December 2003
Vol. 12, Issue 3
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By: Phylip J. Divine

I am pleased to assume the editorship of the Advisor from James Simon. I will work to ensure the Advisor’s tradition of providing you with current legal information in a timely manner.

This issue of Advisor includes a year-end note from Nicholas T. George, President and CEO, as well as the first in a series of three articles on the rapidly changing field of hospital law. The authors, Thomas R. Himmelspach and Philip E. Howes, are both members of the Firm’s Medical Malpractice Defense Practice GroupDefense and Health Law Practice Groups, residents in Buckingham Canton^SM. Their article, “Appropriate Screening Under the Emergency Medical Treatment and Active Labor Act,” discusses requirements placed on hospitals for screening patients as they arrive at the Emergency Room. Recent judicial decisions focus on how the hospital follows its own established standards in carrying out this initial screening. The emergency room is an important element in any community’s healthcare system, and we hope that our readers will appreciate this opportunity to learn more about how our laws regulate its operation.

Phylip Divine is an Associate attorney and member of the Trusts & Estates Practice Group. He can be contacted at pdivine@bdblaw.com or 330.258.6456.

Year-End Greeting from Buckingham’s President and CEO

By: Nicholas T. George, Esq.

As 2003 draws to a close, let me take this opportunity to send holiday greetings to all of our clients and friends. This has been a milestone year for the Firm as we celebrated our 90^th Anniversary. Thank you for the interest you have taken in our history – and for the support you have provided us throughout the decades. Please accept the best wishes of everyone at Buckingham, Doolittle & Burroughs, LLP for a joyous holiday season and a very happy New Year.

Nicholas George is President and CEO as well as a member of the Business and Real Estate & Construction Law Practice Groups. He can be contacted at ngeorge@bdblaw.com or 330.258.6498.

Appropriate Screening Under The Emergency Medical Treatment And Active Labor Act

By: Thomas R. Himmelspach, Esq. and Philip E. Howes, Esq.

Hospitals and physicians treating emergency room patients are under specific duties imposed by EMTALA, a federal law. The scope of the law is broad, and it is continually evolving through judicial decisions and new regulations. To give the reader an overview of the law, we have divided the subject into three general areas to be covered in successive articles. This article addresses appropriate screening requirements under EMTALA.

In 1986, Congress enacted the Emergency Medical Treatment and Active Labor Act (“EMTALA”),^{^[1]} commonly known as the “Patient Anti-Dumping Act.” As the name implies, the Act addresses perceived abuses in emergency department admitting practices. Hospital emergency departments have two duties under EMTALA: (1) to provide an “appropriate medical screening examination” to determine whether an emergency condition exists and, if so, (2) to stabilize the condition before discharging or transferring the patient to another medical facility.^{^[2]}

EMTALA was enacted to prevent “patient dumping,” i.e., “the practice of refusing to provide medical treatment to patients unable to pay or transferring them before emergency conditions are stabilized.”^{^[3]} It provides for recovery of personal injury damages by anyone harmed as a result of a hospital’s violation of the statutory requirements.^{^[4]}

EMTALA applies to all patients.^{^[5]} The hospital’s duty under EMTALA applies without regard to the resources of the patient, but the Sixth Circuit has taken a narrow view of the EMTALA screening requirements, holding that a plaintiff can establish liability under the Act for an inappropriate screening only by showing the defendant acted with an improper motive. See Cleland v. Bronson Health Care Group, Inc. The decision remains the law in the circuit, although the United States Supreme Court noted in 1999 that the ruling was in conflict with decisions in the 1^st,^{^[6]} 4^th,^{^[7]} 5^th,^{^[8]} 8^th,^{^[9]} 10^th,^{^[10]} and District of Columbia^{^[11]} circuits. See Roberts v. Galen of Virginia.^{^[12]}

EMTALA states that a hospital “must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department….”^{^[13]} A medical screening is “appropriate” under EMTALA if it (1) conforms to the hospital’s screening procedures, and (2) is reasonably calculated to identify critical medical conditions that may be afflicting the patient.^{^[14]}

The requirement of an “appropriate screening” does not guarantee a proper diagnosis, and a negligence standard does not apply to determine whether a hospital’s screening met the EMTALA requirement. Rather, an appropriate screening is one that is applied uniformly to all emergency room patients. When a hospital fails to give an emergency room patient the same screening regularly given to others under similar circumstances, and the variation is more than de minimus, it can be liable for damages under EMTALA.

In Johnson v. Nacogdoches County Hospital,^{^[15]} a Texas court of appeals affirmed summary judgment for a hospital on a claim of inappropriate screening under EMTALA. In that case, an RN had met the patient, Mrs. Johnson, in the hallway leading to the ER, asked about her complaints, and wheeled her to the ER triage nurse. The nurse started an assessment 22 minutes later and completed the assessment within fifteen minutes, classifying Johnson’s condition as non-urgent. Johnson then sat in the ER waiting room for 25 minutes before leaving for another facility, where she died of meningitis. Johnson’s estate sued the hospital, alleging EMTALA liability for failing to provide an appropriate screening. Noting that the hospital’s utilization policy required that patients “will be spoken with within ten minutes of arrival,” plaintiff argued that the hospital had failed to provide an appropriate screening, since 22 minutes had passed before the triage nurse began her assessment. The appellate court concluded that the 12-minute delay was not a material deviation from the standard procedure, particularly in light of the evaluation by the RN before Johnson reached the ER.

Likewise, in Crystal Star Phillips v. Hillcrest Medical Center,^{^[16]} the Tenth Circuit Court of Appeals affirmed the dismissal of an EMTALA claim brought against a hospital by the estate of a decedent, where the hospital failed to diagnose the patient’s bacterial endocarditis and discharged him from the ER. The court noted that the hospital had examined the patient in accordance with its screening procedures, and that plaintiff, therefore, had no claim under EMTALA, since the act “does not provide a remedy for an inadequate or inaccurate diagnosis.”

In cases where a hospital has not established a written screening procedure, a plaintiff’s burden to show disparate treatment will depend upon discovery on the defendant’s handling of other patients with substantially similar symptoms. In Guadalupe v. Agosto,^{^[17]} the plaintiff sued a hospital for wrongful death, alleging inappropriate screening under EMTALA. The hospital had no written screening procedure and the plaintiff “made no effort to compare [the decedent’s] screening with screenings of other HIMA patients suffering from substantially similar symptoms.”

The burden of proving disparate treatment to establish an EMTALA screening claim is rigorous and could lead to extensive and burdensome discovery. At least one court has held that the plaintiff must present specific evidence of disparate treatment. In Marshall v. East Carroll Parish Hosp. Service Dist,^{^[18]} the Fifth Circuit affirmed summary judgment for a defendant hospital on an EMTALA screening claim. Defendant’s physician examined the plaintiff, a 15-year-old girl, at the emergency room and discharged her with a diagnosis of respiratory infection. Her condition worsened and she went to another hospital, where she was diagnosed as suffering from a cerebrovascular accident. Plaintiff alleged that the defendant had failed to provide an “appropriate medical screening examination” as required under EMTALA. The defense submitted affidavits of the examining physician and a nurse that the plaintiff’s examination was done in a manner consistent with that for other patients with similar symptoms. In response, plaintiff submitted the affidavit of a nurse that during her 14-year employment at the defendant hospital she had seen several other patients with symptoms similar to the plaintiff’s who were admitted for observation and further testing. The trial court deemed the affidavit conclusory and insufficient to establish a fact issue on the screening claim. The circuit court affirmed, noting that the plaintiff’s affidavit did not describe or identify the other patients and gave no details about the conditions of those patients.

The defense in an EMTALA screening claim can, therefore, expect patient-specific discovery concerning disparate treatment, and the merits of a defense summary judgment may be reviewed in light of the sufficiency of the responses. In Ortiz v. Mennonite Gen. Hosp.,^{^[19]} the court denied summary judgment to a defendant hospital on a medical screening claim under EMTALA, holding that the defendant had failed to adequately answer discovery concerning the hospital’s screening procedures. Because the hospital gave evasive answers to interrogatories about its screening procedures, the court held it was not entitled to summary judgment on the EMTALA claim, and ordered that “MGH now needs to disclose its procedures and its ‘applicable standard of care.’”

Where the failure to conform to the customary procedure was particularly egregious, courts have held hospitals liable for inappropriate screening under EMTALA. For example, in Correa v. Hospital of San Francisco,^{^[20]} a woman who entered a hospital with complaints of chest pain was given a number (47) and told to wait. The woman waited over two hours without anyone attempting to assess her condition, and the court held that the hospital had violated the EMTALA screening requirement. The hospital’s policy statement defined the parameters for an appropriate screening, requiring that emergency room personnel promptly take the vital signs of all patients, compile a written chart, and treat all chest pain cases as critical. The court affirmed judgment for plaintiff on a jury verdict for violation of the EMTALA screening requirement.

On September 9, 2003, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule clarifying EMTALA policies relating to various matters.^{^[21]} The new rules do not discuss standards for appropriate screening under EMTALA, but do address the subject of delays in screening. Under the earlier regulation, 49 CFR 489.24(c)(3), hospitals are prohibited from delaying screening in order to inquire about the patient’s method of payment or insurance status. The rule has now been clarified at 49 CFR 489.24(d)(4) to apply to hospitals, physicians, and nonphysician practitioners. In a “Special Advisory Bulletin,”^{^[22]} CMS addressed the hospital’s duty where a patient inquires about financial liability for emergency services, and stated that the inquiry should be answered by a knowledgeable staff member who could explain that the hospital is ready to provide the necessary screening and/or stabilization without regard to the patient’s ability to pay. CMS added that the staff member should urge the patient to defer discussion on financing until after the screening or stabilization, if possible.

In summary, an EMTALA claim of inappropriate screening is not judged on a negligence standard, but on whether the hospital followed its own standards in examining the patient. Minor deviations from that standard generally will not support liability, but egregious violations will. An EMTALA screening claim involves broad discovery, and a defendant hospital may lose an opportunity for summary judgment by failing to respond substantively to relevant inquiries.

Thomas Himmelspach is a Shareholder and a member of the Medical Malpractice Defense and Health Law Practice Groups. He can be contacted at thimmelspach@bdblaw.com or 330.491.5284. Philip Howes is a Shareholder and a member of the Medical Malpractice Defense and Health Law Practice Groups. He can be contacted at phowes@bdblaw.com or 330.491.5239.

____________________________

[1] 42 U.S.C. 1282. EMTALA was part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

[2] 42 U.S.C. 1395dd(c)(1).

[3] Power v. Arlington Hosp. Assn. (C.A. 4, 1994), 42 F.3d 851, 856. See also H.R. Rep. No. 241, 99^th Cong. 1^st Sess. 27 (1986), U.S.C.C.A.N. 42, 605, 726-27. One study, from 1986, reported that 87% of hospitals transferring patients cited the lack of insurance as the sole reason for the transfer. 314 New Eng. J. Med. 552.

[4] 42 U.S.C. 1395dd(d)(2)(A).

[5] See, e.g., Brooker v. Desert Hosp. Corp. (C.A. 9, 1991), 947 F.2d 412, 414. Recent regulations, however, clarify that a “hospital’s obligations under EMTALA end once an individual is admitted for in-patient care.” 42 CFR. 489.24(d)(2). The rules further prohibit a hospital from admitting a patient in bad faith only as a way of avoiding EMTALA liability for a later inappropriate transfer.

[6] Correa v. Hospital San Francisco (C.A. 1, 1995), 69 F.3d 1184, 1193-94.

[7] Power v. Arlington Hospital Assn. (C.A. 4, 1994), 42 F.3d 851, 857.

[8] Marshall v. East Carroll Parish Hospital Service Dist. (C.A. 5, 1998), 134 F.3d 319.

[9] Summers v. Baptist Med. Center Arkadelphia (C.A. 8, 1996), 91 F.3d 1132, 1137-38.

[10] Repp v. Anadarko Munic. Hospital (C.A. 10, 1994), 43 F.3d 519, 522.

[11] Gatewood v. Washington Healthcare Corp. (D.C. Cir. 1991), 933 F.2d 1037, 1041.

[12] (1999), 525 U.S. 249, 253, n.1., reversing Roberts v. Galen of Virginia (C.A. 6, 1997), 111 F.3d 405, where the Sixth Circuit held that a plaintiff must establish improper motive to recover on a claim under EMTALA for a defendant’s failure to stabilize an emergency room patient before discharge or transfer.

[13] 42 U.S.C. 1395dd (a). The statutory requirements are implemented at 42 CFR 489.24.

[14] See Baber v. Hosp. Corp. of Am. (C.A. 4, 1992), 977 F.2d 872, 879; Gatewood v. Washington Healthcare Corp. (D.C. Cir. 1991), 933 F.2d 1037, 1041.

[15] 2003 Tex. App. LEXIS 7230.

[16] (C.A. 10, 2001), 244 F.3d 790.

[17] (C.A. 1, 2002), 299 F.3d 15.

[18] (C.A. 5, 1998), 134 F.3d 319.

[19] (D.C. Puerto Rico, 2000), 106 F.Supp.2d 327.

[20] (C.A. 1, 2002), 69 F.3d 1184.

[21] 68 FR 53222.

[22] 64 FR 61355.

New Buckingham Attorneys

Since our last Advisor, Buckingham has had a host of wonderful attorneys join the Firm. We would like to take this time to welcome them to the BDB family.

Buckingham Akron^SM

Anoop K. Bhasin – Business Practice Group

Matthew Bradford – Business Practice Group

Matthew R. Duncan – Litigation Practice Group

Buckingham Boca Raton^SM

L.A. Perkins – Litigation Practice Group

Buckingham Canton^SM

G. Brenda Coey – Medical Malpractice Defense Practice Group

Thomas R. Himmelspach – Medical Malpractice Defense and Health Law Practice Groups

Philip E. Howes – Medical Malpractice Defense and Health Law Practice Groups

Edward T. Kennedy – Business and Intellectual Property Practice Groups

Richard S. Milligan – Medical Malpractice Defense and Health Law Practice Groups

Paul J. Pusateri – Employment Law Practice Group

Buckingham Cleveland^SM

David J. Lindner – Real Estate & Construction Practice Group

Jennifer L. Myers – Medical Malpractice Defense Practice Group

Mary Ann Pate – Trusts & Estates Practice Group

Buckingham Columbus^SM

Carla J. Cannon – Workers’ Compensation Practice Group

Kimberly Cocroft – Litigation Practice Group

Frank Schuckmann – Business Practice Group

Kudos

Mary Sue Donohue, Esq. was extensively quoted in the article titled “Heirs, Creditors and Settling an Estate” from Kiplinger’s Personal Finance - December Issue.

Joseph J. Feltes, Esq. is the author of “Chapter Five – Informal Resolution and Its Use in Peer Review” of the American Health Lawyers Association’s Peer Review Guidebook, 3^rd Edition released in October 2003.

Jeffrey D. Weinstock, Esq. authored a chapter in Compliance & HIPAA Made Easy, Fraud & Abuse Compliance & HIPAA Solutions which was released by Anadem Publishing in November 2003.

Practicing in Buckingham Boca Raton^SM

If you do business or have a residence in Florida, we want to remind you we have a Florida office staffed with outstanding attorneys. Our Florida office can address business, estate planning, financing, intellectual property, litigation, employment, and real estate matters, to name a few. We welcome the opportunity to provide legal services when you are traveling to Florida.

For additional information, contact us at 1.800.686.2825.

Speaking Out

Save the Date for these Upcoming Presentations:

On December 18, 2003, James L. Fisher (Buckingham Akron^SM) will speak on “Important Terms and Conditions of Commercial Purchase Agreements” at the Real Property Law Forum: Real Property Issues for the General Practitioner in Akron, Ohio. Please reference www.akronbar.org or www.cuybar.org for additional information.

On January 14, 2004, Steven A. Dimengo (Buckingham Akron^SM) will be a presenter at the Lorman Education Services Continuing Education Seminar in Akron, Ohio. He will speak on “Sales and Use Tax in Ohio.” Please contact Lorman Education Services for additional information at www.lorman.com or 888.678.5565.

On January 20, 2004, Steven A. Dimengo (Buckingham Akron^SM) will present “Proactive Approaches to Tax Compliance: Controls & Voluntary Disclosures,” at the Manufacturers’ Education Council 13^th Annual Ohio Tax Conference in Columbus, Ohio. Please reference www.mecseminars.com for additional information.

On January 24, 2004, John P. Slagter (Buckingham Cleveland^SM) will give a presentation at a Lorman Education Services sponsored seminar titled “Legal Aspects of Condominium Development and Homeowner’s Associations in Ohio.” Please contact Lorman Education Services for additional information at www.lorman.com or 888.678.5565.

Out and About – Recent Presentations:

Business Practice Group

Robert W. Briggs (Buckingham Akron^SM) spoke at an Ohio Grantmakers Forum meeting on “The Role of Private and Family Foundations in Regional Issues.”

Steven A. Dimengo (Buckingham Akron^SM) spoke at a Lorman Education Services Continuing Education Seminar in Beachwood, Ohio. His topic was “Sales and Use Tax for Manufacturers.” He also spoke on “Ohio Sales/Use Tax: Recent Trends, Development and Planning Opportunities” at The Ohio Society of Certified Public Accountants 2003 Federal Tax Planning Symposium and the University of Akron Tax Conference. In addition, Mr. Dimengo presented “Major Business Tax Changes in Ohio” at the Manufacturers’ Education Council in Columbus, Ohio. Most recently, Mr. Dimengo was presenter at the Lorman Education Services Continuing Education Seminar in Cleveland, Ohio. His topic was “Tax Issues Facing Small Businesses.”

Cathy C. Godshall, David J. Lewis (Buckingham Akron^SM), Lisa deFilippis, and Terry W. Vincent (Buckingham Cleveland^SM) were presenters at the 2003 Tax Update Seminar in Akron, Ohio. Their topics were “Tax Exempt Organizations – A Primer,” “ax Consequences of Damage Awards & Settlements,” “What’s New in Employee Benefits,” and “The Slippery Slope-Sliding From a Civil to a Criminal Tax Audit.”

Rana M. Gorzeck (Buckingham Boca Raton^SM) gave a presentation on employment background checks at the American Woman’s Society of Certified Public Accountants Dinner.

David J. Hrina (Buckingham Akron^SM) gave a presentation at the “Homeland Security Conference” in Sandusky, Ohio. His topic was “Environmental Concerns for Transporters of Hazardous Materials.”

Terry W. Vincent (Buckingham Cleveland^SM) participated on a panel that addressed “Tax Shelters and the New Reporting Requirements” at a Cleveland Tax Institute sponsored event. His topics were “Attorney/Client Privilege” and “The Tax Practitioner.” He also presented “The Slippery Slope-Sliding From a Civil to a Criminal Tax Audit” at the Akron Bar Association and University of Akron School of Law 2003 Tax Update Seminar.

Theodore D. Ward (Buckingham Cleveland^SM) gave a presentation to Corporate Plans, a Buckingham client.

Employment Law Practice Group

Jason M. Baasten (Buckingham Canton^SM) was a presenter at Buckingham’s 15^th Annual Employment Law Seminar. He spoke on “The Bureau of Workers’ Compensation Drug-Free Workplace Program.”

Gerald B. Chattman (Buckingham Cleveland^SM) presented “Workplace Violence” at the “Homeland Security Conference” in Sandusky, Ohio.

Natalie F. Grubb (Buckingham Cleveland^SM) spoke on “How to Conduct Background Checks in Compliance with the Fair Credit Reporting Act” at the “Homeland Security Conference” in Sandusky, Ohio and Buckingham’s 15^th Annual Employment Law Seminar held in Independence, Ohio.

Ashley M. Manfull (Buckingham Akron^SM) gave a presentation on “The Proposed New Wage and Hour Overtime Exemption Standards” at Buckingham’s 15^th Annual Employment Law Seminar.

Tod T. Morrow (Buckingham Canton^SM) presented “How to Conduct Background Checks in Compliance with the Fair Credit Reporting Act” at Buckingham’s 15^th Annual Employment Law Seminar.

Health Law Practice Group

Joseph J. Feltes (Buckingham Canton^SM) gave a presentation at the Lorman Education Services sponsored seminar titled, “Health Care Corporate Compliance Programs in Ohio” in Columbus, Ohio.

Shila Nalawadi (Buckingham Canton^SM) presented at two Lorman Education Services Seminars. Her topics were “Confidentiality of Medical Records in Ohio” and “Health Care Corporate Compliance Programs in Ohio.”

Litigation Practice Group

Alan P. DiGirolamo (Buckingham Cleveland^SM) spoke at the Lorman Education Services Seminar titled “Ohio Construction Lien Law.” His topics were “The Impact of Insolvency on Mechanics’ Liens and Mechanics’ Liens Claimants” and “Litigation and Enforcement of Mechanics’ Lien Claims.”

David L. Drechsler and Douglas J. Paul (Buckingham Cleveland^SM) were presenters at the “Homeland Security Conference” held in Sandusky, Ohio. Their topics were “Overview of Trade Secrets Law” and “Avoiding Costly Litigation.”

David L. Drechsler presented “Will Contests: Procedures, Lack of Testamentary Capacity and Undue Influence” at Stark County Annual Probate Seminar and Buckingham’s Complex Probate Litigation Seminar titled “How to Protect an Inheritance.”

William B. Leahy (Buckingham Cleveland^SM) spoke to the Risk and Insurance Management Society in Dearborn, Michigan. His topic was “Insurance Coverage.”

Douglas J. Paul spoke on “Hostile Working Environments: Investigation, Discipline, and Liability Issues” at the 15^th Annual Employment Law Seminar. In addition, he gave a presentation on “Powerful Legal Negotiation in Ohio” at a National Business Institute Seminar in Cleveland.

L.A. Perkins (Buckingham Boca Raton^SM) was a speaker at the American Woman’s Society of Certified Public Accountants Dinner. She spoke on employment background checks.

Medical Malpractice Defense Practice Group

Joseph J. Feltes and Shila Nalawadi (Buckingham Canton^SM) presented on HIPAA issues for the Akron General Medical Center and Mogadore Fire Department & EMS.

Joseph J. Feltes gave a presentation on “Health Care Corporate Compliance Programs in Ohio” at a Lorman Education Services Seminar in Columbus, Ohio.

Mark D. Frasure and Christopher S. Humphrey (Buckingham Canton^SM) spoke on “Medical Records Documentation” at an Akron General Medical Center sponsored seminar titled “Grand Rounds” in Akron, Ohio.

Christopher S. Humphrey spoke at the Ohio Health Care Association, District IV meeting at Bay Community Hospital in Oregon, Ohio. The topic he covered was “Nursing Home Litigation: Anatomy of a Nursing Home Lawsuit.”

Richard S. Milligan (Buckingham Canton^SM) presented “Physician Practice Management” to the residents at Aultman Hospital in Canton, Ohio. He also presented “Nursing Law: Standards for Promoting Client Safety” at the Northeastern Ohio Perianesthesia Association in Canton, Ohio.

Shila Nalawadi spoke on “Confidentiality of Medical Records in Ohio” at a Lorman Education Services Seminar in Columbus, Ohio.

Real Estate & Construction Law Practice Group

Robert A. Hager (Buckingham Cleveland^SM) presented “Preserving and Presenting Claims Under Payment and Performance Bonds” at the Lorman Education Services Seminar titled “Ohio Construction Lien Law.”

Donald B. Leach, Jr. (Buckingham Columbus^SM) was a presenter at the Builders Exchange of Central Ohio. He presented “The How’s and Why’s of Mechanics’ Law.” He also presented “Ohio Mechanics’ Liens” and Hot Construction topics at the Professional Education Systems Institute, LLC in Columbus, Ohio.

John P. Slagter (Buckingham Cleveland^SM) spoke on “Bonding Off Liens” and “The Notice to Commence Suit on Liens” at the Lorman Education Services sponsored seminar titled “Ohio Construction Lien Law Seminar.” He also spoke at the 2^nd Annual Land Use Law Conference on “The Legality of Impact Fees – Appointing the Cost of Development at the CLE International.” In addition, he presented at the “Homeland Security Conference” in Sandusky, Ohio, the Ohio State Bar Association CLE Institute class – Titles to Real Estate in Ohio, and the American Society of Professional Estimators monthly meeting. His topics were “Public Documents Request,” “Liens and Encumbrances Affecting Real Estate,” and updates on Mechanics’ Lien Law and Fairness on Contracts Law.

Trusts & Estates Practice Group

Phylip J. Divine (Buckingham Akron^SM) was a presenter at the National Business Institute sponsored “Adoption Law in Ohio.”

Jeffrey A. Halm (Buckingham Canton^SM) presented at the Institute of Management Accountants on “Risk Management and Asset Protection Planning.” In addition, he was a seminar presenter for the American Heart Association and the Canton Business Network. His topics were “Estate and Charitable Planning Strategies” and “Coordination and Cooperation in Estate Planning,” respectively.

Patricia A. Pacenta