text: III. Adult Guardianship Reform JUDICIAL DETERMINATION OF CAPACITY OF OLDER ADULTS IN GUARDIANSHIP PROCEEDINGS, A HANDBOOK FOR JUDGES ABA Commission on Law and Aging and American Psychological Association (2005) pp. 3-14 Overview of Capacity Assessment A comprehensive assessment of capacity for guardianship proceedings requires collecting information on six factors. In this book, these factors will be referred to as the "Six Pillars of Capacity Assessment." Information about these factors may be obtained from healthcare professionals, court investigators, guardians ad litem, family members, adult protective service workers, and other involved parties. This book describes the six pillars of capacity assessment and how they inform each judicial action step in adult guardianship proceedings. Links to related model forms and resources are provided throughout the book. 1 Six Pillars of Capacity 1. Medical Condition Producing Functional Disability • Historically, many state statutes included "physical illness" or "physical disability" as a sufficient disabling condition, and some opened a very wide door by including "advanced age" and the catch-all "or other cause." Such amorphous and discriminatory labels invited overly subjective judicial determinations. • Today, judges require information on the specific disorder causing diminished capacity. With aging, a wide range of neurological and psychiatric conditions may impact capacity. • Some conditions are temporary and reversible. 2. Cognitive Functioning Component • "Cognitive functioning" is a component of statutory standards for capacity in many states. • The 1997 UGPPA defines an incapacitated person as an individual who … is unable to receive and evaluate information or make or communicate decisions to such an extent that the individual lacks the ability to meet essential requirements for physical health, safety, or self- care, even with appropriate technological assistance. • Cognitive functioning includes alertness or arousal, as well as memory, reasoning, language, visual-spatial ability, and insight. Neurological as well as psychiatric or mood disorders may impact information processing. 3. Everyday Functioning Component • Until recent years, the everyday functioning tests found in state law were fairly vague and subjective, such as "incapable of taking care of himself"; "unable to provide for personal needs and/or property management"; or "incapable of taking proper care of the person's self or property or fails to provide for the person's family." • Vague standards invite judgments of incapacity based upon the court's opinion of the reasonableness of one's behavior—essentially, a subjective test. • Many states now set a higher and more objective bar for weighing functional behavior by focusing only on one's ability to provide for one's "essential needs," such as "inability to meet personal needs for medical care, nutrition, clothing, shelter, or safety." • Healthcare professionals divide everyday functioning into the "activities of daily living" or "ADLs" (grooming, toileting, eating, transferring, dressing) and the "instrumental activities of daily living" or "IADLs"—abilities to manage finances, health, and functioning in the home and community. 2 4. Consistency of Choices with Values, Preferences, and Patterns • Capacity reflects the consistency of choices with the individual's life patterns, expressed values, and preferences. Choices that are linked with lifetime values are rational for an individual even if outside the norm. • Knowledge of values is not only important in determining capacity, but also in the guardianship plan. The UGPPA provides that a guardian must "consider the expressed desires and personal values of the [individual] to the extent known to the guardian." • Core values may affect the individual's preference for who is named guardian, as well as preferences concerning medical decisions, financial decisions, and living arrangements. 5. Risk of Harm and Level of Supervision Needed • Most state statutes require that the guardianship is necessary to provide for the essential needs of the individual (i.e., there are no other feasible options), or that the imposition of a guardianship is the least restrictive alternative for addressing the proven substantial risk of harm. • The social and environmental supports may decrease the risk. Lack of supports may increase risk. In this manner, the degree of risk is not merely a consideration of the condition and its effects, but the consideration of these within the environmental supports and demands. • The level of supervision determined by the judge must match the risk of harm to the individual and the corresponding level of supervision required to mitigate that risk. • In some cases, the risk is low and the need can be addressed through a less restrictive alternative or limitation to guardianship. In other cases, less restrictive alternatives have failed or are inappropriate, and a plenary guardianship is necessary to protect the well being of the elder. 6. Means to Enhance Capacity • The judge must be vigilant for means to enhance capacity through practical accommodations and medical, psychosocial, or educational interventions. • The mere existence of a physical disability should not be a ground for guardianship, since most physical disabilities can be accommodated with appropriate medical, functional, and technological assistance directed by the individual. • Information about enhancing capacity informs many judicial actions: • Hearing. How to maximize capacity at the hearing. • Review Period. What is the appropriate period for judicial review, especially if restoration of capacity through treatments is possible. • Plans. What treatments, services, habilitation should be detailed in the guardianship plan. 3 Judicial Determination of Capacity of Older Adults in Guardianship Proceedings Step One: Screen the Case 1a. Review Trigger • What is bringing this case to court now? • Identify the immediate issue or occurrences that brought the case to court at this time—for example, a question of institutional placement, sale of property, medical treatment, or financial exploitation. • Ensure that the triggering issue concerns protection of the individual, and is not for the convenience or benefit of a third party, such as a family, heir, hospital, or nursing home. Judges may address the concerns of other parties, but "the interests of the incapacitated person should take precedence." 1b. Determine if Guardianship Is Potentially Appropriate • Have all procedural requirements been met? • Is venue proper? • Are notice and service proper? • Has counsel been appointed if required or if needed? • Has individual been informed of hearing rights? • Is guardianship necessary and helpful in this case? Put a mechanism in place to screen out cases that are inappropriate for guardianship. Some courts have designated staff to work with petitioners, ensuring that cases that come before the court for judicial intervention are necessary and that petitioning the court for guardianship is, in reality, a last resort. Seek to determine that: ► There are no less restrictive alternatives. Perhaps the individual has executed durable health care and financial powers of attorney, and there is no allegation of abuse of those powers. Perhaps the only issue is authority for medical treatment and the state has a default surrogate law allowing family members to make health care decisions. Perhaps a more supervised housing setting or intensive in-home services would abrogate the need for a guardian. ► A guardian would solve the issue. There are some situations where putting a guardian in place would not address the problem at hand. "Guardianship is not appropriate in some circumstances. A probate guardian cannot make a person reveal where assets, such as vehicles are hidden, cannot [in some instances] force mental health treatment, cannot provide personal services if the person is never at home, is threatening, locks caregivers out of the home, or is homeless by choice." 4 1c. Determine if Immediate Risk of Substantial Harm • Is this a case of "emergency" guardianship? • A guardianship case may come before the judge as a petition for emergency guardianship. For example, there is need for an urgent medical procedure and no one to provide informed consent, or there is a family dispute and someone is seeking to "kidnap" the individual to an unknown location. Most states, as well as the UGPPA and the National Probate Court Standards have provisions for emergency guardianship. • In some states, and in the UGPPA, the appointment of an emergency guardian is not a finding of diminished capacity, or evidence that a permanent guardian is needed. • Because time is of the essence, procedural requirements for emergency guardianships are less than for permanent guardianship. Thus, it is important to exercise caution. • Be sure the case presents a true emergency according to state law. That is, the individual's health, safety, or welfare will be substantially harmed over the time it takes for compliance with regular guardianship procedures. • Be sure the emergency guardianship does not become an automatic doorway to permanent guardianship that bypasses procedural safeguards. Step Two: Gather Information 2a. Receive Reports • Information about the case may be brought by many parties. • A Court Investigator Report (a guardian ad litem or other court investigator or visitor—the use of these terms varies by jurisdiction) may be required or requested. As the eyes and ears of the court, the investigator can identify the triggering issue, less restrictive alternatives, risk of harm, whether there is a need for clinical evaluation, whether the individual requires counsel, the family situation, who might provide important testimony, and suggestions for limitations to guardianship and/or elements of a guardian plan, as well as evaluate the six pillars of capacity. • A Clinical Evaluation Report may be required or requested. A comprehensive evaluation will cover all six pillars of capacity, namely: the medical condition, cognitive functioning, everyday functioning, values and preferences, risk and level of supervision needed (including social support), and means to enhance capacity at the hearing and later. • Families and other lay persons may submit affidavits providing important information. . 2b. Ascertain if More Information Is Necessary • After reviewing the information, further assessment or investigation may be necessary for the following reasons: 5 ► State statutory requirements. State statutes set out the necessary elements of a clinical evaluation, which generally reflect the elements in the state definition of "incapacitated person." For specific statutory requirements of clinical evaluations, see http://www.abanet.org/aging/guardianship.html. ► Red flags signaling need for more in-depth information. If the individual has temporary or reversible causes of cognitive impairment or other mitigating factors that have not been addressed, a more sophisticated and in-depth evaluation is warranted. ► Clinical statement appears one-sided. A clinical evaluation secured by the petitioner is for the purpose of supporting the petition and may lack attention to the individual's areas of strength, a prognosis for improvement, or important situational factors. An independent assessment can flesh out skeletal or purely one-sided information. 2c. Obtain Additional Reports • If a review of the information reveals that information is not available on all six pillars of capacity assessment or has other shortcomings, then more information must be obtained from the clinician, court investigator, family, or other informants. a model order for independent evaluation. • A judge may need to order an independent and more comprehensive evaluation by a clinical professional. Step Three: Conduct Hearing 3a. Take Judicial Note of Reports The judge by his or her own motion may recognize the report of the guardian ad litem, or physician's report or other clinical statement, and admit them into evidence. 3b. Receive Testimony The judge may receive testimony from witnesses, such as relatives, friends, neighbors, care providers, geriatric care managers, or others, called by the petitioner or the individual who is the subject of the petition. The individual, him or herself, may or may not speak. In some jurisdictions and in some cases, the guardian ad litem or court investigator makes a statement . 3c. Accommodate, Observe, and/or Engage the Individual • The individual has a right to be present at the hearing. • About half of the state laws and the UGPPA require that the individual be present unless good cause is shown. 6 • The individual's presence is encouraged as it: • Allows his or her involvement in the proceedings. Often, people may want their "day in court" and feel more satisfaction from the hearing if they are present and involved, whether a guardian is appointed or not. • Allows the judge an opportunity to observe, personally, the individual. • May shed a different light on the case. • The individual may not be present if: • A medical condition prevents it (e.g., person is in a coma). • The individual does not wish to come. • To determine if the individual can attend, obtain clinical or court investigative reports concerning the individual's presence at the hearing. Assessments of whether attendance at the hearing would be harmful or not realistically possible may be included in the petition, clinical evaluation form, or court investigator report. • The following questions may guide this process: • Does the individual want to be present? • Would it be harmful in any way? • Would the individual understand at least some of the proceeding? • Would the individual be able to communicate in court? • What accommodations are needed (e.g., hearing amplifier, move location of hearing) to maximize participation? The individual and his or her attorney will determine whether the person becomes a witness. However, in an uncontested case, the judge may gain insight and/or may make the person feel involved by engaging him or her with a few questions. Step Four: Make Determination 4a. Analyze Evidence in Relation to Elements of State Law 1. The Medical Condition What is the medical cause of the individual's alleged incapacities and will it improve, stay thesame, or get worse? Based on up-to-date clinical reports, determine the cause of thediminished capacity. Depression and delirium are often mistaken for dementia and need to beruled out. 2. Cognitive Functioning In what areas is the individual's decision-making and thinking impaired and to what extent? Consider whether the individual is lucid or confused, alert or comatose, or can understand information, communicate, or can remember information over time. Consider areas of strength and weakness and the severity of impairment. 7 3. Everyday Functioning What can the individual do and not do in terms of everyday activities? Does the individual have the insight and willingness to use assistance or adaptations in problem areas? Can the person: Care of Self • Maintain adequate hygiene, including bathing, dressing, toileting, dental • Prepare meals and eat for adequate nutrition • Identify abuse or neglect and protect self from harm Financial • Protect and spend small amounts of cash • Manage and use checks • Give gifts and donations • Make or modify a will • Buy or sell real property • Deposit, withdraw, dispose, or invest monetary assets • Establish and use credit • Pay, settle, prosecute or contest any claim • Enter into a contract, financial commitment, or lease arrangement • Continue or participate in the operation of a business • Resist exploitation, coercion, undue influence Medical • Make and communicate a healthcare decision or medical treatment • Choose health facility • Choose and direct caregivers • Make an advance directive • Manage medications • Contact help if ill or in a medical emergency Home and Community Life • Maintain minimally safe and clean shelter • Be left alone without danger • Drive or use public transportation • Make and communicate choices about roommates • Initiate and follow a schedule of daily and leisure activities • Travel • Establish and maintain personal relationships with friends, relatives, co-workers • Determine his or her degree of participation in religious activities • Use telephone • Use mail • Avoid environmental dangers, such as the stove and poisons, and obtain appropriate emergency help 8 Civil or Legal • Retain legal counsel • Vote • Make decisions about legal documents • Other rights under state law 4. Consistency of Choices with Values, Patterns, and Preferences Are the person's choices consistent with long-held patterns or values and preferences? Each of the above factors must be weighed in view of the individual's history of choices and expressed values and preferences. Do not mistake eccentricity for diminished capacity. Actions that may appear to stem from cognitive problems may in fact be rational if based on lifetime beliefs or values. Long-held choices must be respected, yet weighed in view of new medical information that could increase risk, such as a diagnosis of dementia. Key areas to consider include matters such as: • Does the individual want a guardian? • Does the individual prefer that decisions be made alone or with others? • Whom does the individual prefer to be guardian/make decisions? • What makes life good or meaningful for an individual? • What have been the individual's most valued relationships and activities? • What over-arching concerns drive decisions—e.g., concern for the well-being of family, concern for preserving finances, concern for maintaining privacy, etc.? • Are there important religious beliefs or cultural traditions? • What are the individual's strong likes, dislikes, hopes, and fears? • Where does the individual want to live? 5. Risk of Harm and Level of Supervision Needed What is the level of supervision needed? How severe is the risk of harm to the individual? Determine what degree of supervision will address the individual's needs and mitigate the risk of harm. 6. Means to Enhance Functioning What treatments might enhance the individual's functioning? Consider if treatments for the underlying condition might improve functioning. Notice whether the individual might be able to use technological aids to maintain independence. Key interventions are: • Education, training, or rehabilitation • Mental health treatment • Occupational, physical, or other therapy • Home or social services • Medical treatment, operation, or procedure • Assistive devices or accommodation 4b. Categorize Judgment and Make Findings • There is no simple formula that will help judges make the determination. The following broad classification could serve as an initial schema: 9 → If minimal or no incapacities, petition not granted, use less restrictive alternative. → If severely diminished capacities in all areas, or if less restrictive interventions have failed, use plenary guardianship. → If mixed strengths and weaknesses, use limited guardianship. • When appropriate (or if required by law), a concise written record of the key findings and rationale for the judge's decision will serve as: • the basis for any appeal; • the basis for limiting the guardianship order; and • the basis for an effective plan to serve the individual's needs . 4c. If Limited Order, Identify Rights Retained and/or Removed • The cases in which there are "mixed areas" of strengths and weaknesses present the greatest challenge—and the greatest opportunity—for the "judge as craftsman" to tailor a limited order to the specific needs and abilities of the individual. 4d. Identify Statutory Limits of Guardian's Authority • State guardianship statutes, honed by state case law, will set the start-point on which to base the scope of the court order. Statutes vary in the extent of rights and duties automatically transferred to the guardian. • In many states, most or all rights are transferred to the guardian unless retained with the incapacitated person by court order. • In other states, all rights are retained unless specifically transferred to the guardian by court order. • Some statutes carve out basic rights that are retained by the individual unless the court orders otherwise—such as the right to vote or the right to make a will. Step Five: Ensure Court Oversight 5a. Monitor Changes in Capacity and Guardian Actions • Court monitoring of guardianships has many critical functions, one of which is monitoring changes to the individual's level of capacity. • Short-term Review of Capacity If the individual's level of capacity may improve soon with treatment (e.g., for subdural hematoma after a fall), the guardianship should be referred for review within a short time period. 10 • Annual Review of Capacity Unlike with probate of decedents' estates, in guardianship there is a living being whose needs may change over time, may last for many years, and may include excruciatingly complex decisions about medical treatment, placement, and trade-offs between autonomy and beneficence. An initial assessment on which the court made an original order may no longer be valid and a re-assessment may be required. A limited order or guardianship plan may require revision. Annual reports should note changes in capacity. 5b. Instruct Guardian • The guardian can be provided immediate instructions by the court, which may include the frequency of reporting and the requirement to submit a guardianship plan. • A guardianship plan, required in some jurisdictions, is a forward-looking document in which the guardian describes to the court the proposed steps to be taken for care of the individual. A guardianship plan provides an avenue to promote individual autonomy and rights, as well as to strengthen accountability. Guardianship plans are useful because they: ► Establish a baseline against which subsequent reports can be measured. ► Reflect care-planning for nursing home residents under federal regulations. ► Allow for minor changes without consulting the court, but would require court approval for any substantial adjustments. • Guardianship plans should involve the incapacitated person to the extent possible to outline the services and strategies that will be used to implement the order, including, most importantly, how those rights retained in limited orders will be ensured. Even where legal consent is not possible, the assent of the person should be sought. • Guardianship plans can detail treatments and services and the values that should guide future decisions as have been discovered in the clinical and court investigative reports. 11 GUARDIANSHIP MONITORING: A NATIONAL SURVEY OF COURT PRACTICE Naomi Karp and Erica Wood AARP Pub. Policy Instit. and ABA Commn. on L. and Aging (2007) pp. v-xi Guardianship is a relationship created by state law in which a court gives one person or entity (the guardian) the duty and power to make personal and/or property decisions for another (the ward or incapacitated person). A judge appoints a guardian upon finding that an adult individual lacks capacity to make decisions for him or herself. Guardianship is a powerful legal tool that can bring good or ill for an increasing number of vulnerable people with cognitive impairments, affording needed protections, yet drastically reducing fundamental rights. Court monitoring of guardians is required to ensure the welfare of incapacitated persons, identify abuses, and sanction guardians who demonstrate malfeasance. In 2005 the AARP Public Policy Institute, in conjunction with the American Bar Association (ABA) Commission on Law and Aging, conducted a survey to examine current court practices for guardian oversight. In 2006 the two organizations are continuing to study guardianship monitoring through site visits and telephone interviews, and a second report will follow with recommendations on promising practices. Background Guardianships are established through a legal process outlined in state law and are subject to court supervision. Guardianship has a "front end" (procedures providing due process protections before a finding of incapacity and appointment of a guardian) and a "back-end" (procedures for guardian oversight following appointment). Monitoring procedures may include the guardian posting a bond, submission and review of periodic reports and accounts, and sanctions for guardians who fail to file reports in a timely manner or who demonstrate malfeasance. This process differs from state to state, court to court, and judge to judge. Demographic and Societal Shifts The need for effective court monitoring practices is heightened by ongoing demographic trends that will sharply boost the number of guardianships in coming years, including growing numbers of older people, individuals with Alzheimer's disease and other forms of dementia, and people with mental retardation or intellectual disabilities. Moreover, incidents of elder abuse are on the rise, as is the number of not-for-profit, for-profit, and public guardianship agencies that must make critical decisions about multiple wards, sometimes with high caseloads. All of these trends combine to underscore the dire need for oversight when fundamental rights and financial resources are transferred to guardians, leaving at their mercy individuals with diminished capacity. 12 Guardianship Monitoring Reform Efforts A comprehensive 1987 Associated Press series, entitled Guardians of the Elderly: An Ailing System, triggered close to two decades of adult guardianship reform, igniting a rush to revise guardianship statutes, prepare training materials, and strengthen court practices. State legislatures have sought to bolster guardian accountability through provisions on the frequency and contents of guardian reports and accounts, bonding requirements, court review procedures, and sanctions. Despite these reform measures, judicial monitoring practices appear to vary and, in many areas, remain lax. Continuing news accounts throughout the 1990s and beyond indicate that serious problems persist. Whether such accounts reflect isolated examples of abuse in an otherwise well-functioning process or come closer to the norm has been unknown, as data and research are scant. Methodology In 2005, AARP's Public Policy Institute, in collaboration with the ABA Commission on Law and Aging, conducted a national Internet-based survey of how courts monitor guardianship cases, replicating and building on a similar ABA survey in 1991. The 35-question survey focused on actual court practices—seeking to ascertain whether the practices meet, exceed, or fall short of requirements imposed by statutes and court rules and to identify practices that may be "ahead of the curve." AARP sent the survey to approximately 2,100 individuals, including guardians, probate judges, court managers, elder law attorneys, and legal representatives of people with disabilities (identified through relevant national organizations), and received 387 survey responses from 43 states and the District of Columbia. Of these, over half identified their role as guardians. Findings Guardian Reporting and Accounting Requirements • Statutes in all but two states require guardians to submit personal status reports, although the required frequency varies. In the survey, 74.2% of respondents said their court requires annual filing of these reports, yet close to 80% reported that their statute or rule requires annual filing, indicating that a small but statistically significant number of courts do not impose the statutory or regulatory mandate of annual reporting. • Eighty-six percent of survey respondents stated that their statute or court rule requires accountings annually, yet slightly fewer (82.7%) reported that their court requires accountings annually, and although slight, that difference was significant. • A total of 34.1% of respondents stated that their court consistently requires guardians to file plans for future care of the individual, and 9.3% stated that the court sometimes requires the filing of such plans. However, almost half (48.1%) said their court does not require filing of plans. 13 Court Assistance to Guardians • The most commonly available resource for guardians is court-provided written instructions or manuals (43.2% of respondents). More than one-third of respondents (37.5%) reported that training sessions are sponsored by non-court entities for their jurisdiction. Over one-fifth (22%) of respondents said that no guardian training resources are available. • A significant majority of respondents (62.8%) reported that their court routinely specifies the guardian's reporting and accounting responsibilities in the initial guardianship order, but 24.8% said the court does not typically do so. • Only 19.9% of respondents said that the court routinely sends reporting and accounting forms to guardians. Otherwise, forms are available from the court clerk (42.6%), from attorneys (33.1%), or on the court website (33.1%). • More than 40% of respondents (40.1%) said that no samples of appropriately prepared reports and accountings were available to them. Only 18.1% said samples are available from the clerk. Enforcing Reporting Requirements • Some 63.8% of respondents indicated that the court has an effective notification system in place to alert guardians of report due dates; 26.6% said there was no such system. • The most commonly named court sanction for failure to file reports and accountings is sending the guardian a notice of delinquency (46.5%), followed by entering show cause orders (31.8% reporting routine use and 27.4% when appropriate). In addition, 15.5% of respondents said court staff informally contacts the guardian, and only 3.9% reported use of fines. • While close to 40% of respondents did not know what measures the court takes if a guardian habitually files late, 48.6% reported that the court requires such a guardian to appear for a status hearing. Over a quarter (25.6%) said the court revokes the appointment and appoints a successor guardian, and 16.0% said the court asks an investigator or volunteer to obtain more information. Procedures for Review • More than half of respondents (50.6%) indicated that financial accountings are reviewed by a court auditor or other court staff for whom this is a primary responsibility; while 26.6% said the judge who entered the order performs the review, and 14.0% said a judge is assigned to review the accountings. Close to one-fifth of respondents (19.9%) reported that other court staff conduct the review. Some 8.5% of survey respondents said no one has such responsibility on a regular basis. 14 • Regular review of personal status reports is most commonly the responsibility of a court investigator or other court staff for whom this is a primary task (36.7% of respondents) or by the judge who entered the order (30.5%). Verification and Investigation • Over one-third of respondents (34.4%) stated that no one is designated to verify the information in reports and accounts. A total of 16.8% of respondents indicated that court staff verify as needed, and 10.1% said court staff verify each report. In 5.9% of jurisdictions, a special master, guardian ad litem, or other person verifies each report. Thus, only 16% of respondents reported that someone at the court verifies every report. Volunteers rarely fill this function. • No one visits the incapacitated individual in the jurisdictions of 40.3% of those responding. Only about a quarter of respondents (25.9%) reported that someone visits the person on a regular basis. • Does an accounting trigger an inquiry into an incapacitated person's well-being if a possible problem is uncovered? Close to 38% of respondents said the court investigates in such a situation, 13.4% said review of the financial information focuses only on whether the calculations are correct, and 25.1% said that consideration of the individual's wellbeing in review of the accounting varies. • The most common court response to complaints about the guardian—reported by more than half of survey participants—is to appoint a guardian ad litem, special master, or visitor to investigate (51.9%). Other common practices include entering a show cause order or setting a hearing (41.9%) and contacting the guardian (37.0%). Sanctions • The most common sanction was removing the guardian and appointing a successor guardian (67.2%), followed by imposing a fine (48.1%) and appointing a guardian ad litem to investigate (33.3%). Courts may also make a referral to adult protective services (26.9%), report the guardian to law enforcement (26.6%), or report an attorney guardian to the bar association (15.8%). In some instances, courts deny or reduce the guardian's fee (23.8%). Funding for Monitoring • Over two-fifths (43.4%) of respondents stated that funding for monitoring is unavailable or clearly insufficient. About 17% responded that some funding is available, and only 10.9% said sufficient funds are available. • The majority of respondents who identified funding sources stated that their courts rely on multiple sources. The source that 45.5% of respondents named was state legislative appropriations specifically for guardianship monitoring, followed by filing fees (16.5%), and a number of other less common sources. Close to one-third of respondents (31.3%) said there is no specific funding for guardianship monitoring. 15 Role of Attorneys • Close to one-fifth of respondents (18.6%) stated that their state bar has clear and complete ethical guidelines for attorneys representing the petitioner, guardian, ward, or proposed ward, but 14.2% said that the guidelines are clear only in some aspects, 8% said the guidelines are unclear concerning the roles of attorneys, and 9% said there are no applicable guidelines. • Over half of respondents (53.7%) stated that the extent to which attorneys for guardians assist with reporting and accounting varies by attorney, guardian, or case circumstances. • The role of the attorney for the incapacitated individual in monitoring the person's well- being after a guardian is appointed varies greatly. According to one-third of the respondents (33.1%), the court dismisses the attorney after the appointment and has no further role. Only 7.5% stated that the attorney remains the attorney of record and routinely stays actively involved throughout the case, with the remaining respondents describing a lesser role. Court-Community Interaction • Interaction between courts and community entities concerning guardianship monitoring is relatively infrequent. Over one-quarter of respondents (25.3%) indicated that the court is aware of relevant community groups and communicates from time to time, while just under one-quarter (24.0%) said the court has little contact. A small percentage of respondents (10.9%) said the court participates in multidisciplinary groups on guardianship and alternatives or collaborates with such groups on training and education (10.9%). In just a few cases (5.7%), the court has developed referral protocols with community groups. Data Systems and Court Technology • A substantial portion of respondents (40%) did not know how the court maintains data on adult guardianship cases. Only 27.6% said the court has a computerized system to track the number of adult guardianship filings and dispositions, and only 8% stated that the court has a computerized system that tracks and aggregates not only the number of filings and dispositions, but additional data elements as well. • By far the most common data element for which the court maintains statistics is guardian actions on behalf of the ward (82.7% of respondents). More than one-fifth of respondents (22.2%) said the court maintains statistics on the timeliness of guardian reports, 18.9% indicated maintenance of data on whether the incapacitated person was represented by counsel at the time of adjudication, and 18.3% reported data collection on the age of the incapacitated individual. 16 • Only 9.3% of survey respondents said the court maintains data on whether the case involved elder abuse. • While 44% of respondents did not know how the court uses computer technology in guardianship monitoring, over one-third (36.2%) indicated that the court uses such technology to identify late filings. Other uses for monitoring are quite rare. A substantial 22% of respondents stated that computer technology is completely unavailable for guardianship monitoring. • Close to one-third of survey respondents (30.2%) indicated that part of the guardianship file is open to the public, but part is sealed, and nearly another third (28.9%) said the entire file is open and is available at the courthouse. Only a handful of respondents said the entire file is open and accessible through the Internet (3.9%), or that the entire file is sealed (4.1%). Discussion and Conclusions Monitoring is a must, but, in reality, it varies substantially from court to court. Survey findings suggest that some current monitoring practices are promising and worthy of replication, while other aspects of monitoring are ripe for improvement. Salient themes in the survey findings include the following: • Guardianship monitoring practices continue to show wide variation. Key areas of variation include court assistance to guardians, handling of filing deadlines and late filings, designation of reviewers, response to complaints, review of the need to continue the guardianship, sanctions, and roles of attorneys. These varied approaches are likely to yield some "promising practices," to be explored in the next phase of this research. • Reporting practices have advanced over the past 15 years in some key aspects. → Filing of Personal Status Reports. The percentage of respondents stating that their court requires filing of personal status reports rose to 74.2%, up from 67.5% in 1991. The majority of respondents reported that courts require a moderate amount of detail. Thus, more courts are getting regular information in a form that may provide them insight into the incapacitated person's circumstances and condition. → Compliance with Statutory Reporting Requirements. The gap between statute and practice on reporting seems to have narrowed substantially since 1991. Almost 80% of respondents said their statute requires reports, and 74.2% said their particular court requires reports. → Use of Guardianship Plans. Over 34% of respondents reported that their court requires guardians to file forward-looking plans. This number is significant, since plan requirements in statute are relatively new, and only about 10 state statutes require them. 17 • Use of technology in monitoring is minimal; harnessing technology could effect a paradigm shift in monitoring practices. While computer technology is available that could greatly strengthen guardian accountability, surprisingly few courts use it for monitoring. For example, only 3.9% of survey respondents said their court e-mails guardians about reporting status, and only 4.1% said the guardian could check the status of reports and due dates online. Few courts maintain comprehensive guardianship databases electronically. Also, courts vary widely in whether the public has access to case files (electronic or hard copy) with sensitive personal information, raising serious privacy concerns. • Guardian training has increased but remains a compelling need. While training and written instructional materials for guardians are increasingly available, with 40% of survey respondents saying that their court provides such resources, training continues to be a significant unmet need. Over 40% of respondents indicated that no model reports or accountings are available to guide them. • Verification of guardian reports and accounts, as well as visits to individuals under guardianship, is frequently lacking. More than one-third of survey respondents said no one is designated by their court to verify the information in guardians' reports and accounts. Of equal concern, over 40% of respondents report that no one is assigned to visit the vulnerable individual, and only a quarter said that someone visits on a regular basis. Mechanisms serving as the "eyes and ears" of the court are critical. • The role of volunteers in monitoring is minimal, yet offers potential. Fewer than 10% of respondents reported that their courts use volunteers for any monitoring function, despite the fact that some courts have used this potentially low-cost, high- return resource. • Court-community action on monitoring is infrequent, yet could enhance oversight. Community groups on training, and only one-quarter of respondents said that their courts are aware of and work intermittently with relevant community entities such as adult protective services agencies and long-term care ombudsman programs. • Funding for guardianship monitoring remains minimal. Some 43.4% of respondents said that funding for monitoring is unavailable or insufficient. This critical funding gap affects every aspect of monitoring. Heightening the awareness of legislatures, county commissions, and other funding sources concerning the urgent need for monitoring resources is an important step in securing the welfare of vulnerable individuals under guardianship. 18 GUARDIANSHIPS: COLLABORATION NEEDED TO PROTECT INCAPACITATED ELDERLY PEOPLE U.S. Government Accountability Office (GAO) (2004), Report No. GAO-04-655 (available at http://www.gao.gov/new.items/d04655.pdf) What GAO Found All states have laws requiring courts to oversee guardianships, butt court implementation varies. Most require guardians to submit periodic reports, but do not specify court review of these reports. Interstate jurisdictional issues sometimes arise when states do not recognize guardianships originating in other states. Most courts responding to our survey did not track the number of active guardianships, and few indicated the number of incapacitated elderly people under guardianship. Four courts recognized by members of the National Guardianship Network as having exemplary guardianship programs devote staff to strong programs for guardianship training and oversight. Three of these courts offer training to guardians even though state law does not require it. Three also have programs in which volunteers or social work student interns visit people under guardianship and report on their condition. Although state courts and federal agencies are responsible for protecting many of the same incapacitated elderly people, they generally work together only on a case-by-case basis. Some courts send notices of guardianship to the Department of Veterans Affairs and the Social Security Administration, but generally coordination among federal agencies and courts is not systematic. Federal agencies and courts do not systematically notify other agencies or courts when they identify someone as incapacitated, or when they discover that a guardian or a representative payee is abusing the incapacitated person. This lack of coordination may leave incapacitated people without the protection of responsible guardians and representative payees. 19 GUARDIANSHIPS: CASES OF FINANCIAL EXPLOITATION, NEGLECT, AND ABUSE OF SENIORS U.S. Government Accountability Office (GAO) (2010), Report No. GAO-10-1046 (available at http://www.gao.gov/new.items/d101046.pdf) What GAO Found GAO could not determine whether allegations of abuse by guardians are widespread; however, GAO identified hundreds of allegations of physical abuse, neglect and financial exploitation by guardians in 45 states and the District of Columbia between 1990 and 2010. In 20 selected closed cases, GAO found that guardians stole or otherwise improperly obtained $5.4 million in assets from 158 incapacitated victims, many of whom were seniors. In some instances, guardians also physically neglected and abused their victims. The guardians in these cases came from diverse professional backgrounds and were overseen by local courts in 15 states and the District of Columbia. GAO found several common themes. In 6 of 20 cases, the courts failed to adequately screen potential guardians, appointing individuals with criminal convictions or significant financial problems to manage high-dollar estates. In 12 of 20 cases, the courts failed to oversee guardians once they were appointed, allowing the abuse of vulnerable seniors and their assets to continue. Lastly, in 11 of 20 cases, courts and federal agencies did not communicate effectively or at all with each other about abusive guardians, allowing the guardian to continue the abuse of the victim and/or others. The table below provides examples of guardianship abuse cases. Examples of Cases of Abuse by Guardians Victim Guardian/ Case details state 87 year old Former taxi • Guardian embezzled more than $640,000, which included the purchase of a man with cab driver / Hummer and checks written to exotic dancers. Alzheimer's Missouri • County workers found the victim living in the guardian's filthy basement Disease wearing an old knit shirt and a diaper. • Guardian was sentenced to 8 years in prison and ordered to pay $640,000 in restitution . At least 78 Private • Agency management stole at least $454,000 over 4 years. victims agency / • Executive director used wards' funds to pay for his credit card bills, medical Alaska expenses, mortgage payments, and camp for his children. • Victims received partial repayment, but no criminal charges were filed. 20 victims of Licensed • Guardian and his wife sexually and physically abused residents of their various ages social unlicensed group home and billed Medicare for this ''therapy." with mental worker, • Residents lived in a house described by the prosecutor as "dirty and bug- incapacities registered infested" and were videotaped engaged in forced sexual activities. nurse / • Guardian sentenced to 30 years in prison; wife sentenced to 15 years. Kansas Source: GAO summary of closed cases of abuse, neglect and financial exploitation by guardians. Using two fictitious identities-one with bad credit and one with the Social Security number of a deceased person-GAO obtained guardianship certification or met certification requirements in the four states where we applied: Illinois, Nevada, New York, and North 20 Carolina. Though certification is intended to provide assurance that guardians are qualified to fj1lfill their role, none of the courts or certification organizations utilized by these states checked the credit history or validated the Social Security number of the fictitious applicants. An individual who is financially overextended is at a higher risk of engaging in illegal acts to generate funds. In addition, people with criminal convictions could easily conceal their pasta by stealing a deceased person's identity. The tests raise questions about the effectiveness of these four state certification programs. 21 INCAPACITATED ADULTS: OVERSIGHT OF FEDERAL FIDUCIARIES AND COURT- APPOINTED GUARDIANS NEEDS IMPROVEMENT U.S. Government Accountability Office (GAO) (2011), Report No. GAO-11-678 (available at http://www. gao.gov/new.items/d11678.pdf) What GAO Found SSA, VA, and state courts have screening procedures for ensuring that fiduciaries and guardians are suitable. SSA and VA strive to prevent individuals who have misused beneficiaries' payments from serving again, and each is currently developing an automated system that will enhance its ability to compile and maintain information about misuse of benefits by fiduciaries. Similarly, according to the AARP Public Policy Institute, laws in most states require courts to follow certain procedures for screening guardians. However, only 13 states conduct criminal background checks on all potential guardians. There are also statutes and regulations requiring SSA and VA to monitor fiduciary performance. Fiduciaries in each agency must periodically report on their responsibilities. Similarly, most states require courts to obtain annual reports from guardians. There is evidence that guardianship monitoring by state courts, however, needs improving, and promising practices have been proposed to strengthen it. Given limited resources for monitoring, courts may be reluctant to invest in these practices without evidence of their feasibility and effectiveness from projects designed to evaluate these practices. Gaps in information sharing may adversely affect incapacitated adults. When VA and SSA have incapacitated beneficiaries in common, sharing certain information about them could enhance each agency's ability to protect the interests of these beneficiaries. While SSA and VA do not systematically share such information, VA can obtain such information from SSA on a case-by-base basis. SSA officials indicated, however, that obtaining similar information from VA may not be cost-effective given the relatively small proportion of SSA beneficiaries who also collect VA benefits. It is also in the best interest of incapacitated beneficiaries for federal agencies to disclose certain information about these beneficiaries and their fiduciaries to state courts. National organizations representing elder law attorneys and advocating for elder rights have noted that courts have difficulty obtaining such information when it is needed, particularly from SSA. The federal government has a history of funding technical assistance and training related to guardianship for state courts, primarily through the AoA within HHS. In 2008, AoA established the National Legal Resource Center (NLRC) to support improvements in legal assistance for older adults and to support elder rights protections. Among its other projects, NLRC has supported an evaluation of Utah's public guardian program. Because of the federal government's activities in this area, it is well positioned and has an opportunity to lead in ensuring the rights of incapacitated adults with court-appointed guardians by supporting evaluations of promising court monitoring practices. 22 THIRD NATIONAL GUARDIANSHIP SUMMIT GUARDIAN STANDARDS AND RECOMMENDATIONS (2011) Available at http://www.guardianshipsummit.org/wp-content/uploads/2011/11/summit-standards-and- recommendations-12-11.pdf On October 13-15, the ten National Guardianship Network sponsoring organizations, with eleven diverse cosponsors, convened the Third National Guardianship Summit at the University of Utah S.J. Quinney College of Law in Salt Lake City. With 92 delegates, observers, authors, funders and facilitators participating, the Summit was a consensus conference on post-appointment guardian performance and decision-making for adults. The Summit delegates adopted a far-reaching set of recommendations for Guardian Standards, as well as additional Recommendations for action by courts, legislatures and other entitles. These documents from the Summit offer the groundwork for nationally recognized standards for guardians of adults. Below are: (1) basic Definitions used in the Standards and Recommendations; (2) the Summit's "Guardian Standards;" and (3) the Summit's "Recommendations for Action." The Standards and Recommendations were adopted by vote of the plenary session based on recommendations of the Summit's seven interdisciplinary working groups. ### Definitions for Guardianship Summit Standards/Recommendations o Guardian = person or entity appointed by a court with the authority to make some or all personal decisions on behalf of an individual the court determines lacks capacity to make such decisions. o Conservator = person or entity appointed by a court with the authority to make some or all financial decisions on behalf of an individual the court determines needs assistance in making such decisions. o NOTE: The standards and recommendations use the term "guardian" to mean guardian and conservator, unless otherwise specifically indicated. o Person under guardianship [or person under conservatorship], or simply "person" = a person the court has determined requires assistance in making some or all personal and/or financial decisions, and for whom the court has appointed a guardian and/or conservator. o Person-centered planning process. A "person-centered planning process" is one which is led by the individual receiving services and (1) Includes people chosen by the individual; (2) Provides necessary support to ensure that the individual has a meaningful role in directing the process; (3) Occurs at times and locations of convenience to the individual; (4) Reflects cultural considerations of the individual; (5) Includes strategies for solving conflict or 23 disagreement within the process, including any conflict of interest concerns; (6) Offers choices to the individual regarding the services and supports they receive and from whom; (7) Includes a method for the individual to request updates to the plan as needed. This process has been developed over the last few decades, and adopted by federal regulation in 42 U.S.C. §441.301. #1. Core Standards Standard #1.1 The guardian shall develop and implement a plan setting forth short-term and long-term goals for meeting the needs of the person. • Plans shall emphasize a "person-centered philosophy". Standard #1.2 The guardian shall treat the person with dignity. Standard #1.3 The guardian shall make a good faith effort to cooperate with other surrogate decision-makers for the person. • These include where applicable, any other guardian, conservator, agent under a power of attorney, health care proxy, trustee, VA fiduciary and representative payee. Standard #1.4 The guardian shall promptly inform the court of any change in the capacity of the person that warrants an expansion or restriction of the guardian's authority. Standard #1.5 The guardian shall promptly report to the appropriate authorities abuse, neglect, and/or exploitation, as defined by state statute. #2. Guardian's Relationship to the Court Standard #2.1 The guardian shall seek ongoing education concerning: • Person-centered planning • Surrogate decision-making • Responsibilities and duties of guardians • Legal processes of guardianship • State certification of guardians. Standard #2.2 The guardian and conservator shall keep the court informed about the well-being of the person and the status of the estate through personal care and financial plans, inventory and appraisals, and annual reports and accountings. 24 Standard #2.3 The guardian shall seek assistance as needed to fulfill responsibilities to the person. Standard #2.4 The guardian shall use available technology to: • File the general plan, inventory and appraisal, and annual reports and accountings • Access responsible education and information about guardianships • Assist in the administration of the estate. #3. Fees Standard #3.1 The guardian, as a fiduciary, shall: • Disclose in writing the basis for fees (e.g., rate schedule) at the time of the guardian's first appearance in the action • Disclose a projection of annual fiduciary fees within 90 days of appointment • Disclose fee changes • Seek authorization for fee-generating actions not contained in the fiduciary's appointment • Disclose a detailed explanation for any claim for fiduciary fees. Standard #3.2 A guardian shall report to the court any likelihood that funds will be exhausted and advise the court whether the guardian intends to seek removal when there are no longer funds to pay fees. A guardian may not abandon the person when funds are exhausted in cases in which the spend- down occurred over several reporting periods and the guardian failed to address the probability of exhaustion with the court and failed to make appropriate succession plans. Standard #3.3 A guardian may seek payment of fiduciary fees from the income of a person receiving Medicaid services only after the deduction of the personal needs allowance, spousal allowance and health care insurance premiums. #4. Financial Decision-Making Standard # 4.1 The conservator, as a fiduciary, shall manage the financial affairs in a way that maximizes the dignity, autonomy, and self-determination of the person. Standard # 4.2 The conservator shall consider current wishes, past practices, reliable evidence of likely choices, and best interests of the person. 25 Standard # 4.3 A conservator shall, consistent with court order and state statutes, promote the self- determination of the person and exercise authority only as necessitated by the limitations of the person. Standard # 4.4 The conservator shall encourage and assist the person to act on his or her own behalf and to participate in decisions. Standard # 4.5 When possible, the conservator shall assist the person to develop or regain the capacity to manage the person's financial affairs. The conservator's goal shall be to manage but not necessarily eliminate risk. Standard # 4.6 The conservator shall value the well-being of the person over the preservation of the estate. Standard # 4.7 The conservator shall avoid all conflicts of interest and self-dealing, and all appearances of conflicts of interests and self-dealing. • The conservator shall become fully educated as to what constitutes a conflict of interest and self dealing, and why they should be avoided. • The conservator may enter into a transaction that may be a conflict of interest or self- dealing only when necessary, or when there is a significant benefit to the person under the conservatorship, and shall disclose such transactions to interested parties and obtain prior court approval. Standard# 4.8 The conservator shall, when making decisions regarding investing, spending, and management of the income and assets, including asset recovery: • Give priority to the needs and preferences of the person • Weigh the costs and benefits to the estate • Apply state law regarding prudent investment practices. Standard# 4.9 The conservator shall take all steps necessary to obtain a bond to protect the estate, including obtaining a court order. Standard #4.10 The conservator shall use reasonable efforts to: • Ascertain the income, assets, liabilities of the person • Ascertain the needs and preferences of the person • Coordinate with the guardian and consult with others close to the person • Prepare a plan for the management of income and assets • Provide oversight to any income and assets under the control of the person. 26 Standard # 4.11 The conservator shall obtain and maintain a current understanding of what is required and expected of the conservator, statutory and local court rule requirements, and necessary filings and reports. Standard# 4.12 The conservator shall, as appropriate for the estate, implement best practices of a prudent conservator, including responsible consultation with and delegation to people with appropriate expertise. Standard# 4.13 The conservator shall become educated about the nature of any incapacity, condition and functional capabilities of the person. Standard# 4.14 The conservator shall consider mentoring new conservators. #5. Health Care Decision-Making Standard #5.1 The guardian, in making health care decisions or seeking court approval for a decision, shall maximize the participation of the person. Standard #5.2 The guardian, in making health care decisions or seeking court approval for a decision, shall: (a) Acquire a clear understanding of the medical facts (b) Acquire a clear understanding of the health care options and risks and benefits of each (c) Encourage and support the individual in understanding the facts and directing a decision. Standard #5.3 To the extent the person cannot currently direct the decision, the guardian shall act in accordance with the person's prior directions, expressed desires, and opinions about health care to the extent actually known or ascertainable by the guardian; or, if unknown and unascertainable, (a) Act in accordance with the person's prior general statements, actions, values and preferences to the extent actually known or ascertainable by the guardian; or, if unknown and unascertainable, (b) Act in accordance with reasonable information received from professionals and persons who demonstrate sufficient interest in the person's welfare, to determine the person's best interests, which determination shall include consideration of consequences for others that an individual in the person's circumstances would consider. In the event of an emergency, the guardian shall grant or deny authorization of emergency health care treatment based on a reasonable assessment of the criteria listed in Standard 5.2. 27 Standard #5.4 The guardian shall monitor, promote, and maintain the person's health and well-being and shall seek to ensure that the person receives appropriate health care consistent with person-centered health care decision-making. Standard #5.5 The guardian shall seek to ensure that appropriate palliative care is incorporated into all health care. Standard #5.6 The guardian shall keep persons who are important to the individual reasonably informed of important health care decisions. #6. Residential Decision-Making Standard #6.1 The guardian shall identify and advocate for the person's goals, needs, and preferences. Goals are what are important to the person about where he or she lives, whereas preferences are specific expressions of choice. • First, the guardian shall ask the person what he or she wants. • Second, if the person has difficulty expressing what he or she wants, the guardian shall do everything possible to help the person express his or her goals, needs, and preferences. • Third, only when the person, even with assistance, cannot express his or her goals and preferences, the guardian shall seek input from others familiar with the person to determine what the individual would have wanted. • Finally, only when the person's goals and preferences cannot be ascertained, the guardian shall make a decision in the person's best interest. Standard #6.2 The guardian shall fully identify, examine, and continue to seek information regarding options that will fulfill the person's goals, needs, and preferences. • Guardians shall take full advantage of professional assistance in identifying all available options. • These include but are not limited to area agencies on aging, centers for independent living, protection and advocacy agencies, long-term care ombudsmen, and developmental disabilities councils, aging and disability resource centers, and community mental health agencies. Standard #6.3 The guardian shall have a strong priority for home or other community-based settings, when not inconsistent with the person's goals and preferences. Standard #6.4 The guardian shall make and implement a person-centered plan that seeks to fulfill the person's goals, needs, and preferences. The plan shall emphasize the person's strengths, skills, and abilities to the fullest extent in order to favor the least restrictive setting. 28 Standard #6.5 The guardian shall wherever possible, seek to ensure that the person leads the residential planning process; and at a minimum to ensure that the person participates in the process. Standard #6.6 The guardian shall attempt to maximize the self-reliance and independence of the person. Standard #6.7 The guardian shall seek review by a court or other court-designated third party with no conflict of interest before a move to a more restrictive setting. Standard #6.8 The guardian shall monitor the residential setting on an ongoing basis and take any necessary action when the setting does not meet the individual's current goals, preferences, and needs including but not limited to: • Evaluating the plan; enforcing residents' rights, legal and civil rights; ensuring quality of care and appropriateness of the setting in light of the feelings and attitudes of the person; and • Exploring alternative opportunities for long-term services and supports where necessary to better fulfill the person's goals and preferences. Standard #6.9 The guardian shall promote social interactions and meaningful relationships consistent with the preferences of the person. • The guardian shall encourage and support the person in maintaining contact with family and friends as defined by the person unless it will substantially harm the person. • The guardian shall not interfere with established relationships unless necessary to protect the person from substantial harm. Standard #6.10 The guardian shall consider the proximity of the setting to those people and activities that are important to the person when choosing a residential setting. Standard #6.11 The guardian shall make reasonable efforts to maintain the person's established social and support networks during the person's brief absences from the primary residence. 29 #1. Overview of Guardian Standards Recommendation #1.1 State statutes should set forth the mandatory duties of guardians. Court or administrative rules should set forth guardian standards. Recommendation #1.2 The National Guardianship Association, in conjunction with state guardianship associations and state WINGS (Working Interdisciplinary Networks of Guardianship Stakeholders) should promote standards to improve guardian practices and enhance public confidence in guardianship. • Materials should be developed to educate guardians about statutory duties, court rules, aspirational codes of conduct, and best practices. Recommendation #1.3 State statutes should clearly express guardian duties and apply the duties to all guardians. • These duties should be enumerated in a clear and succinct statement supplied to guardians at time of appointment. • These duties should be enumerated in guardian training materials. • The guardian must acknowledge, in writing, receipt of the information. Recommendation # 1.4 Every guardian should be held to the same standards, regardless of familial relationship, except a guardian with a higher level of relevant skills shall be held to the use of those skills. Recommendation #1.5 States should adopt by statute a decision-making standard that provides guidance for using substituted judgment and best interest principles in guardian decisions. • These standards should emphasize self-determination and the preference for substituted judgment. • The Uniform Guardianship and Protective Proceedings Act should be revised to embody these objectives. Recommendation #1.6 A template should be created for developing a person-centered plan. Recommendation #1.7 Where possible, the term person under guardianship should replace terms such as incapacitated person, ward, or disabled person. #2. Guardian's Relationship to the Court Recommendation #2.1 The court or responsible entity should ensure that guardians, court and court staff, evaluators, and others involved in the guardianship process receive sufficient ongoing, multi-faceted education to achieve the highest quality of guardianship possible. 30 Recommendation #2.2 The court should issue orders that implement the least restrictive alternative and maximize the person's right to self-determination and autonomy. • The court should develop a protocol to obtain an accurate and detailed assessment of the person's functional limitations. • The court should conduct a factual investigation and review the assessment to determine the rights to be retained by the person and the powers to be granted to the guardian. • The factual investigation may include contact with the person, interviews with interested persons and family members, and discussions with court-appointed attorneys and court evaluators or any other court representative. Recommendation #2.3 The court should monitor the well-being of the person and status of the estate on an on-going basis, including, but not limited to: • Determining whether less restrictive alternatives will suffice • Monitoring the filing of plans, reports, inventories and accountings • Reviewing the contents of plans, reports, inventories and accounting • Independently investigating the well being of the person and status of the estate • Ensuring the well-being of the person and status of the estate, improving the performance of the guardian, and enforcing the terms of the guardianship order. Recommendation #2.4 The court should provide continuing assistance to the guardian about guardianship law and procedures, the guardian's duties and responsibilities, community resources and the rights of the person. This may include assistance in: • Completion of guardianship plan and reports • Guidance on facility transfer or placement • Providing for care at home • Financial and health care decision-making • What to do when the person dies or disappears • Burial and funeral planning • Mental health services • Government benefits eligibility. Recommendation #2.5 The court should use available technology to: • Assist in monitoring guardianships • Develop a database of guardianship elements, including indicators of potential problems • Schedule required reports • Produce minutes from court hearings • Generate statistical reports • Develop online forms and/or e-filing • Provide public access to identified non-confidential, filed documents. 31 #3. Fees Recommendation #3.1 The court should promote sound administrative practices relating to guardianship fees by: • Encouraging the continuity of judicial experience and expertise on the probate bench, and encouraging specialization of probate courts in accordance with the National Probate Court Standards • Actively monitoring the reasonableness of fiduciary fees • Creating and maintaining training programs for participants in the guardianship process • Collecting data regarding fiduciary fees and costs • Promoting timely review and approval of fees • Promoting electronic filing. Recommendation #3.2 Guardians should be entitled to reasonable compensation for their services. The court should consider these factors in determining the reasonableness of guardian fees: • Powers and responsibilities under the court appointment • Necessity of the services • The request for compensation in comparison to a previously disclosed basis for fees, and the amount authorized in the approved budget, including any legal presumption of reasonableness or necessity • The guardian's expertise, training, education, experience, professional standing, and skill, including whether an appointment in a particular matter precluded other employment • The character of the work to be done, including difficulty, intricacy, importance, time, skill, or license required, or responsibility undertaken • The conditions or circumstances of the work, including emergency matters requiring urgent attention, services provided outside of regular business hours, potential danger (e.g., hazardous materials, contaminated real property, or dangerous persons), or other extraordinary conditions • The work actually performed, including the time actually expended, and the attention and skill- level required for each task, including whether a different person could have better, cheaper or faster rendered the service • The result, specifically whether the guardian was successful, what benefits to the person were derived from the efforts, and whether probable benefits exceeded costs • Whether the guardian timely disclosed that a projected cost was likely to exceed the probable benefit, affording the court an opportunity to modify its order in furtherance of the best interest of the estate • The fees customarily paid, and time customarily expended, for performing like services in the community, including whether the court has previously approved similar fees in another comparable matter • The degree of financial or professional risk and responsibility assumed • The fidelity and loyalty displayed by the guardian, including whether the guardian put the best interests of the estate before the economic interest of the guardian to continue the engagement 32 • The need for and local availability of specialized knowledge and the need for retaining outside fiduciaries to avoid conflict of interest. Recommendation #3.3 To ensure the right of access to guardianship services, states should provide public funding for: • Guardianship services for those unable to pay • Services to coordinate alternatives to guardianship, and the obligation to make such services available to all vulnerable persons. Recommendation #3.4 In the event estate funds are exhausted and the guardian has failed to address the anticipated exhaustion, the court is justified in requiring the guardian to remain serving at least until a succession plan is in place. Recommendation #3.5 The court and court-appointed counsel should actively and timely monitor fiduciary fees. Recommendation #3.6 The court should support any rejection or reduction of fees with a statement of explanation. Recommendation #3.7 The court and all parties should respect the privacy and dignity of the person when disclosing information regarding fees. Recommendation #3.8 The court should resolve fee disputes through a process that is fair, expeditious, and economical, for example, through: • A court-ordered alternative dispute resolution or mediation process; • A referral to a regulatory body responsible for reviewing fees; or • A master or a special judicial resolution process. #4. Health Care Decision-Making Recommendation #4.1 State guardianship statutes should provide that valid health care directives that appoint a health care agent shall remain in effect unless the court determines that the agent is unable, unwilling, or unsuitable to perform the agent's duties under the directive. #5. State Interdisciplinary Guardianship and Alternatives Committees Recommendation #5.1 State courts and National Guardianship Network organizations should collaborate to establish Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS) to advance adult guardianship reform and implement the recommendations adopted by the Third National Guardianship Summit. 33 Recommendation #5.2 A state steering committee should establish the scope, goals and mission of WINGS. The steering committee should: • Conduct needs assessments • Review the guardianship process, court rules and statutes • Identify, recruit and include stakeholders with sufficient expertise and authority. Stakeholders may include, but are not limited to, judges, court administrators, agencies on aging, adult protective services, Attorneys General, state mental health association, state hospital associations, legal service providers, AARP, state guardianship associations and agencies, Alzheimer's Association, financial institutions, service providers, disability advocates, long-term care ombudsman programs, medical professionals and associations, bar associations, family members of persons under guardianship, and members of the public who have experienced the guardianship process • Encourage inclusivity considering local realities, non-traditional partners, and underserved populations • Establish a clear process for setting priorities and developing feasible timelines. Recommendation #5.3 WINGS should develop an agenda to accomplish its goals and objectives. The agenda should include implementation of the standards and recommendations adopted by the Third National Guardianship Summit. Additional projects may: • Encourage and support court monitoring and data collection • Evaluate court procedures • Expand the use of technology, standardized forms, and web site development • Conduct education and cross-training • Recommend improvements and best practices • Advocate for funds to support court systems and guardianship programs. Recommendation #5.4 WINGS should aim to procure tangible and in-kind resources necessary to achieve its mission. • Financial resources may include budgetary allocations, donations and grants. • Human resources may include administrative, logistical, research and technical support provided by paid staff or volunteers. Recommendation #5.5 WINGS should develop a plan to ensure sustainability, including: • Leadership development and committee member terms • Recruitment and orientation of new members • Measurable outcomes with ongoing self-evaluation • Maintenance and development of resources. 34 #6. Steps to Implement the Recommendations of the Third National Guardianship Summit The National Guardianship Network organizations should work to match desired changes in policy and practice with the best possible implementation strategy. • Strategies include statutory change, amendments to the Uniform Guardianship and Protective Proceedings Act, administrative rules/regulations, court rules, best practice promotion and education. • A campaign to build awareness of the need for adoption of the Summit recommendations and standards should build on alliances with entities such as volunteer guardianship programs, the disability community, and public guardians. • The campaign should use case statements to create public awareness of the need for reform while offering examples of integrity, and emphasizing existing standards. The National Guardianship Network should work with the Uniform Law Commission as a core strategy to implement the standards and recommendations from the Third National Guardianship Summit. The National Center for State Courts should take the standards and recommendations from the Third National Guardianship Summit to the probate court standards revision process. 35


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More than $9 million in federally-funded grants will boost Milwaukee Public Schools' efforts to better address the academic, behavioral and mental health needs of students.
MPS reaps more than $9 million in federal grants
Mone among UWM chancellor finalists
The University of Wisconsin-Milwaukee is one step closer to securing a new chancellor after UW System president Ray Cross announced three finalists for the position on Wednesday.
National Bobblehead Hall of Fame and Museum coming to Milwaukee
A group of collectors plans to open a National Bobblehead Hall of Fame and Museum in Milwaukee by 2016, according to co-founder and CEO Phil Sklar.
Energy Innovation Center begins construction, announces new tenant
Phase one of construction for the Energy Innovation Center began on Monday with a focus on creating office space for a segment of the business startups and business service providers that will call the center home.
Retailers to host holiday shopping events
Several area business groups will host holiday shopping events to encourage residents to buy their gifts locally.
Baird creates college curriculum to address talent gap
Milwaukee-based wealth management firm Robert W. Baird & Co. Inc. has partnered with the University of Wisconsin-Madison's Wisconsin School of Business to fill an expected talent gap in its industry.
March Madness will return to Milwaukee in 2017
The BMO Harris Bradley Center in Milwaukee will be the site of first and second round games of the 2017 NCAA Division I Men's Basketball Tournament.
BizTimes Around Town: Whyte Hirschboeck Dudek S.C.'s Board Appreciation reception
Whyte Hirschboeck Dudek S.C. recognized area nonprofit organizations and firm staff members who serve them during a special board appreciation event held Nov. 12 at the Milwaukee Art Museum. The reception, which supported the firm's spirit of philanthropy, also gave nonprofits and nonprofit board members an opportunity to network. More than 200 representatives from southeastern Wisconsin's nonprofit and for-profit communities attended the event.
Carthage takes over Wisconsin Space Grant Consortium
Carthage College, of Kenosha, has been named the lead institution for the Wisconsin Space Grant Consortium and is the only private liberal arts college in the country to be assigned a leadership role.
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A south-side shelter for homeless military veterans will have a full house for its dedication ceremony this morning regardless of how many guests attend.
The Richard Lugar Safe Haven for Veterans has been used "far more than we ever imagined" since opening last winter, according to William Raihl.
"We have 25 capacity, and we have 25 veterans. We are at full capacity," Raihl said Monday in a telephone interview.
Raihl is president and chief executive officer of the Indiana chapter of Volunteers of America, a nonprofit faith-based organization that says it serves "America's most vulnerable groups," including seniors, people with disabilities, recovering addicts, at-risk youths, ex-convicts and the homeless.
The Lugar Safe Havenat 2424 Fairfield Ave., south of Creighton Avenue, is the second veterans shelter opened in Fort Wayne by Volunteers of America. The group also operates Liberty Landing, a 40-bed complex on South Calhoun Street.
Raihl said the newer shelter was named for Lugar because the former 36-year U.S. senator from Indiana "has been very much in the forefront of veterans services and veterans issues."
"He's really been a champion of veterans, not only in front of the scenes but behind the scenes," Raihl said. "He has worked closely with Volunteers of America as well."
Lugar, a Navy veteran, will not attend today's dedication ceremony but might visit in September or October, Raihl said.
Mayor Tom Henry and officials of the U.S. Department of Veterans Affairs are scheduled to be at the 10 a.m. dedication, which will include tours. The VA and the Home Depot Foundation provided funding for the Lugar Safe Haven.
Volunteers of America acquired the former offices of United Hispanic Americans Inc. for $350,000, and the Home Depot Foundation provided nearly $87,000 for remodeling. The project meant turning offices into residential rooms with bathrooms.
The goal is to"make their stay with us as comfortable as possible," Raihl said of the homeless veterans who use the shelter.
In return, each resident "is expected to work with their case manager toward a lifestyle conducive to stable housing," Volunteers of America said in a statement. Veterans are referred by the VA and may stay in the shelter for up to six months.
More than 80 veterans are homeless on any given night in Fort Wayne, according to Volunteers of America.


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Mark Berry introduces the new President of Phoenix Rising, Dr. Gary Solomon, and welcomes Professor Jonathan Edwards to the Phoenix Rising Board of Directors.
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The connection Vol. 2: Adrenal fatigue and leaky gut
Discussion in 'The Gut: De Meirleir & Maes; H2S; Leaky Gut' started by Beyond, Oct 5, 2013.


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I am moving and selling my around 2 year old king bed with 2 attached storage boxes, high quality firm mattress, and 2 side tables for only $600.
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San Francisco Bay Area :
Custom made in 2-3 weeks in your choice of fabric. Headboard height is 50" tall. Queens beds start at $899.00 (the Dillon without tufting) and Kings start at $995.00 (the Dillon without tufting). Please contact me for more information or visit my website at www ...
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mattress sale.....!!!Same day delivery........"Pay upon delivery"
___"Mattress & Boxspring set"______
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tel: 949-331-3240
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1670 W Lincoln Ave
Anaheim CA 92801
Business hours :
Cal King Mattress and Box Spring. Eco Friendly Latex, Pure Bliss brand "Beautiful" sells brand new for $5,199 (http://www.latexbliss.com). Used 1.5 years, excellent condition, always covered.
Super comfortable bed for me but my wife's neck and back pain require a more firm ...
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Used Custom California King Bedroom Set. Made out of Pine. Country/Cottage. Includes Calif. King Bed Frame, 2 nightstands, large dresser and Armoire. $1200.00 OBO
Nov 12 -
Los Angeles :
La Verne
I am selling my IKEA bedframe and mattress together. I've had them for about a year and a half but now my GF has moved in with a King bed and I am giving up my awesome bed. Both are in excellent condition. The mattress has a memory foam top to it built in that makes it super ...
Nov 11 -
San Francisco Bay Area :
SEALY POSTURPEDIC Hybrid Gel Series TRUST Queen Mattress Set - $1,299 ALSO available in King or Cal King - $1,799
For Sale: SEALY POSTURPEDIC Hybrid Gel Series TRUST Queen Mattress Set with OptiCool Gel - allows for a more restful nights sleep. Queen Size with a genuine ...
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Chico :
A modern king sized bed frame with a copper sheen, this piece speaks to contemporary Californian style. Its angular frame and low profile will lend their minimalism to your bedroom while still offering plenty of space to sleep.
Nov 9 -
San Francisco Bay Area :
San Francisco
Capri Pillow-top King-sized bed, which includes the mattress, boxsprings, metal frame on wheels, & the mattress protector. (the frame & mattress protector I bought separately) It's a beautiful cocoa color. I only slept on for about a month & disassembled it. We have to ...
Nov 8 -
Los Angeles :
Los Angeles
Andrew's Furniture
7811 Lichen Dr
Citrus Heights, CA 95621
(916) 728-5101
Monday through Saturday, 11am - 7pm
Shorter footboard sleigh bedroom set. Available in black or cherry finishes. Twin / full / queen bedroom set same price. Cal King / King sizes ...
Nov 7 -
Sacramento :
Citrus Heights
Spectacular Horchow Belissimo King size Bed and two Nightstand-Chests of Drawers This king size bed by Horchow is quite spectacular and will make a statement in any bedroom.
The two nightstand/chest of drawers match the headboard and footboard in their design. Each ...
Nov 7 -
San Francisco Bay Area :
tel 714-833-5098
1670 W Lincoln Ave Anaheim 92801
$595 queen bed
For more details please contact us.
Joyce platform bed is available in bomber brown (blended leather) and mint (fabric) color.
This bed is available in queen ,california king and eastern king ...
Nov 3 -
Los Angeles :
Santa Monica
tel 714-833-5098
1670 W Lincoln Ave Anaheim 92801
$525 queen bed
$595 king bed
Euro platform bed available in oatmeal ( linen fabric ) and grey ( fabric) color.
This bed is available in queen ,california king and eastern king size .
Queen 68 x 91 ...
tel 714-833-5098
1670 W Lincoln Ave Anaheim 92801
$450 queen bed
$525 king bed
Cassini blended leather bed available in queen and eastern king size , in white and black finish color.
Queen 76 x 96 x 37H
E King 92 x 96 x 37H
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Inland Empire :
Nickel Finish Stainless Steel Cal King Bed Frame > would not be for sale if we didn't live in a Condo
Nov 2 -
San Francisco Bay Area :
More pics & info please visit:
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A luxurious and distinctive addition to any bedroom suite, the laminated charcoal veneer Harrison series features raised oblong paneling and an effulgent black sheen. Harrison's ...
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Deep tufted buttons convey a fastidious charm, while the octagonal top presents the possibilities of progress. Delightful to perfection, the Tommy series present the old, while embracing ...
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queen bed item #200720Q
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San Francisco
Hand Carved Brazilian CA King Four Post Bed One Of A Kind From Estate Sale
Product Description
Hand carved in Brazil and cost 15k when it was originally made circa 1990. There is a large metal base that goes all the way around on the bottom - approximately 3" x 3" and the ...
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Orange County :
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NCLB? AYP? Are you, like many parents, finding yourself confused by the alphabet soup of No Child Left Behind legislation? Do you wonder what this means for your school and your child? Read on for information and advice to get you navigating the rules and laws like a pro.
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Monroe Journal A Houston man has been arrested for allegedly stealing livestock in Monroe County. The Monroe County Sheriff's Office arrested William Rashad Wilson, 26, of Houston on Tuesday on the charge of livestock theft. Wilson is accused of stealing cattle from a farm on Camargo Road earlier this month. Monroe County Sheriff Cecil Cantrell […]
Tag Archives | Cantrell
Houston man arrested for rustling
By Floyd Ingram | 3:39 PM | July 22, 2014 | News
Jimmie Kennedy
By Floyd Ingram | 8:36 AM | February 13, 2014 | Obituaries
SMITHVILLE – Jimmie Frances Cantrell Kennedy, 74, died on Tuesday, Feb, 11, 2014, at North Mississippi Medical Center in Tupelo. Born on Sept. 28, 1939, in Smithville, she was a daughter of the late Charles Edward and Frances Beatrice Lantrip Cantrell. She was a graduate of Smithville High School, Class of 1957. On Feb. 9, […]
- Houlka Community Thanksgiving is Nov. 22 November 19, 2014
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text: Home > Medical > Erectile dysfunction > Tools Are you at risk for ED? All sections in Tools » Fitness » Diet » Mind » Medical » General This tool will help you to calculate your relative likelihood of having erectile dysfunction. What is your age 71 - 8061 - 7051 - 60 41 - 50 Have you ever had pelvic surgery, for example prostate surgery? Yes No Have you been diagnosed with diabetes? YesNo Have you been diagnosed with heart disease? Yes No Have you been diagnosed with any circulation disorder? YesNo Do you smoke? Yes No Do you suffer from high blood pressure? YesNo Diet Tools Fitness Tools General Tools Medical Tools Mind Tools Am I eating correctly to lose weight? Am I eating correctly to stabilise my blood sugar levels? Am I eating right for my diabetes? Am I eating right to improve insulin resistance? Am I eating to control PMS? Am I eating to optimise my health? Am I eating to optimise my pregnancy? Am I eating to prevent heartburn? Am I eating too much fat? 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Get free advice from our panel of experts Your question More detail Your name (optional) The information provided does not constitute a diagnosis of your condition. You should consult a medical practitioner or other appropriate health care professional for a physical exmanication, diagnosis and formal advice. Health24 and the expert accept no responsibility or liability for any damage or personal harm you may suffer resulting from making use of this content. I agree * You must accept our condition To prevent spam please solve this simple math problem: Forum Rules