SPOKEN LANGUAGE.
HE HAS A SEIZURE DISORDER ASSOCIATED WITH LANDAU KLEFFNER. HE HAS NOT
EXPERIENCED A SEIZURE SINCE FALL 2010. THIS CONTINUES TO eE MONITORED. VITAMIN
D WAS ADDED TO OFFSET THE POSSIBLE LO55 OF VITAMIN D BY TAKING SEIZURE
MEDICATION
OVER THIS PAST YEAR, HE HAS eEEN HEALTHY AND HAD NO HOSPITALIZATIONS.
Developmenta I Information
Developmental Information :
SAM WAS DELIVERED BY ASSISTED VACUUM PROCEDURES. AFfER BEING DISCHARGED, HE
WAS RE-HOSPITALIZED FOR JAUNDICE, WHICH WAS TREATED WITH PHOTOTHERAPY. HE
WAS AGAIN HOSPITALIZED AT FIFTEEN MONTHS DUE TO DEHYDRATION. SAM'S
DEVELOPMENTAL MILESTONES WERE FIRST OBSERVED BY THE FAMILY AS BEING DELAYED
BE6INNING W1TH THE LOSS OF EARLY-ACHIEVED LANGUAGE SKILLS. HE REGAINED SOME
RECEPTIVE LANGUAGE SKILLS AND IS NOW ABLE TO VOCALIZE.
AT THE AGE OF 3, SAMMY WAS DIAGNOSED WITH A FORM OF CHILDOOD EPILEPSY,
LAUNDAU-KLEFFNER SYNDROME. EEG REPORTINGS HAS INDICATED SEIZURE ACTIVITY,
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THOUGH NONE WERE OBSERVED AT THAT TIME. EVENTUALLY, SAM BEGAN TO EXPERIENCE
"STARING SPELLS" THAT WERE DIAGNOSED AS SEIZURES.
SAMMY HAD STREP SEVERAL TIMES AFfER ENTERING SCHOOL. FOR THIS REASON, HIS
PEDIATRICIAN HAD RECOMMENDED THAT A FULL BLOOD WORK UP BE COMPLETED. THERE
WERE SOME ABNORMALITIES 1NDICATED IN THE TEST RESULTS. DUE TO STREP ON
OCCASION CAUSING HEART COMPLICATIONS, AS A PRECAUTIONARY MEASURE, THE PCP
SENT HIM TO A CARDIOLOGIST FOR AN EKG, WHICH CAME BACK NORMAL.
DURING THE FALL OF 2010, SAM EXPERIENCED TWO GRAND MAL SEIZURES WITHIN THE
SPAN OF 24 HOURS. HIS MEDICATIONS WERE AD]USTED AND HE HAS NOT EXPEREINCED
ANY SINCE.
HAD A GROWTH SPURT OF 2 INCHES IN 2013, CAUSING STRETCH MARKS ON HIPS.
IN OCTOBER 2013, SAMMY'S CHIARI MALFORMATION WAS FIXED VIA DURA
DECOMPRESSION SURGERY, FOR WHICH HE WAS IN THE HOSPITAL FOR A WEEK AND A
HALF.
PsychosocialInformation
Psychosocia l Information:
SAMMY HAS NO PSYCHIATRIC OR MENTAL HEALTH DIAGNOSIS. HOWEVER, WHEN UPSET,
SAM MAY PqRTICIPATE IN SELF IN]URIOUS ACTIVIiV, SUCH AS BITING HIMSELF. IN THE
PAST THIS OCCURRED VERY REGULARLY. HE NOW DOES NOT PARTICIPATE IN THIS AT
HOME, AND DOES SO OCCASIONALLY AT SCHOOL. HOWEVER, THOUGH THE FREQUENCY
HAS DECREASED, WHEN THE SIB DOES OCCUR, IT IS MUCH MORE EXTREME AND INTENSE.
SAM A150 DOES NOT HAVE NORMAL SLEEP PATTERNS, WHICH HE HAS STRUGGLED WITH
SINCE HE WAS A BABY,
�hysical Assessment
System Area: Nervous System
Description:
SAMIS DIAGNOSED WITH LANDAU-KLEFFNER SYNDROME
SAM HAS A HISTORY OF SEIZURES, FOR WHICH TAKES MEDICATIONS DAILY AND HAS A
PRN MEDICATION TO BE ADMINISTERED SHOULD HE EXPERIENCE A SEIZURE.
MEDICATIONS AL50 ASSIST WITH RESTLESS LEG SYNDROME
SAM EXPERIENCES HEADACHES, FOR WHICH HE TAKES MEDICATION DAILY.
SAM HAS A VERY HIGH PAIN TOLORANCE AND DOES NOT AFFECT AFfER EXPERIENCEING
PAIN
IN OCTOBER 2013, SAMMY'S CHIARI MALFORMATION WAS FIXED VIA DURA
DECOMPRESSION SURGERY, FOR WHICH HE WAS IN THE HOSPITAL FOR A WEEK AND A
HALF.
System Area: Mus[ubskeletal
Description:
SAM HAS VERY LOW MUSCLE TONE
SAM HAS RESTLESS LEG SYNDROME, FOR WHICH HE TAKES MEDICATIONS FOR.
SAMMY HAS NO ARCHES IN HIS FEET
System Area: Respiratory
Description:
SAM EXPERINECE SEASONAL ALLERGIES, FOR WHICH HE TAKES PRN OTC MEDICATION
FOR. SAM ALSO IS ALLERGIC TO AMOXICILLIAN. IN THE PAST, HE HAS EXPIERENCED
HIVES, 8UT THERE IS ALSO A CONCERN FOR RESPIRATORY RESPONSE DIFFICULTV.
System Area: Genitourinary
Description:
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Pri�t Individ�tal Support Plan(ConfidcntiaL) ragc i 4 oi �7
SAM IS NOT POTTY TRAINED
Immunization booster .
Name Of Immunization/Booster: Other
If Immunization/Booster is 'Other' specify: DPT
Date Administered (MM/DD/YVYV): 12/09/1997
Name Of Immunizacion/Booster: Other
If Immunization/800ster is 'Other' specify: DPT
Date Administered (MM/DD/YYYY): 02/03/1998
Name Of Immunization/Booster: Other
If Immunization/Booster is 'Other' specify: DPT
Date Administered (MM/DD/YYYY): 04/03/1998
Name Of Immunization/Booster: Other
If Immunization/Booster is 'Other' spetify: DPT
Date Administered (MM/DD/YYYY): 03/24/1999
Name Of Immunization/Booster: Haemophilus influenzae type b
If Immuniza[ion/Booster is 'Other' specify:
Date Administered (MM/DD/YYYY): 12/09/1997
Name Of Immunization/Booster: Haemophilus influenzae type b
If Immunization/800ster is 'Other' specify:
Date Administered (MM/DD/W`!Y): OZ/03/1998
Name Of Immunization/Booster: Haemophilus influenzae type b
If Immunization/Booster is 'Other' specify:
Date Administered (MM/DD/YYYY): 04/03/1998
Name Of Immunization/Booster: Haemophilus influenzae type b
If Immunization/Booster is 'Other' specify:
Date Administered (MM/DD/YYYY): 12/29/1998
Name Of Immunization/Booster: Other
If Immunization/800ster is 'Other' specify: �P�
Date Administered (MM/DD/YYYY): 02/03/1998
Name Of Immunization/Booster: Other
If Immunization/Booster is 'Other' specify: IPV
Date Adminls[ered (MM/DD/YYYY): 04/03/1998
Name Of Immuniza[ion/Booster: Other
If ImmunizatioNBooster is 'Other' specify: IP�
Date Administered (MM/DD/YYYY): 12/29/1998
Name Of Immunization/Booster: Other
If Immunization/Booster is 'Other' specify: MMR
Da[e Administered (MM/DD/YYYY): 12/29/1998
Name Of Immunization/Boos[er. Hepatitis B - Shot #1
If Immunization/Boos[er is 'Other' specify:
Date Administered (MM/DD/YYYY): 09/16/1997
Name Of Immunization/Booster: Hepatitis B - Shot #2
If Immunization/Booster is 'Other' specify:
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Date Administered (MM/DD/YYYy): 10/29/1997
Name Of Immunization/Booster: Hepatitis B - Shot #3
If Immunization/Booster is 'Other' specify:
Date Administered (MM/DD/YYYY): 07/OS/1998
Name Of Immunization/Booster: Varitella
If Immunization/Booster is 'Other' specify:
Date Administered (MM/DD/YYYV): 09/23/1998
Health and Safety
General Health and Safety Risks
SAM IS NOT AWqRE OF RISKS INVOLVING FIRE SAFEN, TRAFFIC SAFEN, STRANGER
AWARENESS, OBTAINING EMERGENCY SERVICES, OR GENERAL SAFEN PRECAUTIONS. HE
NEEDS TO BE PROTECTED FROM HEAT SOURCES DUE TO A HIGH PAIN TOLERANCE AND
SHOULD BE MONITORED AROUND WATER.
AT THIS TIME, DUE TO HIS AGE, SAM HAS NO AWqRENESS OF MONEY MANAGEMENT.
SAM IS UNABLE TO SELF MEDICATE. HE TAKES HIS MEDICATIONS IN APPLESAUCE DAILY.
HE IS AWqRE OF THIS AND GETS THE APPLESAUCE OUT WHEN IT IS TIME TO TAKE HIS
MEDICATIONS.
SAM WORKS ON LEARNING COMMUNITV SIGNS AT SCHOOL TO WORK ON ENVIRONMENTAL
SAFETY
Fire Safety
AT THIS TIME SAMMY IS WOULD NOT KNOW WHAT TO DO IN THE CASE OF A FIRE. HE
WOULD NEED q5SI5TANCE TO EVACUATE A BUILDING. DURING FIRE DRILLS AT SCHOOL,
HE FOLLOWS THE REST OF HIS C1A55 OUT OF THE BUILDING, BUT WOULD NOT DO THIS
INDEPENDENT�Y.
Treffic
AT THIS TIME SAM IS NOT AWqRE OF TRAFFIC SAFETY AND SHOULD BE MONITORED AT
ALL TIMES IN THE COMMUNITY.
Cooking/Appliance Use
SAMMY DOES NOT USE ANY COOKING APPLIANCES INDEPENDENTLY. HE WILL REQUEST
FOOD AND DRINKS THAT HE WANTS. HE SHOULD ALSO BE MONITORED WITH HOT
FOOD. DUE TO SAMMY'S HIGH PAIN TOLERANCE, HE HAS BEEN KNOWN TO EAT
SOMETHING THAT HAS JUST COME OFF THE STOVE. HIS FOOD SHOULD BE ALLOWED TO
COOL BEFORE GIVING IT TO HIM. OVER THE PAST YEAR, HE HAS BEGAN TO USE THE
MICROWAVE WITH ASSISTANCE AS TO WHICH BUTTONS TO PUSH.
HE SHOULD ALSO NEVER 8E LEFf ALONE IN THE KITCHEN WHEN FOOD IS BEING
PREPARED DUE TO HIS LACK OF SAFEN SKILLS.
Outdoor Appliance
SAMMY DOES NOT USE ANY OUTDOOR APPLIANCES.
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W ater Safety
SAM'S MOTHER REGULATES SAMMY'S BATH WATER. SHE DOES NOT LEAVE SAM ALONE
WHILE BATHING OR WHILE PREPARING HIS BATH. IN A POOL, HE WOULD NEED TOTAL
OFSWAT Rc SAM WOULDONOTNOUMP`INTOAANY FORM OF��'1ATEROTHOUGH WIOLLNSTEP NITO
A BODY OF WATER AND WALK, BUT WILL THEN CLING TO WHOEVER IS SUPERVISING HIM.
Safety Precaution
SAMMY IS UNAWARE OF THE DANGERS OF POISONOUS MATERIALS. THESE ITEMS NEED
TO BE KEPT OUT OF SAMMY'S REACH OR LOCKED UP. IT WAS REPORTED THAT HE WOULD
INGEST PERSONAL HYGIENE ITEMS. SAMMY WILL PICK UP ANYTHING OFF THE COUNTER
AND DRINK WHATEVER IS IN THE CUP. THIS IS BECOMING A CONCERN FOR HIS FAMILY
AND NOW IS CAREFUL OF WHAT IS LEF! ON THE COUNTERS. SAMMY WILL AL50 PICK UP
FOOD FROM ANY SURFACE AND EAT IT, INCLUDING FROM THE FLOOR.
Knowledge of Self-Identifying Information
W ARYANNDE TIFBATION BRACE ETTWITHHHSIDIDENTIFYINGNINFORMATIONHONOIT.
SAMMY IS NOT LEFf UNSUPERVISED IN ANY SETTING
Stranger Awareness �
WANTS OR NEE SASOMETHING,DHE WILL APPROACH A S RANG RH AMMY IS SUPERVISED
IN ALL SETTINGS TO ELIMINATE THE THREAT THAT STRANGERS POSE.
Sensory Concerns
Sensory Concems:
SAM HAS A VERY HIGN PAIN THRESHOLD/TOLERANCE. HE NEEDS TO BE MONITORED
AROUND ANY POTENTIALTHREATS.
SAM DOES NOT PREFER TO WEAR SHOES, AND MAY TAKE THEM OFF IN ANY SETTING.
WHEN SAMMY HAS A HEADACHE, HE MAY REQUEST A HEAD RUB.
Meals/Eating
EA EN WBTH HaIS HANDSO). AT/SCHOOLH WI�TH OSE ERAL PROMP 5(OHE DOES USE AOFORK
APPROPRIATELY, THOUGH HE RE515T5 THIS. SAM IS A PICKY EATER AND HIS MOTHER IS
ATTEMPTING TO CHANGE HIS DIET TO INCLUDE HEALTHIER OPTIONS, THOUGH SHE IS
PLEASED THAT WEIGHT IS NOT A CONCERN FOR SAM AT THIS TIME. AFTER FOOD IS
PREPARED, TT MUST HAVE TIME TO COOL BEFORE IT IS GIVEN TO SAM. DUE TO HIS PAIN
INSENSITIVIN, HE MAY NOT REALIZE THAT IT IS HOT AND MAY BURN HIMSELF.
HIS MOTHER WORRIES ABOUT CHOKING BECAUSE SAMMY DOES HAVE A TENDENCY TO
DOES NOTODCLOSE H SOMOUTHM ROP RLYOLWHENMHIE AOSITOO FOODIOFfENIFALL5A0UTY
ENOUGHESA IVA� WH NOCHOEWING. ESOAMMY WILL A 50 E�ATSOFOFTOFEANY SUR ACE,
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INCLUDING THEFLOOR.
Supervision Care Needs
Supervision Care need Type: Day Supervision
Number of hours of supervision: 6
Description:
SAMMY ATTENDS THE VISTA SCHOOL DURING THE DAY AND IS SUPERVISED AT ALL TIMES.
HE RECEIVES 27.5 HOURS A WEEK (75°/ OF THE TIME) WITH A ONE ON ONE AID, AND UP
TO S HOURS A WEEK OF SERVICES FROM A PERSONAL CARE ASSISTANT.
Is intensive supervision required in this setting?: Yes
Supervision Care need Type: Home Supervision
Number of hours of supervision: 24
Description:
DUE TO SAMMY'S UNAWARENESS OF DANGERS HE NEEDS TO BE SUPERVISED 24 HOURS A
DAY.
SAM HAS AN IN HOME BEHAVIORAL THERAPIST FROM VISTA SCHOOL COME TO HIS HOME
WEEKLY FOR TWO HOURS.
Is intensive supervision required in this setting?: Yes
Supervision Care need Type: Community Supervision
Number of hours of supervision: 2q
Description:
DUE TO SAMMY'S UNAWARENESS OF DANGERS HE NEEDS TO BE SUPERVISED AT ALL
l7MES IN THE COMMUNITY.
Is intensive supervision required in this setting?: Yes
Reason for intensive staffing
Reason for Intensive Staffing Supports: Kitchen safety or require assistance with meal
preparation/diet
Other Reason:
Plan for Reducing Intensive staffing supports:
Reason for Intensive Staffing Supports: Requires Assistance with MetliCa[ion
Administration
Other Reason:
Plan for Reducing Intensive staffing supports:
Reason for Intensive Staffing Supports: Unable [o evacuate independently
Other Reason:
Plan for Reducing Intensive staffing supports:
Reason for Intensive Staffing Supports: Unable to recognize common hausehold dangers
Other Reason:
Plan for Reducing Intensive staffing supports:
Reason for Intensive Staffing Supports: Elopement risk
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O[her Reason:
Plan for Reducing Intensive staffing supports:
Behavioral Support Plan
Is there a behavioral support plan in place ? : Yes
If Yes, is it restrictive? : No
Summary:
SAMMY HAS A BEHAVIOR PLAN AT THE VISTA SCHOOL LEARNING TO WAIT AND
TOILETING.
ON OCCASION HE ALSO PARTICIPATES IN SELF INJURIOUS BEHAVIOR, IT IS NOT AS OFTEN
AS 7T ONCE WAS, BUT WHEN IT DOES OCCUR IT IS MORE EXTREME. THIS IS ALSO
ADDRESSED IN A BEHAVIOR SUPPORT TRIAGE PLAN AT VISTA SCHOOL.
BOTH PLANS CAN BE FOUND IN HIS MAIN IDD FILE.
Crisis Support
Is there a crisis support plan in place ?: Yes
Summary:
THE VISTA SCHOOL HAS AN INDIVIDUALIZED CRISIS PLAN FOR WHEN SAMMY HAS SELF
INJURIOUS RESPONSES/ BITTING HIS HANDS.
Health Care
Name of Designated Health Support Person: MICHELE POSSENTI
Address Line 1: 113 WOODVIEW DR.
Address Line 2:
Address Line 3:
City: MT. HOLLY
State: Pennsylvania
Zip: 17065
Phone: (717) 486-5092
Pager Number:
Is the individual able to make health tare No
decisions?:
Is there an advance directive in place?: No
If No, What steps will be taken to asslst the
person to complete an advance directive?:
NONE AT THIS TIME DUE TO HIS AGE.
If the individual cannot make health decisions, Yes
has a substitute decision maker been identified?:
If substitute decision maker is identified, is it a: Family Member
If substitute decision maker is not identified,
then what steps will be taken to identify a
substitute decision maker and by when?:
Name, Contact information of decision maker:
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MICHELE POSSENTI
Health Promotion
Health Condition/Issues: SEIZURES
Promotion/Strategy Support Required:
SAMMY TAKES DAILY MEDICATION AND FOLLOWS UP WITH HIS NEUROLOGIST. HE AL50
CARRIES A DIASTAT INJECTION IN CASE HE EXPERIENCES A SEIZURE
Frequency of Support: DAILY/DOCTOR EVERY 6 MONTHS/AS NEEDED
Desired Ou[come: PREVENT SEIZURES
Reason/Agency Responsible: MOTHER/CARE TAKERS/ DOCTORS
Health Condition/Issues: HEADACHE
Promotion/Strategy Support Required:
PRNIBUPROFEN
Frequency of Support: AS NEEDED
Desired Outcome: PREVENT HEADACHES
Reason/Agency Responsible: SAMMY/MOTHER/ SCHOOL/PHYSICIAN
Health Condition/Issues: ALLERGIES
Fromotion/Strategy Suppor[ Required:
SAMMY IS AILERGIC TO AMOXICILLIAN AND HAS SEASONAL ALLER6IE5. HE SHOULD
AVOID AMOXICILLIAN AND USE PRN OTCS FOR SEASONAL ALLERGIES
Frequency of5upport: DAILY/AS NEEDED
Desired Outcome; AVOID EFFECTS OF ALLERGIES
Reason/Agency Responsible: SAM/FAMILY
Health Condition/Issues: LANDAU-KLEFFNER SYNDROME
Promotion/Strategy Support Required:
LANDAU-KLEFFNER AFFECTS SAM'S COMMUNICATION/VERBAL SKILLS AND IS THE CAUSE
OF HIS SEIZURES.
SAM RECEIVES SPEECH THERAPY AND HIS SEIZURES ARE MONITORED AND CONTROLLED
BY MEDICATION
SAM USES A COMMUNICATION DEVICE
Frequency of Support: DAILY
Desired Outcome: ADDRESS THE SYMPTOMS RELATED TO
LANDAU-KLEFFNER
Reason/Agency Responsible: SAM/FAMILY/DOCTOR/CARETAKERS
Health Condition/Issues: RESTLESS LEG SYNDROME
Promotion/Strategy Support Required:
SAM TAKES MEDICATION TO CONTROL THIS
Frequency of Support: DAILY
Desired Outcome: PREVENT SYMPTOMS OF RESTLESS LEG
SYNDROME
Reason/Agency Responsible: SAM/FAMILY/DOCTOR
Health Condition/Issues: HIGH PAIN TOLERANCE
Promotion/Strategy Support Required:
SAMMY IS MONITORED AROUND ANYTHING THAT MAY BE CONSIDERED A THREAT DUE TO
HIS HIGH PAIN TOLERANCE
Frequency of Suppor[: DAILY
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Desired Outcome: PREVENT INJURY
Reason/Agency Responsible: SAM/FAMILY/DOCTOR/CARE TAKERS
Health Condition/Issues: LOW MUSCLE TONE
Promotion/Strategy Support Required:
SAM RECENES OCCUPAT[ONAL AND PHYSICAL THERAPY TO TRY TO ASSIST WITH LOW
MUSCLETONE
Frequency of Support: AS AVAILABLE THROUGH VISTA SCHOOL
Desired Outcome: HELP WITH LOW MUSCLE TONE
Reason/Agency Responsible: VISTA SCHOOL/SAM
Functional Information
Physical Development
Physical Development :
SAMMY'S FINE AND GRO55 MOTOR SKILLS ARE DEVE�OPMENTALLY DELAYED. HE WALKS
WITH A PREDICTABLE PATTERN, BUT IS GENERALLY SLOW. HE RESI5T5 PROMPTS TO WALK
FASTER. SAM HAS AN AWKWARD GAIT AND LOW MUSCLE TONE AND IS JUST ABLE TO GET
IN AND OUT OF THE FAMILY VAN. HE NEEDS ASSISTANCE GETTING SITUATED IN HIS SEAT
AND HIS SEATBELT ON AND OFF. DUE TO TIGHTNESS IN HIS HAMSTRINGS, IT CAN BE
DIFFICULT FOR HIM TO SIT ON THE FLOOR. HE HAS MILD LIMITATIONS IN FLEXIBILIN OF
HIS NECK AND TRUNK. HE IS UNABLE TO GALLOP, HOP, OR SKIP. HE DOES NOT
UNDERSTAND HIS BODY IN SPACE OR THE CONCEPT OF MOVING HIS HEAD A CERTAIN
WAY SO HE WOULD NOT HIT IT (SUCH AS GETTING IN AND OUT OF VAN), 50 HE IS
MONITORED WITH THIS. HE CAN GO UP THE STAIRS BY ALTERNATING HIS FEET BUT
WHEN HE COMES DOWN THE STAIRS HE DOES NOT ALTERNATE HIS FEET. SAM HAS NO
ARCHES. HE DOES NOT TOLARATE BRACES OR ORTHODIC INSERTS FOR ARCH SUPPORT.
THE DURA DECOMPRESSION SURGERY THAT HE HAD IN OCTOBER 2013 CAN ALSO CAUSE
WEAKNE55 OF THE LEGS. SAM LIMPS AT TIMES.
DUE TO HIS DELAY IN FINE MOTOR SKILLS, HE CANNOT DO BUTTONS, ZIPPERS, OR
SNAPS. SAM HAS MADE PROGRE55 WITH FINE MOTOR SKILLS BY INCREASING SKILLS
WITH IPAD AND IPHONE.
SAM HAS NO ISSUES NOTED WITH HIS HEARING OR VISION. THOUGH DUE TO SURGERY IN
2013, HE DOES NOT PREFER TO MOVE HIS HEAD UP AND DOWN, WHICH CAN EFFECT
WHAT HE WILLINGLY LOOKS AT.
Adaptive/Self Help
SAM RELIES ON OTHERS FOR HIS ENTIRE DAILY LIVING NEEDS. HE NEEDS ASSISTANCE
GETTING DRESSSED AND UNDRESSED. THE SCHOOL IS USING IMITATION TO WORK ON
THESE SKILLS. SAMMY IS ABLE TO PULL UP PANTS AFTER TOILETING. HE NEEDS
ASSISTANCE WITH PUTTING HIS SHIRT AND SHOES ON. HE LIKES TO TAKE HIS SHOES
OFF, BUT WHEN PUTTING THEM BACK ON, HE NEEDS ASSISTANCE AND IS MORE
SUCCESSFUL WITH THIS TASK WHEN STANDING UP.
SAMMY TAKES BATHS RATHER THAN SHOWERS. HIS MOTHER BATHES HIM AND DOES NOT
LEAVE HIM ALONE IN THE BATHTUB AT ALL. HE ALSO NEEDS HELP WITH GENERAL
HYGIENE SUCH AS BRUSHING HIS HAIR AND BRUSHING HIS TEETH.
SAMMY IS NOT TOILET TRA[NED AT THIS TIME, THOUGH HE CONTINUES TO WORK ON
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THIS WITH THE BEHAVIOR THERAPIST AT THE VISTA SCHOOL. HE WEARS PULL-UPS. HE IS
ABLE TO PULL HIS PANTS AND PULL UPS DOWN ONCE HIS PANTS ARE
UNBUTTONED/UNZIPPED. IT HAS BEEN DIFFICULT TO ASSIST SAM IN TOILET TRAINING
BECAUSE HE DOES NOT GO TO THE BATHROOM WHEN HE NEEDS TO, HE WILL INSTEAD
HOLD IT AS LONG AS POSSIBLE. HE FOLLOWS A TOILETING BEHAVIOR SUPPORT PLAN AT
SCHOOL TO ASSIST IN TOILETING, WHEN PROMPTED TO WASH HIS HANDS, HE DOES NOT
PREFER TO DO THIS. HE MAY TRY TO WASH ONE HAND AND NOT THE OTHER.
SAM IS UNABLE TO SE�F MEDICATE. HE TAKES HIS MEDICATIONS IN APPLESAUCE DAILY.
HE IS AWARE OF THIS AND GETS THE APPLESAUCE OUT WHEN IT IS TIME TO TAKE HIS
MEDICAT[ONS.
SAMMY DOES NOT COMPLETE HOUSEHOLD CHORES AT THIS TIME.
Learning/Cognition
SAMMY LEARNS BEST THROUGH GESTURES, VISUAL CONTEXT, PROMPTING CORRECT
RESPONSE, AND SHAPING WITH LOTS OF REPETITION. REPETITITION IS NECESSARY TO
MAINTAIN THIS SKILL AS WELL. HE LEARNS BEST WITH ONE ON ONE SUPPORT. SAMMY
DOES NOT TOLERATE PHYSICAL PROMPTS AND DOES NOTIMMITATE TO LEARN. HE ALSO
HAS A SHORT ATTENTION SPAN. SAM IS ABLE TO FOLLOW SIMPLE D[RECTIONS, HE IS
ABLE TO FOLLOW STEPS OF 2 DIRECTIONS WITH PROMPTING BETWEEN TASKS
SAMMY NEEDS CONSISTANCY AND A SMALL TEAM IN ORDER TO BE SUCCESSFUL.
SAMMY IS WORKING ON TYPING SKILLS AT SCHOOL (SPECIFICALLY WITH WRITING HIS
NAME) TO ASSIST WITH HIS COMMUNICATION. HE USES AN I PAD FOR COMMUNICATION
AT SCHOOL HE HAS MADE PROGRESS IN TYPING HIS NAME, SAM, MORE INDEPENDENTLY.
SAM HAS NO AWARENESS OF MONEY MANAGEMENT. MONEY HAS NO VALUE TO SAM. AT
THIS TIME, HE DOES NOT NEED TO MANAGE ANY MONEY FOR HIMSELF AND HIS MOTHER
WOULD DO THIS FOR HIM.
Communication
Primary Mode of Communication: Other
Communication Details:
SAM IS FUNCTIONING BETWEEN THE PRE-LINGUISTIC AND LINGUISTIC PHASES OF
COMMUNICATION DEVELOPMENT. SAMMY IS NON-VERBAL AND MOM REPORTS THAT HE
USES HIS I-PAD TO COMMUNICATE. HE WILL ALSO USE GESTURES OR GUIDES OTHERS TO
WHAT HE WANTS.
AT SCHOOL HE IS WORKING ON USING HIS I-PAD, BUT AL50 UTILIZING ALTERNATE
MODES IF HE IS UNABLE TO COMMUNICATE HIS NEEDS/WANTS THROUGH HIS I-0AD.
HE IS WORKING ON ORIENTING TOWARD HIS COMMUNICAITON PARTNER, WAITING FOR
ATTENTION, AND MAKMG EYE CONTACT. HE IS WORKING ON LEARNING HOW TO TYPE HIS
NAME AT SCHOOL.
Socia l/Emotional Information
Social/Emotional Information :
SAMMY SOCIALLY INTERACTS WITH THE FAMILY FOR BRIEF PERIODS OF TIME. HE IS VERY
AFFECTIONATE WITH THOSE IN HIS LIFE. THOUGH HE LIKES THE COMPANY OF OTHERS, HE
DOES NOT HAVE ANY "FRIENDS" AT THIS TIME. HE PREFERS MORE OF ADULT
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INTERACTION, RATHER THAN PEERS. HE DOES NOT UNDERSTAND SYMPATHY, EMPATHY,
RESPECT, OR AUTHORIN.
HE INITIATES SOQAL INTERACTIONS BY GRABBING, TAPPING, OR TAKING A PERSON'S
HAND/ARM. HE WILL NOT WAIT FOR SOMEONE TO LOOK AT HIM WHEN HE WANTS TO
COMMUNICATE. AT TIMES, HE MAY ENGAGE IN NEGATIVE ATTENTION SEEKING
BEHAVIORS, SUCH AS GRABBING OTHERS.
HE IS WORKING ON ORIENTING TOWARD HIS COMMUNICATION PARTNER, WAITING FOR
ATTENTION, AND MAKING EYE CONTACT.
Educationa I/V ocational Information
Student: Yes
FrequencY� Fulltime
Current Educational Status: 11TH GRADE AUTISM CLASS
School: THE VISTA SCHOOL
Address Line 1: 1021 SPRING BOARD DRIVE
Address Line 2:
City: HERSHEY
State: Pennsylvania
ZiP: 17033
Phone: (717) 583-5102
OVR Client: No
OVR Counselor Name:
OVR Counselor Phone:
Does this consumer have training goals?: No
List training goals:
Comments:
SAMMY IS WORKING ON AN IEP GOAL OF RECOGNIZING WORDS AND WRITING.
SAM WORKS ON VOCATIONAL SKILLS WHILE AT THE VISTA SCHOOL
VISTA SCHOOL DOES MAKE REFERRALS TO OVR DURING THE LAST YEAR OR TWO OF
SCHOOL, AS APPROPRIATE
Employment/Volunteer Information
Work Status: None
Frequency:
Position:
Employer/OrganizaFion:
Address Line 1:
Address Line 2:
City:
Sta[e:
Zip:
Phone:
Does this consumer have employment/volunteer No
goals?:
List Employmen[/volunteer goals:
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rnn� maiv�dual tiupport Plan (Confideotial) Page 23 of 29
Comments:
Understanding Communication
When this is happening...:
SAMMY IS DENIED/DELAYED SOMETHING (I.E. A REQUEST) OR FORCED TO DO SOMETHING
THAT HE DOES NOT WANT TO DO.
The individual does...:
HE WILL HAVE A TANTRUM, BITE THE BACK OF HIS HANDS, AND GRAB AT THE PERSON.
We think it means...:
HE IS UPSET.
We should...:
IGNORE THE BEHAVIOR AND REDIRECT HIM TO A POSITIVE AND APPROPRIATE BEHAVIOR
WHILE CONTINUING TO MAINTAIN HIS SAFEN.
When this is happening...:
SAMMY BECOMES UPSET FOR NO APPARENT REASON.
The individual does..,:
HE WILL HAVE A TANTRUM, BITE AND PULL, ETC.
We think it means...:
SAMMV IS TRYING TO COMMUNICATE OR ASK FOR SOMETHING WE DO NOT UNDERSTAND.
We should...:
TRY TO GIVE HIM WAYS TO COMMUNICATE TO FIGURE OUT WHAT HE WANTS.
Other Non-Medical Evaluation
NomMedical Evaluation Area: Psychology
If Evaluation Area is 'Other', Please Specify:
Name/Type of Evaluation: PSYCHOLOGICAL
Date of Evaluation(MM/DD/YYYY); 02/18/2002
In Need of Enhanced Communication Services?:
Evaluator Name(First Name, Last Name): RIGHTMYER, JOHNATHAN
Evaluator Agency:
KONRAD ASSOCIATES
Services and Support
Individual Outcome Summary
Outcome Phrase: SUPPORTS COORDINATION
Outcome Start Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/DD/YYYY): 03/16/2016
Outcome Actual End Date (MM/DD/riYY):
Has the outcome been successfully Yes
accomplished:
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Outcome Statement:
SAMMY AND HIS FAMILY WILL RECEIVE NECESSARY REFERRALS TO COMMUNIN
RESOURCES AND PROGRAMS.
Reason for Outcome:
SAMMY NEEDS TO RECEIVE SUPPORTS COORDWATION SERVICES SO THAT HE HAS
ACCE55 TO COMMUNIN RESOURCES AND REFERRALS.
Concerns Related to Outcome:
NONE
Relevant Assessments Linked to Outcome:
ANNUAL ISP MEETINGS, IEP REPORTS, CONTACT WITH SAM AND HIS SUPPORT TEAM
Outcome Phrase: COMMUNICATION
Outcome Start Date (MM/DD/VYYY): 03/17/2015
Outcome End Date (MM/DD/YYYV): 03/16/2016
Outcome Actual End Date (MM/DD/VYYV):
Has the outcome been successfully Yes
accomplished:
Outcome Statement:
SAM'S TEAM WILL HELP HIM IMPLEMENT AND MAINTAIN EFFECTIVE COMMUNICATION.
Reason for Outcome:
SAM NEEDS TO HAVE AN EFFECTIVE MEANS OF COMMUNICATION
Concems Related to Outcome:
I PAD AVAILABLE AT HOME AND AT PROGRAM THROUGH SCHOOL DISTRICT
Relevant Assessments Linked to Outcome:
ANNUAL ISP MEETINGS, SCHOOL IEPS, CONTACT WITH SAM AND TEAM MEMEBERS
Outcome Phrase: EDUCATION
Outcome Start Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/DD/YYYY): 03/16/2016
Outcome Attual End Date (MM/DD/VYYY):
Has the outcome been successfully Yes
aaomplished:
Outcome Statement:
SAM WILL CONTINUE TO INCREASE HIS KNOWLEDGE OF DAILY LIVING SKILLS,
COMMUNICATION SKILLS, AND VOCATIONAL SKILLS
Reason for Outcome:
SAM NEEDS TO ATTEND VISTA SCHOOLIN ORDER TO HAVE AN APPROPRIATE LEARNING
ENVIRONMENT TO GIVE HIM THE BEST CHANGE OF SUCCESS.
Concems Related to Outcome:
GRADUATION IN Z018
Relevant Assessments Linked to Outcome:
ANNUAL IEP MEETINGS, CONTACT WITH SUPPORT TEAM
Outcome Phrase: NECESSARYTHERAPIES
Outcome Star[ Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/DD/YYYY): 03/16/2016
Outcome Actual End Date (MM/DD/YYYY):
Has the outcome been successfully Yes
accomplished:
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Prmt I�dividu¢I Support Plan (Confidcntial) Page 25 of29
Outcome Sta[ement:
SAMMY WILL WORK ON IMITATING/MODELING OTHERS TO INCREASE SKILLS RELATED TO
PHYSICALACTIVITES.
SAMMY WILL WORK ON MODELING LANGUAGE/COMMUNICATION BY UTILIZING HIS I-PAD
Reason for Outcome:
SAM NEEDS TO RECEIVE NECESSARY THERAPIES, SUCH AS SPEECH, OCCUPATIONAL,
BEHAVIORAL AND PHYSICAL THERAPIES, THROUGH THE VISITA SCHOOL TO ASSIST HIM IN
BEING SUCCESSFUL AND AS INDEPENDENT AS POSSBLE.
Concems Related to Outcome:
PROGRESS IN AREAS RELATED TO THESE THERAPIES
Relevant Assessments Linked to Outcome:
SCHOOLIEPS, ASSESSMENTS FROM THERAPISTS, CONTACT WITH SAM AND HIS SUPPORT
TEAM
Outcome Phrase: HOMEBASED BEHAVIOR TECHNICIAN
Outcome Start Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/OD/YYVY): 03/16/2016
Outcome Actual End Date (MM/DD/YYYY):
Has the outcome been suc�essfully Yes
accomplished:
Outcome Statement:
SAM AND HIS FAMILY NEED ASSISTANCE TO TRANSITION AND TRANSFER INFORMATION
AND SKILLS FROM SCHOOL TO HOME.
Reason for Outcome:
SAM AND HIS FAMILY NEED THE ASSISTANCE OF A HOME BASED MOBILE THERAPIST TO
ASSIST WITH TRANSITIONIN6 INFORMATION/SKILLS FROM SCHOOL TO HOME. SAM WILL
CONTINUE TO RECEIVE THE ASSISTANCE OF A HOME BASED BEHAVIOR TECHNICIAN ONCE
A WEEK FOR TWO HOURS.
Concerns Related to Outmme:
NONE
Relevant Assessments Linked to Out[ome:
ANNUAL ISP MEETING, IEP MEETINGS, AND CONTACT WITH SAM AND HIS SUPPORT TEAM
Outcome Phrase: INDEPENDENCE
Outcome Start Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/DD/VYVY): 03/16/2016
Outcome Ac[ual End Date (MM/DD/YYYY):
Has the outcome been successfully Yes
aaomplished:
Outcome Statement:
SAMMY WILL WORK ON SKILLS TO INCREASE INDEPENDENCE TO HAVE AN EVERY DAY LIFE
Reason for Outcome:
IT IS NECESSARY FOR SAMMY TO WORK ON DAILY LIVING SKILLS 50 HE IS ABLE TO BE AS
INDEPENDENT AS POSSIBLE
Concerns Related to Outcome:
SAM'S RELIANCE ON FAMILY
Relevant Assessments Linked to Outmme:
ANNUAL IEP/ISP/CONTACT WITH FAMILY AND SUPPORT TEAM
Outcome Phrase: ADDITIONAL ASSISTANCE AT SCHOOL
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Outcome Star[ Da[e (MM/DD/YYVY): 03/ll/2015
Outcome End Date (MM/DD/VYYY): 03/16/2016
Outcome Ac[ual End Date (MM/DD/YYYY):
Has the outcome been successfully Yes
acmmplished:
Outcome S[atement
SAMMY NEEDS A ONE ON ONE AID TO BE MOST SUCCESSFUL AT SCHOOL.
Reason for Ou[come:
SAMMY RECENES THE ASSISTANCE OF BOTH A BEHAVIORAL STAFF SUPPORT AND ONE ON
ONE AIDE WHILE AT SCHOOL. SAMMY ALSO NEEDS THEIR HEIP TO RELAY
INFORMATION/SUPPORT TO OTHER STAFF
Concems Related to Outcome�
SAMMY'S EXTENSIVE NEEDS
Relevant Assessments Linked to Outcome:
ANNUAL IEP/GOAL CHARTING
Outcome Phrase: SELF CARE
Outcome Start Date (MM/DD/YYYY): 03/17/2015
Outcome End Date (MM/DD/YYYY): 03/16/2016
Outcome Actual End Date (MM/DD/YYYV):
Has the outcome been successfully No
accomplished:
Outcome Statement:
SAM WILLUSETHETOILETINDEPENDENTLY
Reason for Outcome:
BY USING THE TOILET INDEPENDENTLY, SAM WILL BE MORE INDEPENDENT AND RELY LESS
ON HIS MOTHER FOR HIS CARE. THIS WILL AL50 ALLOW HIM TO PARTICIPATE WITH
SOCIAL AND COMMUNITY GROUPS SUCH AS CAMP.
Concems Related to Outcome:
PAST PROGRAMS HAVE NOT WORKED
CONSISTENCYISIMPORTANT
Relevan[ Assessments Linked to Outcome:
PROGRE55 NOTES
Outtome A[tion Plan
Related Outcome Phrase: SUPPORTS COORDINATION
What are current needs:
SAMMY NEEDS TO RECEIVE SUPPORTS COORDINATION SERVICES SO THAT HE CAN HAVE
ACCESS TO COMMUNIN RESOURCES AND REFERRALS.
What action are needed:
SAMMY WILL RECEIVE SUPPORTS COORDINATION SERVICES 50 THAT HE CAN HAVE
ACCE55 TO COMMUNITY RESOURCES AND REFERRALS. SAM AND HIS MOTHER WILL MEET
WITH SC ANNUALLY TO UPDATE THE ISP. IN ADDITION TO THIS, SAM'S TEAM MEMBERS
WILL CONTACT SC FOR ANY OTHER NEEDS
Who's responsible:
SAM/FAMILY
SC
https://www.hcsis.statz.paus/HCSIS/pgm/asp/ISPP'P.ASP 8/28/2015
rnm im�vmuai 5upport Plan (Confidential) Page 27 of 29
TEAM MEMBERS
Frequency and duration of actions needed:
ANNUALLY, MORE IF NECESSARY, FOR THE DURATION OF THE PLAN YEAR
By when (MM/DD/1'YVY); 03/16/2016
How will you know that progress is being made
towards this outcome?:
PROGRESS IS MADE AS SAMMY AND HIS FAMILY RECEIVE NECESSARY REFERRALS AND
INFORMATION FOR AVAILABLE SERVICES
Related Outcome Phrese: COMMUNICATION
What are current needs:
SAM NEEDS TO HAVE EFFECTIVE MEANS OF COMMUNICATION
What action are needed:
SAM HAS FOUND THAT THE IPAD WORKS BEST AND HAS INCREASED HIS COMMUNICATION
SKIL�S. TEAM WILL WORK WITH SAM TO ENCOURAGE HIM TO USE THE IPAD.
Who's responsible:
SAMMY
FAMI�Y
SCHOOL
SPEECH THERAPIST
Frequency and duration of actions needed:
DAILY FOR THE DURATION OF THE PLAN YEAR
By when (MM/DD/YYYY): 03/16/2016
How will you know that progress is being made
towards this outwme?:
PROGRESS IS MADE AS SAMMY IS ABLE TO COMMUNICATE MORE EFFECTIVELY.
Reiated Outcome Phrase: EDUCATION
What are current needs:
SAM NEEDS TO CONTINUE TO RECIEVE HIS EDUCATION THROUGH THE VISTA SCHOOL
What action are needed:
SAM WILL CONTINUE TO RECEIVE HIS EDUCATION AND THERAPIES THROUGH THE VISTA
SCHOOL.
Who's responsible:
SAM
FAMILV
THE VISTA SCHOO� THROUGH SOUTH MIDDLETON SCHOOL DISTRICT
Frequency and duration of ac[ions needed:
MONDAY THROUGH FRIDAY THROUGHOUT THE REGULAR AND EXTENDED SCHOOL VEAR
FOR THE DURATION OF THE PLAN YEAR
By when (MM/DD/YYYY): 03/16/2016
How will you know that progress is being made
towards this outcome?:
PROGRE55 IS MADE AS SAMMY ACHIEVES GOALS OUTLINED IN HIS IEP.
Related Outcome Phrase: NECESSARY THERAPIES
What are current needs:
SAM NEEDS TO RECEIVE NECESSARY THERAPIES, SUCH AS SPEECH, MUSIC, PHYSICAL,
BEHAVIORAL THERAPY, AND OCCUPATIONAL THERAPIES, THROUGH HIS SCHOOL IN ORDER
TO BE AS SUCCESSFUL AND INDEPENDENT AS POSSIBLE
https://www.hcsisstate.pa.us/HCSIS/pgm/asp/ISPPT.ASP 8/28/2015
Print Individual Support Plan (Confidentinl) rage �o o. o
What action are needed:
SAM WILL CONTINUE TO RECEIVE NECESSARY THERAPIES AS DICTATED ON HIS IEP
Who's responsible:
VISTA SCHOOL
SAM
Frequency and duration of actions needed:
AS INDICATED IN SAM'S IEP FOR THE DURATION OF THE REGULAR AND EXTENDED
SCHOOL YEAR DURING THE DURATION OF THIS PLAN YEAR.
By when (MM/DD/YYYV): 03/16/2016
How will you know that progress is being made
towards this outcome?:
PROGRESS IS MADE AS IEP GOALS ARE MET.
Related Ou[come Phrase: HOME-BASED BEHAVIOR TECHNICIAN
What are current needs:
SAM NEEDS TO RECEIVE HOME BASED HBT ONCE A WEEK IN ORDER TO TRANSFER SKILLS
FROM SCHOOL TO HOME.
What action are needed:
SAM WILL CONTINUE TO RECEIVE HOME BASED HBT SERVICES FOR TWO HOURS A WEEK.
Who's responsible:
FAMILY MEMBERS
T55
CBHMP (FUNDING SOURCE)
Frequency and duration of actions needed:
ONCE A WEEK FOR TWO HOURS FOR THE DURATION OF THE PLAN YEAR
By when (MM/DD/YYYY): 03/16/2016
How will you know that progress is being made
towards this ou[[ome?:
PROGRE55 IS MADE AS SKILLS TRANSITION FROM SCHOOLTO THE HOME
Related Outcome Phrase: INDEPENDENCE
What are <urrent needs:
SAM NEEDS TO WORK ON HIS DAILY LIVING SKILLS TO INCREASE HIS INDEPENDENCE
What action are needed:
IT IS NECESSARY FOR SAM TO CONTINUE TO WORK ON BECOMING AS INDEPENDENT AS
POSSIBLE AS HE CONTINUES TO GROW INTO A YOUNG ADULT.
Who's responsible:
SAM
SUPPORT TEAM
Frequency and duration of actions needed:
DAILY FOR THE DURATION OF THE PLAN YEAR
By when (MM/DD/YYYY): 03/16/2016
How will you know that progress is being made
towards this outcome?:
PROGRE55 IS MADE AS SAMMY IS ABLE TO INCREASE HIS DAILY LIVING SKILLS
Related Outcome Phrase: ADDITIONAL ASSISTANCE AT SCHOOL
What are current needs:
SAMMY NEEDS A ONE ON ONE AID TO REACH HIS HIGHEST POTENTIAL AT SCHOOL.
What ac[ion are needed:
https://www.hcsis.state.pa.us/HCSIS/pgm/asp/ISPPT.ASP 8/28/2015
Yrm[ Individttal Support Plan (Confiden[ial) Pagc 29 of 29
SAMMY WILL RECEIVE A ONE ON ONE AID 75% TO 100% OF THE TIME AT SCHOOL AND
REGULAR SUPPORT FROM A PCA.
Who's responsible:
VISTA SCHOOL
Frequency and duration of actions needed:
SAMMY WILL RECEIVE SUPPORTS AS OUTLINED IN THE IEP FOR THE DURATION OF THE
SCHOOL YEAR AND EXTENDED SCHOOL YEAR
By when (MM/DD/YYYY): 03/16/2016
How will you know that progress is being made
towards this outcome?:
PROGRE55 IS MADE A SAMMY IS AB�E TO CONTiNUE TO INCREASE SKILLS WHILE AT
VISTA SCHOOL.
Related Outcome Phrase: SELF CARE
What are current needs:
SAM NEEDS TO TOILET INDEPENDENTLY SO THAT HE CAN BE MORE INDEPENDENT AND
PARTICIPATE IN ACTIVIl7E5 WITH MINIMAL ASSISTANCE.
What action are needed:
CORNERSTONE AGENCY WILL WORK WITH SAM WITH AN INTENSE PROGRAM TO HELP HIM
BECOMEINDEPENDENT WITH HIS TOILETING
Who's responsible:
PROGRAM DEVELOPED BY VISTA SCHOOL
PROGRAM TO BE IMPLEMENTED BY CORNERSTONE AGENCY
FOLLOW UP AND CONTINUED SUCCESS WILL BE WITH SAM AND HIS FAMILY.
Frequency and duration of actions needed:
WEEK ONE: WEEK OF 2/19/14 - 22 HOURS OR 88 UNITS
WEEK TWO: WEEK OF 2/26/14 - 32 HOURS OR 128 UNITS
WEEK THREE: WEEK OF 3/5/14 - 15 HOURS OR 60 UNITS
By when (MM/DD/1'YYY); 03/16/2015
How will you know that progress is being made
towards this outcome?:
SAM WILLBEINDEPENDENT WITH TOILETING
Service Summary
No Current Information for this Section:
Plan Admin
Monitoring
Individual requires the following monitoring Non-Statutory Frequency
frequency :
Reason for Nomstatutory frequency :
SC SERVICES ONLY
https://www.hcsisstate.pa.us/HCSIS/pgm/asp/ISPPT.ASP 8/28/2015
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IN RE: : IN THE COURT OF COMMON PEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
SAMUELPOSSENTITALHELM .
: ORPHANS' COURT DIVISION
An Alleged Incapacitated Person .
No. - 15 -
CONSENT OF PROPOSED PLENARY GUARDIAN
OF THE PERSON OF SAMUEL POSSENTI TALHELM
I, Michele Possenti, proposed Guardian of the Person and Estate of Samuel
Possenti Talhelm, the alleged incapacita[ed person, agree to accept the appointmen[ as
permanent Guardian of[he Person and Estate and aver that:
1. I am the mother of Samuel Possenti Talhelm, the alleged incapacitated person.
2. I reside at 113 Woodview Drive, Mount Holly Springs, PA 17065.
3. I certrfy that I speak, read and write the English language.
4. I have no interest adverse to the alleged incapacitated person.
5. I am not a fiduciary, or an officer or employee of a corporate fiduciary, of an
estate in which the alleged incapacita[ed person has an interest, and I am not the
surety, or an officer or employee of the corporate surety, of such fiduciary.
Data:� \1��tV�l �5`J��1 I
Michele Possenti
IN RE: : IN THE COURT OF COMMON PEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
SAMUELPOSSENTITALHELM .
: ORPHANS' COURT DIVISION
An Alleged Incapacitated Person .
No. - 15-
CONSENT OF PROPOSED PLENARY GUARDIAN
OF THE PERSON OF SAMUEL POSSENTI TALHELM
I, Paige Talhelm, proposed Guardian of the Person and Estate of Samuel Possenti
Talhelm, the alleged incapacitated person, agree to accept the appointment as pertnanent
Guardian of the Person and Estate and aver that
1. I am the sister of Samuet Possenti Talhelm, the alleged incapacitated person.
2. I reside at 113 Woodview Drive, Mount Holly Springs, PA 17065.
3. I certify that I speak, read and vmte the English language.
4. I have no interest adverse to the alleged incapacitated person.
5. I am not a fiduciary, or an officer or employee of a wrporate fiduciary, of an
estate in which the alleged incapacitated person has an interest, and I am not the
surety, or an officer or employee of the corporate surery, of such fiduciary.
Date: q�I I/l5 ✓ `""-f` ��—
Paige Talhelm
VERIFICATION
The Undersigned hereby verifies tha[the statements made in the foregoing
document are true and correct to the best of my knowledge, infortnation and belief. I
understand that false statements herein are made subject to penalties of 18 Pa.C.S.
Section 4904, relating to unsworn falsification to authorities.
Dated:�l l�_ � A ��I � YI�J�JS�
Michele Possenti