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It I'!'r: - 1''-' ."'1 ilf' 'I' 'i I il ,,1' ,! ". ,'i 1:'__ l_fl-fl_ ! 11,ii"li< "J ! -1 "I' '''I, ' ", '" " I" 'i ", Ill' I, il) .{"I, ~ I '1 'I 1 , , " , " , I ! ~ -I i '-II ", , I' 'I I '''I'l; ,II ,-,' , 'I, i,-j 'I' I!' ,', .!)!, " I' II 'i" , }' I r , I 1\ 'I I_~I,._ I t_ I " " ~ / I " 11 I , ' 'i' I ;; "I 'I' i~;/I it I ",;\':;,,1' ,!': ," "I' I' ,i,'l, ,;" ,;(;1;,1\ ;/', ,,1\,\,,'1>,' ";'1),.1.,,", i 'J/,F ," 1-",1'1.';\ 'I' "j I' ,\ , , " ~' , I, :' " " ,I' , ":1 -I: , " :,i " " ii' " 'i 'J' , jl '111:;'-,\ ". l' \,1 '\ 1,1 -V-; 't' ," ;1 ','11'" '1'/1' ,'_-(1,1'1' '1:_:--'--'" 'lid'! , " "~"~oj ii',l_ ,,:\ ,: I, ," '" " "I' , \. I' " I,', I"/-, " i' 'I 1,..-\" 'J II'II! '{' ;'1' , ", 1,1'1' I, }! ",-'t"," ~ J 11\ , , " ",\',I! , 1- ~ I! 'I' " , ': :I'-I~ ,) : , I 'rj, ',:1\,' ,11.' ;, ' 1-' " I '1-1 " !' " ",_I_ II.' ~ 1 ,', .'1.1 , " d,i;. ,( I' ,', 'I ,',it , ," , " '"I' ,I ;,1\ " ,-,\1 l-;L ',':1 , t _ ,~: Ii', "11 If!! ;1\; ,,'''1 " '~ f: ' I,,' , " -Ii 'I , , " ", 'I O{, i,,_1 I, "'II " 'I '-'" 11'-: ',"t , I" " '1",1 , , I'''' ",;J.!',1 , ,1,_;', " ,,\1' " ,,' " , "1"',- .'11. I, , ' 'I'" !{ 'I , , !,' i :~i,\I, r " ',:' ", '" " ,I '''.lr , " I',,' ',,"1 '1;"1 , '" i ","1 , " " , " I .,,-, ,,' , i"" "i"i>; " ),' " 11\ , . , ," , , '" , " , " /tl' " , " " " , " " .,' I .,' ", , " " ", ," 5, On January 25, 1994 the defendant was admitted to Thornwald Home at 442 Walnut Bottom Road, Carlisle, Cumberland County, E'A 17013. The defendant has remained at Thornwald Home as a nursing care resident from January 25, 1994 to the present, 6. At the time of the admission of the defendant I Sarah Ellen E'ennella signed a Nursing Home Admission Agreement for her care at Thornwald Home. A copy of that Admission Agreement is attached hereto and identified as Exhibit "A". 7, On January 25, 1994 the defendant, Sarah Ellen E'ennella, signed the Nursing llome Admission Agreement by and through the authority of her daughter, Cheryl A. Winters, who had been appointed by the defendant as her attorney-in-fact pursuant to a General E'ower of Attorney dated December 7, 1993. A copy of that General E'ower of Attorney is attached hereto and identified as Exhibit "6". Cheryl A. Winters as responsible party, agent and attorney-in-fact for the defendant, Sarah Ellen E'ennella, also signed the Nursing Home Admission Agreement dated January 25,. 1994, Exhibit "A" on behalf of the defendant, as agent for the defendant and bound the defendant to the terms of the Nur.sing Home Admission Agreement. 8. The defendant's son, Norman W. E'ennella, Sr., also was named her attorney-in-fact pursuant to a General Power of Attorney dated March 24, 1989. A copy of that General E'ower of Attorney is attached hereto and identified as Exhibit "C". At defendant's direction all of plaintiff's Statements of Account for defendant have been sent to defendant's son, Norman W, E'ennella, Sr, for PtMtU..Co2 D4 6/10/96 4 payment. 9, The plaintiff has made demand upon the defendant, Sarah Ellen Pennella, and her agent and attorney- in- fact, Norman W. Pennella, Sr" to make payment in full for the services rendered to Sarah Ellen Pennella by the plaintiff from January 25, 1994 to th~ present time. The defendant or her agents agreed to pay for those services under the terms of the Nursing Home Admission Agreement, but the defendant and her attorney-in fact, Norman W. Pennella, Sr, have failed or refused to make payment in full on this account. 10. Pursuant to Paragraph 2.8 of the Nursing Home Admission Agreement, Exhibit "A", the defendant agreed to pay a late charge calculated on the basiD of one and a quarter percent (1.25') per month on charges for services and supplies that are at least thirty (30) days past due. Plaintiff assessed those late charges beginning with the unpaid charges as of January 1, 1995, 11. Pursuant to Paragraph 2.8, the defendant also agreed to pay reasonable costs of cc.llecting past due accounts I including attorn~ys' fees. Plaintiff is paying legal counsel to aSDist in the collection of this account on an hourly rate, which is presently $100,00 per hour. The counsel fees and costs incurred by the plaintiff for the collection of this account as of May 6, 1996 total $750.60. Those counsel fees are fair and reasonable and those customarily charged for legal work of this nature. 12. From the time of the admission of the defendant to Thornwald P.nn.ll.,Co2 D4 6/10/96 5 Home a copy of her monthly statements from the plaintiff for the cost of her cara has been sent to her son, Norman W. Pennella, Sr. at Box 56, Hills Grove, PA 18619, attornay-in-fact for the defendant, Sarah Ellen Pennella. 13. From the time of the defendant's admi.ssion on January 25, 1994 to the present, the defendant, her son, Norman W. Pennella, Sr" or other third parties have made partial payments on account of the monthly statements for the services the plaintiff has rendered to the defendant at its nursing care facilit)', Thornwald Home. 14. The services rendered to the defendant, Sarah Ellen Pennella, by the plaintiff were necessary for her health and welfare, or were requested by the defendant or her agents. 15. The fees charged by the plaintiff for the servi~eB that were provided to the defendant were all fair and reasonable and those customarily ~harged for the services provided. 16. As of June 6, 1996 the unpaid balance for the services rendered to the defendant by the plaintiff through May 31, 1996 equaled $16,581.57, A copy of the most recent statement for the defendant's account is attached hereto and identified as Exhibit "011. WHEREFORE, the plaintiff, United Church of Christ Homes, Inc. demands judgment against the defendant, Sarah Ellen Pennella, in the amount $16,581.57, for unpaid services to May 31, 1996, interest at the rate of 1.25\ for unpaid account balances from June 1, 1996, P'M.\I..Co~ D4 6/10/96 6 THORNWALD HOME NURSING HOME ADMISSION AGREEMENT THISAGREEMENTmadethls 2',tli dayol ,JilIlU'''-'' ,91" betwoen Thornwald Home, located at 442 Walnut Bottom Road, Carlisle, Pennsylvania, (herelnaltercalled HOME) and Sarah EI J en Pennl' J la , of CarliB 10. 1'0111"',:1 vlIllla , (hereinafter called RESIDENT) lor the admission 01 RESIDENT to HOME, and Clieryl A. \';lutl'l"!; , 01 Carlisle. Pc"""y ] "a"lil ,(HESIDENT's legal represontatlve or Individual who has lawful access to nL,SID!;NT's Income or financial rC50urccs av:;.lIable to pay for HOI~E's services, hereinafter called RESPON~IBU: Pf.flTY) shall commence on lillluar\' ;~I;,_ It/l.U~ RESIDENT, having applied for admission, and RESPONSIBLE PARTY, If any, affirm that the Information provided In HOME's Application lor Admission Is true and correct, and acknowledge that the submission 01 any lalso Inlormatlon may constitute grounds for terminating this agreement. Therefore, HOME, RESIDENT, and RESPONSIBLE PARTY, If any, agree to the following terms and conditions: 1. PROVISION OF SERVICES 1.1 Basic Services Provided by HOME HOME agrees to provide basic services to RESIDENT which Include room and board, routine nursing services, social services, dietary services, housekeeping and room/bed maintenance, activities, bedding, linen, and such personal services as may be determined by HOME to be legally and reasonably required for the health, safety, welfare, good grooming, and well-being of RESIDENT. 1.2 Supplemental Services and Supplies Provided by Home Home agrees to provide supplemental services and supplies as shown on the HOME's Schedule of Charges as may be requo5ted by RESIDENT or as may be determined by HOME to be legally and reasonably required for the health, safety, welfare, good grooming, and well-being of RESIDENT, 1.3 Services of Physicians Medications, treatments, therapy, diet and other services are provided under the direction of RESIDENT'S attending physician, HOME agrees to permit RESIDENT to choose his or her own physician, HOME reserves the right to appoint a physician for RESIDENT If RESIDENT or RESPONSIBLE PARTY falls to do so, or If physician selected by RESIDENT or RESPONSIBLE PARTY falls to comply with HOME's policies, procedures or regulations, EXHIBIT L PAGE -!.- 1.4 Services of Other Providers HOME agrees to permit resident to choose other providers of non-facility services conditioned by the provider's compliance with HOME's policies and procedures, 2. FEES AND CHARGES 2.1 Obligation of RESIDENT or RESPONSIBLE PARTY RESIDENT, or RESPONSIBLE PARTY solely from RESIDENT's financial resources, shall ba responsible for the payment of all charges assessed by HOME for the services and supplies HOME provides to RESIDENT. Non-payment of charges may result In HOME's termination of this agreement after notification to RESIDENT or RESPONSIBLE PARTY, 2.2 Schedule of Charges RESIDENT or RESPONSIBLE PARTY acknowledges receipt of HOME's Schedule of Charges for basic and supplemental services, which are considered part of this agreement. HOME retains the unilateral right to raise, lower, or modify the Schedule of Charges, and such change shall be effective no sooner than thirty (30) days after RESIDENT or RESPONSIBLE PARTY receives written notice thereof, If RESIDENT requests items or services not included on the schedule of charges, HOME will advise resident of the cost, if arlY, of such item or service, 2.3 Advance Payment 01 Basic Service Charges RESIDENT, or RESPONSIBLE PARTY solely from RESIDENT's financial resources, agrees to pay basic service charges In advance, The first payment shall be In the aggregate amount of the basic service charges for each day starting with the date this Agreement commences to the end of the month, Thereafter, advance charges for basic services shall be due on the twenty-fifth (25th) day of the month In which services are being provided, Advance payment of basic service charges Is not required if RESIDENT or RESPONSIBLE PARTY has reasonable expectation that services will be covered by Medicare or Medicaid, If HOME does not concur with RESIDENT or RESPONSIBLE PARTY's expectation of Medicare coverage, RESIDENT or RESPONSIBLE PARTY must request in writing that a demand bill be submitted to the Medicare Intermediary, When such written request Is made, no advance payment will be required while the Medicare Intermediary reviews the request. If RESIDENT or RESPONSIBLE PARTY believes that RESIDENT is eligible for Medicaid benefits payable to HOME and submits a completed application for Medicaid benefits, no advance payment will be required while the application Is being reviewed_ 2 EXHIBIT L PAGE -? 2.4 Payment 01 Medicare Deductible and Co-Insurance Amounts Except when RESIDENT Is eligible for Medicaid or when Medicare deductible and co-Insurance amounts are covered by an Insurance with which HOME has a participating provider relationship, RESIDENT, or RESPONSIBLE PARTY solely from RESIDENT's financial resources, agrees to pay Medicare deduotlbles and co- Insurance amounts. Payment of deductible and co-Insurance amOllnts Is due on the twenty-fifth (25th) day of each month following the month In which the services or supplies were provided, 2.6 Payment of Medicaid Income Based Co-payments RESIDEI-JT, or RESPONSIBLE PARTY sololy from RESIDENT's financial resources, agrees to pay fJ,(:ilcaid Income bE:',:;d co-payments 1:1111€ f.m2unt dClCrmlnGd by the Medicaid pro;)ram, Payment o( lv1edicald co-paym'3nt amounts Is due on the twenty-fifth (25th) day of each month following the month In which services were provided. 2.6 Payment of Supplemental Services and Supplies Charges RESIDENT, or RESPONSIBLE PARTY solely from RESIDENT's financial resources, agrees to pay supplemental charges for services and supplies not Included In the basic service charge, Payment for f.upplemental charges Is due on the twenty-fifth (25th) day of each month following the month In which the scrvlces or supplies were provided, 2.7 Payment of Services by Physicians and Other Providers Payment of services provided by Physicians Is the responsibility of RESIDENT, Except where services of other providers are payable to the home by Medicare or Medicaid under the terms of HOME's provider agreements, RESIDENT Is responsible for payment of services by other providers. 2.8 Late Charges and Costs of Collection RESIDENT, or RESPONSIBLE PARTY agrees to pay late charges calculated on the basis of one and one-Quarter percent (1.25%) per month on charges for services and supplies that are at least thirty (30) days past due. RESIDENT, or RESPONSIBLE PARTY agrees to pay reasonable costs o( collecting past due accounts, Including attorneys fees. 2.9 Relunds of Overpayments Overpayments will be refunded within thirty (30) days following the last day of the month In which RESIDENT Is discharged, 3. MEDICARE AND MEDICAID 3.1 Participation In Medicare and Medicaid HOME participates In both the Medicare and Medicaid Programs. HOME agrees 3 EXHIE31T L PAGE L to provide services of the same quality and type of care regardless of source of payment. RESIDENT and RESPONSIBLE PARTY, if any, acknowledge that no representation, statement, or claim has been made by anyone connected with HOME that services to RESIDENT are or will be covered under Medicare or Medicaid. HOME makes no guarantee that services will be coverod under either program, RESIDENT or RESPONSIBLE PARTY releases HOME, Its agents and employeos from any liability or responsibility In connection with RESIDENT's potential claim for covorago under the Medicare, Medicaid, or any other governmental assistance program, 3.2 Acceptance 01 Medicare and Medicaid Rates In the event RESIDENT is determined eligible for benefits under the Medicare and/or Medicaid program and Is entitled under one or both of these programs to have paymenlmade for all of the items and services provided by HOME, HOME agrees to accept the payment. from these programs, plus any related deductible, coinsurance and copayment amounts owed by RESIDEI'>JT, as payment in full for the Itoms and services covered thereunder, 3.3 Application for Benellts RESIDENT shall Apply promptly for eligibility and benefits under the Medicare and/or Medicaid program as soon as RESIDENT appears to meet said program's eligibility requirements, If RESIDENT fails to apply promptly, HOME Is authorized In Its sole discretion to prepare all necessalY forms and documents from Information provided by RESIDENT or RESPONSIBLE PARTY for RESIDENT or RESPONSIBLE PARTY's signature, which RESIDENT or RESPONSIBLE PARTY shall not withhold unreasonably, HOME will submit such forms and documents to the appropriate state and/or federal agencies for a determination of RESIDENT's eligibility and benefits under the Medicare and/or Medicaid program, 3.4 Non-Covered Services RESIDENT, or RESPONSIBLE PARTY solely from RESIDENT's financial resources, agrees to pay charges for non-covered Items and services, Payment for supplemental charges is due on the twenty-fifth (25th) day of each month following the month In which the services or supplies were provided. 4. BED RESERVE PROVISIONS 4.1 Private Pay Residents In the event RESIDENT, while not eligible for benefits payable to HOME under thF.l Medicaid program, is discharged from HOME for the purpose of being admitted to a hospital or for tile purpose of therapeutic leave, HOME shall reserve RESIDENT's bed until suctltime as RESIDENT returns to HOME or RESIDENT or RESPONSIBLE PARTY notifies HOME in writing of RESIDENT or RESPONSIBLE 4 EXHIRIT fl.... PAGE ..:.!...- PARTY's Intention to terminate this Agreement. HOME sholl charge and RESIDENT sholl pay HOME's current dally private rote for each day a bed Is reserved for RESIDENT until RESIDENT either retlJrns to HOME or terminates this Agreement. 4.2 Medicaid Residents In the event RESIDENT, while eligible for bone fits payable to HOME under the Medicaid program, Is discharged from HOME for the purpose of being admitted to a hospital, HOME shall reserve a bed fc" flESIDENT for up 1.0 flfteon (15) days per h::Jspltal stay. Altor sucl1time, HOME' ,',!' r,ot be obllgateC: 10 reserve a bed for J;,=SIDENT, bu', 1'1111 readmit Rf:SIDEI\- tile first cgl:bV forni-private bed upc c::,silc.:'ge h Jl tile IDcpilal. In the event RESIDENf, while eligible for IJonefils payable to HOME under the Medicaid program, Is discharged from HOME for t.he purpose of therapeutic leave, HOME shall reserve RESIDENT's bed for up to fifteen (15) days per year If RESIDENT Is receiving skilled care or up to thirty (30) days per year If RESIDENT Is receiving Intermediate care, After such time, HOME shall continue to reserve RESIDENT's bed If, before the expiration of said period, RESIDENT or RESPONSIBLE PARTY notifies HOME in writing of RESIDENT's Intention to return to HOME and RESIDENT's agreell1entto pay HOME Its then current rate for each additional day RESIDENT's bed is reserved, 4.3 Medicare Residents Medicare does not provide benefits payable to HOME for reserving a bed. In the event RESIDENT is eligible for benefits payable to HOME under the Medicaid program, bed reserve provisions will be In accordance with those described above for Medicaid residents, In the event RESIDENT is not eligible for benefits payable to HOME under the Medicaid program, bed reserve provisions will be In accordance with those described above for Private Pay residents, 6. PERSONAL AND OTHER PROPERTY 6.1 RESIDENT Responsibility RESIDENT or RESPONSIBLE PARTY agree to provide SllCh personal clothing and effects as needed or desired by RESIDENT, subject to space limitations In HOME. RESIDENT is permitted to retain personal possessions that meet sofety criteria, HOME may place restrictions on Items that Infringe upon the rights of others or are contraindicated by RESIDENT's physician as documented In the medical record by RESIDENT's physician, RESIDENT Is responsible for maintaining Insurance on any personal property or valuables 'kept at HOME. RESIDENT or RESPONSIBLE PARTY accept sole risk 5 EXHIBIT ...LL- PAGE .'J' - and liability for personal property or valuables kept at home, 5.2 HOME Responsibility HOME shall provide RESIDENT with a locked space If requested by RESIDENT. Use of said locked space, and the placement or stQrage of any Items therein, Is recognized as being at the solo risk and liability of RESIDENT or RESPONSIBLE PARTY, and no liability or responsibility whatever with respect to any such Items Is assumed by HOME, HOME accepts no liability to replace or be responsible for stolen, damaged, lost or misplaced personal property or valuables, HOME strongly recommends lt13t no Jewelry or other valuables be brought to or maintained at HOME, 6. RESIDENT'S PERSONAL FINANCES 6.1 RESIDENT Funds Management RESIDENT Is encouraged to manage his or her own personal financial affairs, HOME will manage RESIDENT's personal financial affairs only when RESIDENT or RESPONSIBLE PARTY designates the transfer of such responsibility In writing, RESIDENT funds managed by HOME will net be commingled with HOME funds, If funds managed for RESIDENT are In excess of $50,00, the amount In excess of $50,00, or, at HOME's option, all funds being held for RESIDENT, will be held In an Interest bearing account at a local financial Institution insured by the Federal Deposit Insurance Corporation or the Federal Savings and Loan Insurance Corporation, 6.2 RESIDENT's Access to Funds If assistance with financial management Is provided, HOME agrees to issue up to $50.00 In cash to RESIDENT upon request during normal business hours, provided that RESIDENT's account balance equals or exceeds the amount requested. Withdrawal of amounts over $50,00 will require reasonable advance notice. 6.3 RESIDENrs Personal Needs Allowance RESIDENT Is permitted to retain a portion of RESIDENT's income as a personal needs allowance, in an amount determined by the Medicaid Program. RESIDENT Is not required to use any portion of RESIDENT's personal needs allowance for basic or supplemental charges, nor will HOME impose a charge against RESIOENT's personal funds for services paid for by Medicare or Medicaid, 6.4 HOME Accounting If HOME provides assistance with financial management to RESIDENT, HOME shall maintain a separate, current Individual record of financial transactions for RESIDENT and shall give RESIDENT or RESPONSIBLE PARTY a quarterly 6 , EXHIBIT ...fL. PAGE ...l.- accounting of transactions made on RESIDENT's behalf, Upon request, RESIDENT or RESPONSIBLE PARTY shall be allowed to review RESIDENT's f1nanclall'ecord during normal working hours. Deposits and expenditures shall bo documented with written receipts. Dlobursement of funds to RESIDENT or RESPONSIBLE PARTY shall be documented and RESIDENT or RESPONSIBLE PARTY shall acknowledge the receipt of funds In writing, Accounts shall clearly reflect deposits, receipt of funds, disbursal of funds and the current balance. 6.6 I ~odlcr:lc' end ssr P.CGOU~CO Uml(cll(':o~ r~ollllcatlor : ~r:~.' :r~T Is c.1i~:~I..: {or li,edlcald, I iOiM.: 1'1111 no\lly RE~ 18[21 ~T or RESf ,j1~SII3Ll: PART" Ilhen \110 account balance (::culTI'.llates to a pc '1ttllat is $200 less thar, the Medicaid and or SSI resource limitation that RESIDENT may lose his or her Medicaid or SSI eligibility If the resource limit Is exceeded, 6.6 RESIDENT Funds Procedure Following Termination of Service by HOME In the evont of termination of service by HOME alter thirty (30) days written notice, HOME will provide RESIDENT or RESPONSIBLE PARTY with an Itemized written account of RESIDENT's funds and Immediate payment of any balance remaining In RESIDENT's account with HOME. 6.7 RESIDENT Funds Procedure Following Termination of Service by RESIDENT If RESIDENT chooses to leave HOME olter giving written notice, HOME shall, within thirty (30) days after RESIDENT leaves, provide RESIDENT or RESPONSIBLE PARTY with an Itemized written amount of funds, Including notification of funds still owed to HOME by RESIDENT or a refund owed to RESIDENT by HOME. 6.8 RESIDENT Funds Procedure Following Discharge or Death of RESIDENT Upon discharge of RESIDENT, HOME shall return RESIDENT's funds being managed by HOME to RESID,ENT or RESPONSIBLE PARTY, Upon the death of RESIDENT, HOME shall surrender to RESIDENT's estate funds and valuables of RESIDENT which were entrusted to HOME or left In HOME. In addition, an Itemized written account of RESIDENT's funds and valuables which were entrusted to HOME shall be surrendered within 30 working days of RESIDENT's death. A signed receipt shall be obtained and retained by HOME. 7. TERM, TERMINATION, TRANSFER, OR DISCHARGE 7.1 Term of Agreement The term of this Agreement shall commence on the date set forth above and will 7 EXHIBIT ,/L. PAGE ....:L. remain In effect until It Is terminated by either party es described herein or until a different or subsequent agreement Is executed. Notification of adjustment In charges for baslo or supplemental se/vlces and supplies shall be considered an amendment to this agreement, but at the time of suoh adjustment, execution of a different or subsequent agreement shall not be necessary to effect such change 01 rates. 7.2 Termination, Discharge or Transfer Initiated by RESIDENT RESIDENT or RESPONSIBLE PARTY may terminate this Agreement by giving advance written notice to HOME of RESIDENT's discharge from HOME. Obligation of RESIDENT or RESPONSIBLE PARTY solely from RESIDENT's finanGlal resources, to pay HOME for services rendered through the date of discharge shall continue until such financial obligations have been satisfied. RESIDENT or RESPONSIBLE PARTY may Initiate RESIDENT's discharge at any time. RESIDENT will not be forced to remain In HOME against RESIDENT's will for any period of time, Requests by RESIDENT or RESPONSIBLE PARTY to transfer to another room will be subject to the availability of the room requested and the needs of RESIDENT and other residents, HOME will advise RESIDENT or RESPONSIBLE PARTY of any additional charges for requested room If different than assigned room, 7.3 Termination, Discharge or Transfer Initiated by HOME , HOME may terminate this Agreement by giving thirty (30) days advance written notlca to RESIDENT or RESPONSIBLE PARTY. HOME may discharge or transfer RESIDENT only under the following conditions: a) transfer or discharge Is neGessary for RESIDENT's welfare and RESIDENT's needs cannot be met in HOME; b) RESIDENT's health has Improved sufficiently and the services of HOME are no longer required, as documented by RESIDENT's physician; . 0) the health or safety of others at HOME Is endangered; d) RESIDENT has failed, after reasonable notice, to pay for or have Medicare or Medicaid pay for, RESIDENT's stay at HOME; e) HOME ceases to operate. 8 EXHI81T (L PAGE ..L... 7,4 Notice of Transfer or Discharge by Home In the event of transfer or discharge, HOME will provide advance notice of thirty (30) days except when RESIDENT has urgent need for further medical attention, RESIDENT Is absent from HOME for thirty (30) days, RESIDENT's health has Improved to the extent that the services of HOME are no longer required, or RESIDENT's stay endangers the health or safety of others at the facility. At minimum, the notice will contain the following Informallon: a) the reason fo' transfe' (;r discharge; b) , 1(' C:;ctIVE' ~G of " ',.1"" fQr ( dlscl1 :Jge; c) the location to which RESIDENT Is to be transferred; d) a statement that the resident has the right to appeal the action to the Pennsylvania Department of Public Welfare, Office of Hearing and Appeals, P,O, BOl: 2676, Harrisburg, PA 17106-2675; e) the name, address, and telephone number of the state long term care ombudsman (the local Area Agency on Aging): n the name, address, and telephone number of the agency responsible for protection and advocacy of developmentally disabled Indlvldual~; g) the name, address, and telephone number of the agency responsible for the protection and advocacy of mentally ill persons. 8. RESIDENT RECORDS 8.1 Record Maintenance HOME shall maintain records In accordance with the requirements of federal and state governmental agencies or other third party reimbursement sources, 8.2 Confidentiality and Authorization HOME acknowledges that RESIDENT's personal and medical records are confidential. RESIDENT or RESPONSIBLE PARTY authorizes access and use of such records to HOME. In the event of RESIDENT's admission to a hospital or referral to other healtt1 care providers, RESIDENT or RESPONSIBLE PARTY authorizes the release of Information to such institution or health care provider. In addition, RESIDENT or RESPONSIBLE PARTY authorizes the release of Information on the medical record to third party payors or potential payors, government or regulatory agencies, the state ombudsman, and the HOME's liability carrier or 9 F.XHIBIT 1L- PAGE ..:..L- HOME's legal counsel. 9. MEDICAL TREATMENT AUTHORIZATION 9.1 Authorization by RESIDENT or RESPONSIBLE PARTY RESIDENT or RESPONSIBLE PARTY authorizes HOME to provide care and treatment consistent with the terms of this agreement, 10. THIRD PARTY PAYMENTS 10.1 Authorization 10 Bill Third Party payors RESIDENT or RESPONSIBLE PARTY authorizes HOME to bill any third party payor directly for service rendered which may be covered by any Insurance or government assistance program, Including Medicare, Medicaid, and private Insurers, 10.2 Assignment of Medicare Payments RESIDENT or RESPONSIBLE PARTY requests that payment of authorized Medicare benefits be made on RESIDENT's behalf to HOME for any services furnished RESIDENT by HOME. RESIDENT or RESPONSIBLE PARTY authorizes any holder of medical Information about RESIDENT to release to the Health Care Financing Administration Elnd Its agents any Information needed to determine these benefits or the benefits payable for related services, 11. MISCELLANEOUS PROVISIONS 11.1 Governing Law This Agreement shall be governed by and construed In accordance with the laws of the Commonwealth of Pennsylvania, 11.2 Severability If any of the provisions In this Agreement are declarad to be Invalid, such provisions shall be severed from the Agreement and the other provisions hereof shall remain In full force and effect. 11.3 Headings Section headings contained In this Agreement are for reference purposes only and do not constitute part of this agreement. 11.4 Entire Agreoment This AgrElement together with HOME's Application for Admission, Schedule of 10 EXHIBIT t.L PAGE J.:::.... Charges, Resident Handbook, Resident Rights, policies on Advance Directives Ilnd Financial Assistance constitute the entire undorstandlng between the parties with respect to the matter contained herein, superseding all prior and contemporaneous agreements and understandings, express or Implied, oral or written. No addltlon or modification to this agreement may be made by RESIDENT or RESPONSIBLE PARTY without the consent of HOME, and such addition or modification shall be In writing signed by RESIDENT or RESPONSIBLE PARTY and a corporate officer of United Church of Christ Homes, Inc.. 11.5 Modlfl cations HOME may modify c; Emend IIlls AgreonKnt unilaterally to assure compliance with subs(. :,Ient change.: h [<:II'""n:,(' I::.w cr rog ,'::;tio;" I~o\i<,,;o of (ny fuel, cllr.n]eS will be provided to F,ESIOI::I\l' (Ir nC:SPOI\SIULE P/,nTY 11.6 Notices All notices required or permitted under this Agreement shall be In writing and shall be deemed to have been given, made and received when personally delivered or sent by regular U.S. Mall addressed to the party(les) as set forth above. Any party may change the address to which notices are to be sent by giving notice of such change In the manner described above, 12. ACKNOWI.EDGEMENTS 12.1 Schedule of Charges RESIDENT and RESPONSIBLE PARTY, If any, acknowledge receipt and understanding of HOME's Schedule of charges. 12.2 Resident Handbook RESIDENT and RESPONSIBLE PARTY, If any, acknowledge receipt and understanding of HOME's handbook on HOME's rules (Resident Handbook) and agrees to abide by HOME's rules. 12.3 Resident Rights RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of Resident Rights. 12.4 Advance Directives RESIDENT and RESPONSIBLE PARTY, If any, acknowledge receipt and understanding of HOME's policy on Advance Directives. 12.5 Financial Assistance RESIDENT and RESPONSIBLE PARTY, If any, acknowledge receipt and uhderstandlng of HOME's Financial Assistance policy. 11 EXHIBIT .!..!- PAGE ..lL. (- ,- I 'l;f.NI\I(~:YWE~)l:, ATTORNE-': ( r r KNOW ALL MEN llY TlmS~: PR~:Sf.NTS, THAT I, SA1WI Ii. PENN~;LLA (IF CARLISl.li, CUMlmRLANll COUNTY, 1'f.NNSYl.VANIA, DO IIf.REllY APPOINT CIlERY'. A. WINTEIIS, 01' CAIU.ISI.E, CUMBELANIl COUN'\'Y, PENNSYLVANIA AS MY TRUE ANll I.AW~UL ATTOIINEY-IN-~'ACT, TO DO ANll PER~'ORM AU. ACTS ANIl TRANSACT ALL BUSINESS WITIIOUT 1.IMITA'flON, ~'OR ME, ANll IN MY NAHli, WIIICII I COULll 110 II' PERSONALLY PRESENT, INCLUlllNG 1'111'. POWER TO SELL REAL liSTA'fIi ANll liXECUTE CONTRACTS OR llEEllS, IIEREBY RATIFYING ANll CONFIRMING ALL TIlNC MY SAID ATTORN~:Y-IN-FACT MAY ANll SIIALI. DO I'URSUANT TO TIIESE PRESENTS. I FURTIIER AUTIlOlllZE MY ATTORNEY-lt.-FACT TO IIAVE ACCESS TO ANY SAFE DEPOSIT BOX IN MY NAME AT ANY INS'l'lTUTlON. TillS POWER OF ATTOllNEY SHALL IWT liE AITECTEll CJlI IlEVOKI':1l IIY SUllSEQIJENT 1l1SAIIIL/TY OR DEATII. A SPECIMEN 01' 1'111'. SIGNATURE OF THE PERSON TO WIIOM TillS POWER IS GIVEN IS SET ~'ORTIl BELOW. IN WITNESS WIIEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THIS f Q..DAY OF DECEMllER, 1993. ....::fJ'Ut/l.. ~ dJJ-,;:dib- SARAII E. PENNELLA STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND ) ) (55 ) ON TillS 7 {).DAY OF DECEMBER, 1993, BEFORE ME, 1'111'. UNDERSIGNED OFFICER PERSONALLY APPEARED TilE ABOVE NAMED SARAII E. PENNELLA, WII0 DECLARED TilE ~'OREGOING LETTER OF ATTORNEY TO BE HER TRUE ACT AND DEED, AND DESIRE THAT TilE SAME MIGHT BE RECORDED AS SlICH. IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY \lAND AND SEAL 1'111'. DAY AND YEAR HRST ABOVE WRITTEN. ~ \ ..~ I S .. '- I '... W. 0 li>JIAL SfAL I ,~ri~uw~s, ',uh'y h~". NOTARY PUBLIC j 5., .IIJ01.... Twp. Cu",b..I..d o,u.ty _"2 Com",'",.. l.~ ~.,.. II. ~ ,-- -- TilE SIGNA'l'URE OF TilE IIEREIN llES1GNATr:D ATTORNEY-IN-FACT IS AS FOLLOWS: 6VA<J.-,--_4~~_r.1iM CIIERYl. ~.-~ 1 NTEIlS (DAUGHTER) EXHIBIT ..lL PAGE .1- '[J ~l S"'" '" c ...., <::I 0::- 1>oN~;;2~ ~ 0-- ~ g.,:J (l:l~"t " '" ~ ::l .; r::: E c__ ~ ~~c <"'lU :j: ~~ .' -c c ~ ~ o o o r- -c I~ a 0' ..... ~ -c c ..... -c ~ .. ~ - it ~ a -,- ~ .... llJ ., nlj.; .-._. ~l ~h. 0: '" 1/". ~ " c c ~ c c c W c - ~ I U; J: ([ 0: ([ (f'. ([ ... U; Z Z U; 0. 1- ~~ u. ..: >: ()' a u. 0' u. t-Cf,.- t-I-q~ u.Cf-I>C C ,- C ()':Z :r b. Ii. ()' C..... Ct a: ~ C C _ lI. (/ .. lL t- lJ. f- C ~, <l 0: Z ,..~. C 1: lJ.. l~ t- >:: _ lJ,. Z >- ). ll. ({ IJ... <l :: a. ): 0: h.. ~ .. c'. ' I C, V' I'" (\. ,.... C f' --;I ,~ 'I 'I "'I 0; ., ~ ,_ g v' ~ 'f. .. -- ..._..-....~-~_._.__._-_._...__._.. i I (]' I ", Q. 0: ~ 3 C cr Z\Ct!: ~ <I~lf. E crx... is cc.... ~ ZO:J: ~ .. I t'; ~ '" - ---._- c c ~ __. __........,_._____m. EXHIBIT .:L. PAGE..:. I I": ..... 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IIN THE COURT OF I PLEAS or CUMBERLAND I PENNSYLVANIA I ICIVIL ACTION I INO. 96-3974 CIVIL TERM COJOlON COUNTY I UNITED CHURCH OF CHRIST HOMES, t/e/4/b/a THORNWALD ~OME, Plaintiff CHERYL A. WINTERS and NORMAN W. PENNELLA, EXECUTORS or THE ESTATE or SARAH E. PENNELLA, DECEASED BY I SUBSTITUTION rOR SARAH E. PENNELLA, I DECEASED I Defendants I STIPULATION FOR ENTRY OF JUDGMENT NOW COMES the plaintiff, by its Attorneys, peather & Feather, P.C., and the defendants by their attorneys Flower, Morgenthal, Flower & Lindsay, P.C. who present the following stipulation! 1. The plaintiff is a Pennsylvania not-for-profit corporation which operates a nursing and personal care facility known as Thornwald Home at 442 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania, 17013. 2, The defendants are the personal representatives of the estate of ~arah Ellen Pennella who died September 6, 1996. 3, At the time of her death, Sarah Ellen. Pennella resided at Thornwald lIome. 4. At the time of the death of Sarah Ellen Pennella the plaintiff had instituted suit in the above captioned case to collect unpaid nursing home residential fees, the interest on the unpaid balance and reasonable attorneys fees for the collection of the unpaid nursing home fees and interest as authorized under the Nursing Home Admission Agreement signed by Sarah Ellen Pennella and one of the named defendants, Cheryl A. Winters. 5. Aft.er the death of Sarah Ellen Pennella on September 6, 1996 the defendants Cheryl A. Winters and Norman W. Pennella, executors of the estate of Sarah E. Pennella were substituted as defendants for the decedant. 6. The parties have reached an agreement fOl: the entry of judgment against the defendants and in favor of plaintiff in the amount of $24,390.49 (allocated as principal amount of $16,817.49 for unpaid nursing home charges, $5,230.00 for accrued interest to June 30, 1997, $2,343.00 for attorneys fees), together with intercst on the unpaid principal amount at the rate of 18\ per year from July 1, 1997 until paid in full and court costs, WHEREFORE plaintiff and the defendants by and through their respective attorneys of record request the court to enter judgment as follows, "Judgment is entered against the defendants and in favor of the plaintiff in the amount of $24,390.49 (allocated as principal amount of $16,817,49 for unpaid nursing home charges, $5,230.00 for accrued interest to June 30, 1997, $2,343.00 for attorneys fees), together with interest on the unpaid principal amount at the rate of 18\ per year. from July 1, 1997 until paid in full and court costs." Respectfully submitted, FEATHER & FEATHER, P.C. FLOWER, MORGENTHAL, FLOWER & LINDSAY "" J c~ ~ e <r- .. ~ " " I I , I , I " \ .i I[ " , ir ,... ;!: , Ie - I i' N (~~ .' :t,; ~:. n.; . '/!:!' I ,')~.l " ... N ~~~ . , '" f',j , fl, :i !"j~ t hi 'I ,... tj 11' I' 1'\ , .. , I' , '" ' , " " " , " " " " " , " , , " " , I' 1, It It ..' ' " " " ?Q!~~/t; I ,I IV o Lctw eJ'-Pf':r "', &-p-, 7/~,v / t..t 1'1 t:'.J '-V Lk V j( ,I. 'VI ~I Cd-h,) I t' I, .;15 ". if ~ ~3 '17 ',' '/-j) I I' " " I I P v;). 'I, "'-l n J.,I "-f, I 'i1if'; '". ,J ., I r.:.. 7.10(11 I-~ , "I!l '.' ~ N I/~ t.~(. '''' il , I ,) ~.'" -u Jj .' ,': .~ " ~' , 'I~I ~.~ I~-,'I., " I , ' ,~"" \; 21'll ' ;~ .. :::-.. ',- ,,.,. r:;) ~ I , I " I' , ' , , , I '" " "