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07-0342
A. l IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB Plaintiff VS. No. ©'7 - 2L/Z ?lviC??L COMPLAINT IN CIVIL ACTION ROBERT AND LINDA CRUM FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Michael J. Dougherty, Esquire PA I.D. # 76046 WELTMAN, WEINBERG, & REIS, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 WWR#05397059 jk IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB Plaintiff vs. ROBERT AND LINDA CRUM No. COMPLAINT IN CIVIL ACTION IMPORTANT NOTICE AVISO IMPORTANTE YOU ARE IN DEFAULT BECAUSE USTED ESTA EN REBELDIA YOU HAVE FAILED TO TAKE ACTION PORQUE HO FALLADO EN TOMAR REQUIRED OF YOU IN THIS CASE LA ACION EXIDIDA DE SU UNLESS YOU ACT WITHIN TWENTY DAYS PARTE EN ESTE CASO. FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP: A MENOS DE LA FECHA DE USTED ACTUE DENTRO DE DIEZ DIAS DE LA FECHA DE ESTE AVISO, SE PUEDE REGISTRAR UNA SENTENCIA CONTRA USTED SIN EL BENEFICIO DE UNA AUDENCIA Y PUEDE PERDER SU PROPIEDAD O OT tOS DERECHOSIMPORTANTES. USTED DEBE LLEVAR ESTA AVISO A UN ABOGADO ENSEGUIDA. SI USTED NO TIENE UN ABOGADO Y NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, DEBE COMMUNICARSE CON LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE OBTENER AYUDA LEGAL: Lawyer Referral Service 4th Floor, Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 COMPLAINT 1. Plaintiff is a corporation with offices located at P. O. Box 180970, Fort Smith, Arkansas 72918. 2. Defendant, Linda Crum, is an adult individual with a last known address at 416 North East Street, Carlisle, Pennsylvania 17013. 3. Defendant, Robert Crum, is an adult individual with a last known address of 416 North East Street, Carlisle, Pennsylvania 17013 COUNTI BEVERLY V. LINDA CRUM 4. Pursuant to Plaintiff's Statement of Account dated November 11, 2005 and the Resident Admission Agreement, and at the specific instance and request of Defendant, Linda Crum, Plaintiff provided certain goods and services to Defendant, Linda Crum, as more specifically shown by Plaintiff's Statement of Account and Resident Admission Agreement, a true and correct copy of which is attached hereto, marked Exhibit "1" and made a part hereof. 5. Defendant received and accepted the aforementioned goods and services that were provided by Plaintiff. 6. The prices charged by Plaintiff were fair and reasonable and were the market prices that prevailed at the time of the transactions at issue. 7. The prices charged by Plaintiff were the prices that Defendant agreed to pay. 8. Plaintiff avers that there is a balance due and owing from Defendant in the amount of $1.7,518.16, as is shown by Plaintiff's Statement of Account attached hereto as aforementioned Exhibit "1" and made a part hereof. 9. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and/or refused to pay the aforementioned balance. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Linda Crum, in the amount of $17,518.16, and costs. COUNT 11 BEVERLY V. ROBERT CRUM 10. Plaintiff incorporates all preceding averments as if fully set forth at length herein. 11. At all times pertinent hereto, Defendant, Robert Crum, was the husband of Defendant, Linda Crum. 12. Under the doctrine of necessaries, Defendant, Robert Crum, is liable for payment of the outstanding balance for the services provided to Defendant, Linda Crum. 13. Defendant, Robert Crum, is liable to Plaintiff for payment in the amount of $17,518.16. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Robert Crum. in the amount of $17,518.16, and costs. WELTMAN, WEINBERG & REIS, CO., L.P.A. Michael J. Douglxerty, Esquire PA I.D. # 76046 WELTMAN, WEINBERG, & REIS, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 WWR#05397059 R m ;a n tix [-J?z H? O I tnHH yyyy t7l7yzy 1 aqj Ch ro00 oro SUO ?E W t9tlh Ln \ I En Q 1 3 Cn w •• I tj tD 1 m h7 h7CVi Z ro t7 C 3 I \ O N3 y H t7 I 3[] to [n N H H Ln N N I I H N t7 H I Dj H N t? I N Y•• I N 1 M 1 0 I \ mZ ? 00Hx1 ' R I .. .. I ?. 1 O 0 z 1 +d H H 1 tltn o x N z O U1 1 1 z H y I I I 1 p I<] ) H h) O I Y 0 1P '.O I V1 1 ts) .b •• i ? 0 00 n Z 10 ay d Y O m w 1 H \ O I to •• o I .. [><) * t3+) 1 H 1 .. 1 7. 3 0 co (] n W I o p H r t+) I w x 1 ?i I 0 -C0 to 0 Z ? I to z yto I 1 M t-! 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Continuation of the previous Admission Agreement: The Resident Specific Information section of the original Resident Admission Agreement dated __7T i ,( r-4Ce-?,: , has been reviewed and there is no significant change. The terms of the original agreement are in effect for this readmission and the Resident Specific Information section of that agreement is on file in the Business Office available for review. All terms of the original Resident Admission Agreement are incorporated by reference as though set forth herein. Acknowledgements: The Resident acknowledges that the following information was provided upon or before readmission to the facility. The Resident must initial the lines below to indicate acknowledgement: The option to open a Resident Trust Fund Account. If the payor source has changed since the last discharge, a list of supplies and services included in the daily rate paid by the new payor and those items or services for which the Resident can be separately charged. A copy of the facility policy regarding implementation of the Patient Self Determination Act and of the applicable state law. I do do not have an advance directive. If your condition warrants, you may be placed in the facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the facility will discuss such a transfer with you. Under law, you cannot be discharged from- this facility unless you agree or unless, following an appeal, it is redetermined that you may be involuntarily discharged or transferred. Resident Date Witness if Resident Signed with a Mark Date Witness if Resident Signed with a Mark Date •I.:' • ? r t Legal Representative Date Legal Representative's Telephone Number Ujal Rep sentativels Social t.ecurity N&.., ?_. Agent Date Agent's Telephone Number ftent's ?tQCi>a1 S ufi No. acility Administ?for or De gftee Date BE 202A (5195) White - Business Office Pink - Medical Records Yellow - Resident • ig . ,4? VERIFICATION I, Michael J. Dougherty, Esquire, attorney for the Plaintiff(s) do hereby swear and affirm that the averments in the attached Complaint in Civil Action are true and correct to the best of my knowledge, information and/or belief. These averments are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to usworn falsification to authorities. Date: 1 /0 /07 WWR# vt /n `Y C- co O 'n ?( ? J rn °G v' l '. L CASE NO: 2007-00342 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BEVERLY HEALTHCARE WEST SHORE VS CRUM ROBERT ET AL MARK CONKLIN 4q,01 010 Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon CRUM ROBERT the DEFENDANT , at 2055:00 HOURS, on the 22nd day of January 2007 at 416 NORTH EAST STREET CARLISLE, PA 17013 ROBERT CRUM by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 4.40 .00 10.00 .00 32.40 Sworn and Subscibed to before me this of day Sheriff or Deputy Sheriff of So Answers: r R. Thomas Kline 01/23/2007 WELTMAN WEINBERG REIS By. /?Z_1/ /,/V Deputy heriff , A. D. W }, SHERIFF'S RETURN - REGULAR CASE NO: 2007-00342 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BEVERLY HEALTHCARE WEST SHORE VS CRUM ROBERT ET AL MARK CONKLIN , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon CRUM LINDA DEFENDANT the at 2055:00 HOURS, on the 22nd day of January-, 2007 at 416 NORTH EAST STREET CARLISLE, PA 17013 by handing to ROBERT CRUM, HUSBAND a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: So Answers: Docketing Service 6.00 .00 Affidavit .00 Surcharge 10.00 R. Thomas Kline .00 16.00;/ 01/23/2007 WELTMAN WEINBERG REIS aa"0 Sworn and Subscibed i- to 00 By: "/ /W before me this day Deputy Sheriff of A.D. Nichole M. Walters, Esquire Attorney I.D. No. 84478 The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB, Plaintiff No. 07-342 V. ROBERT AND LINDA CRUM, CIVIL ACTION - LAW Defendants PRELIMINARY OBJECTIONS TO PLAINTIFF'S COMPLAINT AND NOW COMES the Defendants, Robert and Linda Crum, by and through their attorneys, Nichole M. Walters, Esquire of the Elder Law and Consumer Protection Clinic of The Dickinson School of Law of The Pennsylvania State University, and sets forth as follows in support of these Preliminary Objections to Plaintiffs Complaint: 1. The Plaintiff, Beverly Healthcare - West Shore Health and Rehab, is a company with its principal place of business located at P.O. Box 180970, Fort Smith, Arkansas 72918. 2. Plaintiff is represented by Weltman, Weinberg, & Reis, CO, L.P.A., located at 325 Chestnut Street, Suite 501, Philadelphia, PA 19106. 2 3. Defendants are Robert and Linda Crum, both adult individuals, residing at 416 North East Street, Carlisle, PA 17013. 4. Defendants are represented by the Elder Law and Consumer Protection Clinic of The Dickinson School of Law of The Pennsylvania State University, located at 45 North Pitt Street, Carlisle, PA 17013. 5. Plaintiff filed a Complaint against Defendant Linda Crum and Defendant Robert Crum. Plaintiff alleges that Defendant Linda Crum purportedly breached a contract because she failed to make payments on an account with the Plaintiff. Plaintiff alleges that Defendant Robert Crum owes money to Plaintiff's facility under the doctrine of necessaries. 6. Plaintiff's Complaint was served on the Defendants on January 22, 2007. 7. Plaintiff sent Defendants a notice dated June 26, 2008 saying Defendants have 10 days to respond to the Complaint. PRELIMINARY OBJECTION PURSUANT TO Pa R.C P MgWa)(2) - FAILURE OF A PLEADING TO CONFORM TO LAW OR RULE.. OF COURT OR INCLUSION OF SCANDALOUS OR IMPERTINENT MATTER A. Failure to Conform to Pa RCP 1019(1) 8. Paragraphs 1 through 7 of Defendant's Preliminary Objections to Plaintiff's Complaint are hereby incorporated by reference as if set forth at length. 9. Plaintiff's Complaint fails to conform to a rule of law or Court in that it does not comply with Pa. R.C.P. 1019(i). 10. Pa. R.C.P. 1019(i) requires the Plaintiff to attach to the Complaint the writing or material part thereof upon which the Complaint is based. 11. The Plaintiff's Complaint alleges a cause of action arising out of a written contract, the "Resident Admission Agreement." 12. Plaintiff has failed to attach a copy of this alleged written contract to the Complaint, and only provided a "Readmission Agreement," which does not contain any specific terms, and which refers to an "original Resident Admission Agreement." 13. Defendant Linda Crum cannot possibly discern the terms of the written contract alleged to exist'in the Plaintiff s Complaint without viewing a copy of that contract. Thus, the Defendants cannot properly answer the Plaintiff's Complaint without having a complete copy of the "Resident Admission Agreement." WHEREFORE, Defendant Linda Crum respectfully requests that this Honorable Court grant the Defendants' Preliminary Objections pursuant to 1028(a)(2) and require the Plaintiff to produce a copy of the alleged written contract, or have its Complaint dismissed with prejudice for failure to conform to Pa. R.C.P. 1019(1). B. Failure to Conform to Pa. R.C.P. 1024 14. Paragraphs 1 through 13 of Defendant's Preliminary Objections to Plaintiffs Complaint are hereby incorporated by reference as if set forth at length. 15. Plaintiff's Complaint fails to conform to a rule of law or Court in that it does not comply with Pa. R.C.P. 1024. 16. Pa. R.C.P. 1024 requires that every pleading containing an averment of fact not appearing of record in the action shall state that the averment is true upon the 4 signer's personal knowledge or information and belief and shall be verified. Such verification shall be made by one or more of the parties filing the pleading. 17. Plaintiff's Complaint contains the verification of Michael J. Dougherty, Esq. and not the verification of Beverly Healthcare - West Shore Health and Rehab. 18. Michael J. Dougherty, Esq. of Weltman, Weinberg, & Reis, CO, L.P.A. is neither a party filing the pleading nor does he have personal knowledge or information to properly verify the facts averred in the Complaint. WHEREFORE, Defendants respectfully request that this Honorable Court grant the Defendants' Preliminary Objections pursuant to 1028(a)(2) and require the Plaintiff to provide proper verification of the averment of facts, or have its Complaint dismissed for failure to conform to Pa. R.C.P. 1024. C. Inclusion of scandalous or impertinent matter 19. Paragraphs 1 through 18 of Defendant's Preliminary Objections to Plaintiff's Complaint are hereby incorporated by reference as if set forth at length. 20. Plaintiff's Complaint violated Pa. R.C.P 1028(a)(2) in that it includes scandalous or impertinent matter. 21. Exhibit 1 of Plaintiff's Complaint includes sensitive information, including Defendant Linda Crum's social security number, insurance policy number, birth date, and address, together which could easily be used to steal Defendant Linda Crum's identity. 22. Exhibit 1 of Plaintiff's Complaint includes information protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), including health- related services provided and prescriptions administered. 5 23. The information referenced in Paragraphs 20 through 22 is immaterial and inappropriate to the proof of the cause of action. WHEREFORE, Defendants respectfully request that this Honorable Court grant the Defendants' Preliminary Objections pursuant to 1028(a)(2) and require that the Plaintiff redact information pertaining to services and prescriptions Defendant Linda Crum received and other personal and sensitive information. PRELIMINARY OBJECTIONS PURSUANT TO Pa RCP 1028(x)(3) INSUFFICIENT SPECIFICITY IN A PLEADING 24. Paragraphs 1 through 23 of Defendant's Preliminary Objections to Plaintiff's Complaint are hereby incorporated by reference as if set forth at length. 25. The Plaintiff's Complaint fails to state a cause of action upon which relief can be obtained. 26. The Plaintiff's Complaint is insufficiently specific to allow Defendants to properly answer. Defendant assumes that in Paragraphs 4 through 9 of Plaintiff's Complaint, Plaintiff is purportedly alleging that Defendant Linda Crum breached a contract between Plaintiff and Defendant Linda Crum. However, the Complaint fails to set forth the specific terms of the alleged contract it claims were breached. Instead, Plaintiff attached as Exhibit 1 a "Readmission Agreement" which makes reference to an alleged "original Admission Agreement" signed by Defendant Linda Crum. The Complaint, together with Exhibit 1, fails to set forth any specific terms of the alleged contract. 6 27. Without knowing the specific terms of the contract that Plaintiff alleges was breached by Defendant Linda Crum, it is impossible for Defendant Linda Crum to form answers with regard to breach of contract allegations. 28. The Plaintiff claims in Paragraph 8 of the Complaint that it is entitled to $17,518.16 for the goods and/or services which it provided to Defendant Linda Crum. The account statements provided by Plaintiff show the most recent balance of Defendant's account as $17,518.16, but it cannot be readily determined by looking at the account statement attached to the Complaint that payments made on the account were properly credited to Defendant Linda Crum's account. WHEREFORE, Defendants request that this Honorable Court require the Plaintiff to amend its Complaint to: a) state a cause of action upon which Plaintiff bases its request for relief; b) specifically allege the terms of the purported contract; c) allege the specific charges and credits posted on Defendant Linda Crum's account to demonstrate how Plaintiff determined damages; or d) have its Complaint dismissed for insufficient specificity. Respectfully submitted, Date: 3 Q Nichole M. Walters, Esquire The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 Attorney for the Defendants 7 IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB, Plaintiff V. No. 07-342 ROBERT AND LINDA CRUM, Defendants CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Lyndsey W. Leatherman, Certified Legal Intern, certify that on July 3, 2008, I served the foregoing Preliminary Objections to Plaintiff's Complaint by placing a true and correct copy of the same in the United States first class mail, postage prepaid, addressed as follows: Michael J. Dougherty, Esq. Weltman, Weinberg & Reis, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date: 3 d 8 By. VV , Lyn sey W. Leatherman Certified Legal Intern Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 8 na 00 BEVERLY HEALTHCARE - : IN THE COURT OF COMMON PLEAS WEST SHORE HEALTH AND REHAB, : OF CUMBERLAND COUNTY, Plaintiff PENNSYLVANIA V. NO. 07-342 : CIVIL ACTION - LAW ROBERT AND LINDA CRUM, : Defendants PRAECIPE TO ENTER APPEARANCE To the Prothonotary: Kindly enter the appearance of Nichole M. Walters and the Elder Law and Consumer Protection Clinic on behalf of Defendants Robert and Linda Crum. Date: -11 2A o_ By: T Nichole M. Walters The Elder Law and Consumer Protection Clinic 45 North Pitt Street Carlisle, PA 17013 717-240-5152 PA Attorney ID: 84478 pp ?t to .. 1--i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff VS. ROBERT CRUM LINDA CRUM Defendants No. 07-342 AMENDED COMPLAINT IN CIVIL ACTION FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Karina Velter, Esquire PA I.D. #94781 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 WWR#05397059 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff VS. Civil Action No. 07-342 ROBERT CRUM LINDA CRUM Defendants NOTICE TO DEFEND NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claim set forth in the following pages, you must take action within twenty (20) days after this complaint and Notice are served, by entering a written appearance personally or by an attorney in filing in writing with the Court your defenses or objections to to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for money claimed in the Complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. AVISO LE HAN DEMANDADO A USTED EN LA CORTE. Si usted quiere defenderse de estas demanddeas expuestas en las paginas siguientes, usted tiene veinte (20) dias de plazo al partir de la fecha dela demanda y ]a notificacion. Hace falta asentar una comparencia escrita o en persona o con un abogado y entregar a la corte en forma escrita sus defensas o sus objeciones a las demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso o notificacion. Ademas, la corte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisioner de esta demanda. usted puede perder dinero o sus propiedadas u otros drechos importantes para usted. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP: LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTA. SI NO TIENE ABOGADO O SINO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICO, VAYA EN PERSONA O LLAME FOR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ADAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. LAWYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 S BEDFORD ST CARLISLE, PA 17013 (717) 249-31665 AMENDED COMPLAINT 1. Plaintiff, Beverly Healthcare - West Shore Health and Rehab, is a corporation with offices located at P.O. Box 180970, Fort Smith, AR 72918. 2. Defendant Linda Crum is an adult individual with a last known address at 416 North East Street, Carlisle, PA 17013 3. Defendant Robert Crum is an adult individual with a last known address at 416 North East Street, Carlisle, PA 17013. COUNTI BEVERLY V. LINDA CRUM 4. Pursuant to the Resident Admission Agreement dated June 20, 2005, and Plaintiff s Statement of Account dated July 6, 2006, and at the specific instance and request of Defendant, Linda Crum, Plaintiff provided certain goods and services to Defendant, Linda Crum, as more specifically shown by Plaintiff s Resident Admission Agreement and Statement of Account, a true and correct copy of which is attached hereto, marked as Exhibit "1" and "2" respectively, and made part hereof. 5. Defendant received and accepted the afore-mentioned goods and services that were provided by Plaintiff. 6. The prices charged by Plaintiff were the prices that Defendant agreed to pay. 7. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and/or refused to pay the balance owed on this account.. 8. Plaintiff avers that there is a balance due and owing from Defendant in the amount of $17,518.16, as is shown by Plaintiff's Statement of Account attached hereto as afore-mentioned Exhibit "2", and made a part hereof. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Linda Crum, jointly and severally, in the amount of $17,518.16, and costs. COUNT II BEVERLY V. ROBERT CRUM 9. Plaintiff incorporates all preceding averments as if fully set forth at length herein. 10. At all times pertinent hereto, Defendant, Robert Crum, was the husband of Defendant, Linda Crum. 11. Under the doctrine of necessaries, Defendant, Robert Crum, is liable for payment of the outstanding balance for the services provided to Defendant, Linda Crum. 12. Defendant, Robert Crum, is liable to Plaintiff for payment in the amount of $17,518.16. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Robert Crum, jointly and severally, in the amount of $17,518.16, and costs. This law firm is a debt collector attempting to collect this debt for our client and any information obtained will be used for that purpose. WELTMAN, WEINBERG & REIS, CO., L.P.A. vlk? Karina Velter, Esquire PA I.D. #94781 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 WWR#:05397059 EXHIBIT 1 ' 479201 1101 GoIlden Ventures JUL-23-2008 11:06 From: xx[X. P. of IftheLegal Repr ( ] Conservator c [ ] Conservator c rA Other, specify If yoti are signing My relationship tt On this ?-d this Agreement an this Flacility. 01:26:26 p.m. 07-28-2008 4/16 To:B6I P.2/9 ADMSSION AGREEMENT SIGNATURE PAGE - The parties to this Agreement are: 's (Name of Resident)(Name o ReaideI49d Representative) entative signs the Agreement, check the Tyke of Legal Representative (below). Person [ J Guardian [ ] Durable Power of Attorney [ l Agent Acting Estate for Health Care (DPAHC) Under General POA his Agreement on behalf of the Resident, note your relationship to the R"deint: the Resident is y of ?24 0?, ;he above Parties agree to be bound by the provisions of I agree that on the -4 20 day of _ 20_ the Resident shall be admitted to city, state, zip if Date . 2 a /1) Resident's Social Security Number Resident's Telephone Number Signed with a Mark Date a Mark Date Date Legal! s Address Co PA Legal Representative's Social Security No. Legal Representative's Telephone Number Rev, 03/13/03 Whi - Business Office pink - Medical Records Yellow - Resident 15 7d z cu z 0 479M 1101 Gollden Ventures JUL-23-2008 11:96 From: 01:26:49 p.m. 07-28-2008 To. BEI P. 3/9 Date Agent's Social Security Number Agent's Telephone Number d Date oil I contained on pages 1 through 16 of the Admission) 'al Records Yellow - Resident 5/16 0 IV in tL z R 479-201 1101 GoIlden Ventures Jl1L-23-2008 11:06 From: 01:27:01 p.m. 07-28-2008 To:BEI P.4/9 All claims based ' whole or part on the same incident, transaction, or related course of care or services prov?'ded by the cility to the Resident shall be arbitrated mi one proceeding. A claim shall be waived and forever barr if it arose and should reasonably have been discovered for to the notid'e of arbitrad n is given to the Facility or received by the Resident and such claim is not presented in the arbitration pr eedina. PARTIES WA1MG T OF JAW BE OR AWARD The Resident uni A.gr0ement, (2) t. furnishing of sen by Mitten notice thirt days, this , if the Resident is The undersigned explained to him/ that he/she is the agre4ment and ac Date- Signature: (Resi Witn'iess: If the resident is incotftpetence or r following: / Date: Relationship to R c? For Facility: Rev, 05/13/03 JNDERSTAND AND AGREE THAT THIS CONTRACT CONTAINS A BINDING PROVISION WHICH MAY BE ENFORCED BY THE PARTIES, AND THAT By O THIS ARBITRATION AGREEMENT, THE PARTIES ARE GIVING UP AND R CONSTITUTIONAL RIGHT' TO HAVE ANY CLAM DECIDED IN A COURT RE A JUDGE AND A JURY, AS WELL AS ANY APPEAL FROM A DECISION DAMAGES. stands that (1) he/she has the right t to sock legal counsel concerning this Arbitration execution of this Arbitration Agreement is not a precondition to admission or to the s to the Resident by the Facility, and (3) this Arbitration Agreement may be rescinded the Facility from the Resident within thirty days of signature. If not rescinded within tration Agreement shall remain in effect for all subsequent stays at the Facility, even charged from and readmitted to the Facility. tifies that he/she has read this Arbitration Agreement and that it has been fully that he/she understands its contents, and has received a copy of the provision and sident, or a person duly authorized by the Resident or otherwise to execute this d its terms. sable to consent or sign this provision because of physics( disability or mental a minor and an authorized representative is signing this provision, complete the ?Q 5 - Business Office Pink - Medical Records Yellow - Resident 6/16 X 0 z 479201 1101 GoIlden Ventures JLL-23-2006 11:07 From: Date AulbPl Print P.5/9 z x fR 0 Rev. 03%13/0 01:27:30 p.m. 07-28-2008 7116 479201 1101 GoIlden Ventures JUL-23-2008 11:67 From: 4. i R? -=-1;7, ?L ?I 8. _9. - r ?.? 10, I 01:27:39 p.m. 07-28-2008 To:BEI P.6/9 RESmENT-SPECMC FORMATION 'er Son e - This Facility accepts a following types of payments. Medicare [ edical Assistance ``'' V`,??a4 [CLs Administration KNO JEAGEMENTS - By signing the Admission Agreement Signature page, the 3en al Representative acknowledges that he or she has been given and has read this in its tirety, and all addenda. The Resident also acknowledges that the following was p vided upon or before admission by the Facility. Wtial the lines below (if not write A A ' t of supplies and services that are included in the Facility's private morttlily rate or t will be paid for by the Medical Assistance or Medicare programs and a list of supplies an services not included in the Facility's private monthly rate or paid for by the Medical As stance or Medicare programs for which the Resident will be separately charged about the Facility's bed-hold procedures. Al bet As As the CO] Av the I he XXW NOTICES Representative are The Resident desig provided to the Re Rev. of/13/03 Whit, I ;n explanation of how to apply for and use Medicare and Medical Assistance and how to receive funds for previous payments covered by these benefits. sent explaining that the Resident may file a grievance with the appropriate State about resident abuse, neglect, and/or misuse/theft of resident personal property in I>ty. of the State Resident Rights. explanation of the Facility's Rules and Regulations. a applicable, if your condition warrants, you may be placed in the Facility's .are-Certified Distinct Part Unit. At some point, circumstances may occur which will residing in another unit more appropriate for you. In that case, the Facility will is such a transfer with you. Under law, you cannot be discharged ffom this Facility you agree or unless, following an appeal, it is determined that you may be ntarily discharged or transferred. do not$- have an advance directive, been informed, both orally and in writing, in a language I understand, ofmy rights a rules and regulations governing my conduct and responsibilities during my stay at -ility. been given a copy and had an opportunity to review the Facility's Notice of Privacy :es. Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal sponsible for notifying the Facility in writing of any change of address. .tes the following person(s) to be notified when any legally required notices are lent, Agent, and/or Legal Representative. - Business Office Pink - Medical Records Yellow - Resident 11 8116 H Iz. O 479.201 1101 Gollden Ventures 01:28:11 p.m. 07-28-2008 9/16 JLL-23-2008 11:07 From: To:BEI P-7/9 A. 11 Legal Rep esentative And/Or Agent I Nam Homd Phon + e [ rIC Work Phone[ [ [ ]C J ] Street, City s to -'?-- State I B. ; Other Per on To ]Re Notified a Zip ? : Names > ? z HOMO Phone Work Phone[ ICI ][ II[]CHH][J _Z K14 Street{ C4ajLfte?0 P -.- ; i State ZIP , XXV.? MAM - Ac Facility is authorized to handle the Resident's mail as follows: (Check 02 box only.) f 1 All mail given ecrly to the Resident [ ] AM mail read to the Resident C ] F jrward $11 of a Resident's mail to. [ ] Give personal mail to the Resident; forward business mail to: i XXV) RESIDE 'S Pffmc AN A. Nth: B. SPI ECZALTX: C. AD, MSS: a i D. TE EEPHONE: Axvt RESIDE TRUST FUND AUTHORMAJION -A Resident Trust Fund is an amount of Mon held by the aciiity for the Resident's personal use. (Examples of use: To allow the resident to pay for to m and boar beauty shop charges, cigarettes, postal ?aPs. or other similar by the j esident.) signing below, the Resident authorizes the Facility to set up a trust fund in his/her desired name. i The individ al financial records shall be available through quarterly statements, and on request, to the Resident or hi er Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/13/03 Whi -Business Office Pink - Medical Records Yellow - Resident 12 • 479201 1101 GoIlden Ventures JUL-23-2008 11:07 From: 01:28:34 p.m. 07-28-2008 To:BEI P.8/9 shall be authorized by the Resident or his/her Agent or Legal Rept'esGnttative in writing. The following persogs may auth 'ze withdrawals on the Rea• ent's behalf Name lof Authoriziid Person Name of Authorized Person Date ifResidenj Signed with a k Date Legal Representative's Signatu/ Date (if applicable) Signature lif applicable) Date 10/16 z tZ. c? XXVUL CREDIT wouldlilce the con CARD AUTHORIZA QN - Facility accepts MasterCard and VISA. If Resident enience of paying amp s due each month through one of th needs informatio ese, please provide the and authorization: Credii Card i Account # Expiq'tion Date I i F hereby authorize Agreement: acility to charge t e account listed above for monthly charges incurred under this Resident or Agent Signature Date 'u If the esident is incompetence or i able to copse t or sign this provision because of physical disability or mental a manor and ' provision is being signed by an authorized the following: representative, complete -e l Date: l 0 Relationship to Resident: Signa? re: I Aut r ized Re resentative witness: For Facility: Rev. 0$/13/03 Date: Whi -Business Office Pink - Medical Records Fellow - Resident 13 4.79'201 1101 Gollden Ventures JLL-23-2008 11:08 From: Print P. 9/9 x co N_ Q i9 z w 0 «J i Rev, 03/13/03 01:28:54 p.m. 07-28-2008 11 /16 7d r? 479201 1101 GoIlden Ventures 41 Z Of 1 1045 RECORD OF ADMISSION we st Shoi+e Health and Rehab Ce Name; CRUM LINDA Mrs Admwba Date/ rime: , , . 06/22/2005 12:09 AM Addren: 416 EASE ST Gooder, Date of Butt: Femalo CARLISLE, PA 17013 Religion. Phone 1: 440800M Phone 3: Medicare Number: Primary Pay Saarm Social Sec 0: Medkald: HMO/lasurance State: Primary Ina.: MEDICARE Policy #: Secondary Ina.: Medicare Policy #: Tertiary Ina.: Policy #: Responsible Party: Notify In case of emergency or death Next of MR: Chnn, Robert MARTIN IUDY 4116 X East Street , Carlisle, PA 17013 Home: Relationahip: Office Homo: S : Spouse Cell: Otflcs: Cell : Next Of MR: Ne=t Of Kin: Home: Reiationshlo: Omce: Ceti: Primary Physician: Sams, Michael, Dr. 3544 North Propw Avg.,, Harrisburg, pA 17110, Alternate Pbysielan: 01:29:22 p.m. 07-28-2008 13 J1 6 09:02:06 a, m. 07-23.2008 215 8 of Admits: Client 1fE: Racathatcily. 1 40173 Whitenot Hispanic o Age: MasiW 3tatssn CidZeestiP: Married USA Prlnsary Lazwon=e: Medicine Part A: ?itrr Medicare Part B: Nudw Auft Contact: Antis. Con. ta- ? AutL Coataetr Relationship: Sistor Home: Rdadomtip: 0111ce: CeiL• Office: 717-652-8766 F= 717-545-4808 ODke: Faw Pager: Office: Fa:: Othe Pharmacy: r Ofllce: 1 800 994-6337. Fa:: 1800 543-08070ther: Oitlce: Fa:: Other: Allergies: PENICILIJN Admitting Diagnoses: HOSP QUAL STAY AT: FROM DATE: 5 OTHER SNF STAY: JIM FROM DATE: Rii1uw0 TO DATE: Discharge: Discharge to: Reason: Discharge Diagnoses: Name. CRUM, LINDA, Mrs. Current Location: Hedth Record #: Client #: INNa Vs. 'e; pmpm"Wft r --Jidk :;,ww.::4.:,;,WiWO MAO* , :r ? €aooawe•'sn OOGMWAV or" ., 479-201 1101 Gollden Ventures ? I L V/ I I V YJ 01:29:48 p.m. 07-28-2008 14 /16 W02:20 a, m. 07-23-2006 3 /5 wEC RD OF ADMtSSfON Naar; LIlrIDA. Mrs. Address: 6 of AdW112 C&M:Y; RaedLthuleityt 416 EASE ST dead" Date oi$irdk 1 40173 Age: Marital Stat.: Whitc,aot Hispmmjc 0 CARLISLE PA 17013 Oa: ?Ied Citireaship: USA , Phone 1: m Prf ' Lan", Phone Z: biedleare rq am w Medicare Part A Frhnw State arce: Boeial See lM: Medicaid: u I 3>it6 : Y Medicare Part g; Prlmery Iris M MICARg Palt?y#; '1/101NMM Noah Secondary Iasi Medlca:,r * AatTt, Contact: Tertiary Ins.: PO ' g0 Am% Caurtact: Poit?y N: Respowbis P . Notlly JA case of e Aatb, Contact: amrgeacy or ?4 Robert death 1 Next O?Kta: 4116 N. East Saner ? MARTIN, XTDY Culislc, PA 17013 I Rome: dwmwm? Reladotablp: 01lfee: Snoa9c HOW ReLttety?pt Next Of lCin: Om er: Call: S1s>Aa Nat Of XQL- Bonn: Omer Ralatlonaldpi Ofiiee: r $Olae: 10e1I: ' Ofttce: Rdatbashtp. t'Y Physidam 3 Michael Dr Can. , , 35441 Ave., a Hrri:bn PA 17110, Oman 7I7.6S3.g766 yam 7171545-950a Pacer: Alternate 1'hysidaas 01Fica: Fiat: Pager: Pharmacy: O1SCa; Fax: Other: Ogler 1800 994.6337 Fax.- 1800 543-08070thsr. Auergies: pENICUIM OiYieat Fa: Other: Adatttttag ?--- - 130" QUAL STAY AD TO DATE: FROM DATE: -+:acuersm 1),,Ch2r9e Diagooux; FROM DATE: O'1'RLR SNF STAY: TO DATE: mumarse to., Reason: )A. Mrs. C OCa ' Record ft C11aAt #t 911,i too/zoo'd tic-1 9aio eta !1,! U 4021 aHS?t.a?o,i ?ss?lo Soot-9a-des qA"mmvm)#A "0 .s. ? •a?s?MMr odw 479.201 1101 Gollden Ventures 01:30:15 p.m. 07-28-2008 15 /16 ?.?ul 1 IVY7 09:02:34 a.m. 07-23-2008 415 READMISSION AGREEMENT ? On On this / W .,day of ??- < the parties below a w day of the Resident shall be readmitted to this that on facility, ? Condn . n don Agr=ent: The Resident Specific Information section of the original Resident Admission Agreement dated -A' significant change. The terms of the on rtal a?' I ' L '?-' has been reviewed and there is no Information section of that agreementgis on file in the BusiscestOfor fficet available sfor review. All Residterms of tific. he original Resident Admission Agreement are incorporated by reference as though set forth herein. ec g men e: The Resident acknowledges that the following information was provided upon or before readmission to the facility. The Resident must initial the lines below to indicate acknowledgement: The option to open a Resident Trust Fund Account. If the payor source has changed since the last discharge, a list of supplies and services included in the daily rate paid by the new payor and those items or services for which the Resident can be separately charged. A copy of the facility policy regarding implementatiofl of the Patient Self Determination Act and of the applicable state law. I do do not have an advance directive. If your condition warrants, you may be placed in the facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the facility will discuss such a transfer with you. Under law, you cannot be discharged from this facility unless you agree or unless, following an appeal, it is determined that you may be involuntarily discharged or transferred. Resident Date Witness if Resident Signed with a Mark Witness It Resident Signed with a Mark Legal Representative Legal Representative's Telephone Number Agent Date Date Date 1eegal Repqsentativefs Social Security N& iL ?. Date Agent's Telephone Number - Age nt'sciai'S unit No. acility Administhtor or D ghee Date BE 202A (3193) White - Business Office Pink - Medical Records YeGuw -Resident ' 479201 1101 Gollden Ventures 4121J11 1045 RECORD OF ADMISSION Nom. West Health and Rehab Ce CRUM, LINDA, Mrs, Admiadon Dawnme: Address; 06/Z2/2005 12;09 AM 416 EASE ST Gender: Date of Birth: Female CARLISLE, PA 17013 Religion: Phone 1: Phone 2: M edit er: Primary Pay Scarce: !Social Sec Medicaid: HM0/1t?surance ` State; Primary Ins.: MEDICARE Policy Secondary Ins,: Medicare Policy Tertiary Ins.: Policy Responsible Party: Notify ht case of emergency or death Next Of Kin: Crum, Robert 4116 N. Fast Street MARTIN, JUDY Carlisle, PA 17013 Home: Relationship: Office: Home: spouse Cell: Office: Neat Of Kin: Cell' Neat Of Kin: Home: Relationship: Office: Home: Cell: Office: Primary Phydcian: Sams, Michael Dr Cell: , . 3544 North Progress Ave., ,Harrisburg, PA 17110, Office: 71 Alternate Physician: Office: 01:30:42 p.m. 07-28-2008 16/16 09:02:49 a. m, 07-23 -2008 515 8 of Admits: Client RaedE ty: 1 40173 Whitl,not Hispanic 0 Age: Marital Status: Citizenship: M USA i angnage: Primary E sh Medicare Part A: Medicare Part B Y : Number Auth. Contact: Auth. Contact: Autb. Contact: Relationship: Sister Relationship: Fax: 717-545-9808 Pater; Fax: Pager. Office: Pharmacy: Fax: Other: Office: 1 800 994-6337 Fax: 1800 543-08070ther: Allergies; PENIQLLIN Office: Fav Other: HOSP QUAL STAY AT: ?? OTHER SNF STAY: FROM DATE: desow ,M FROM DATE: ? TO DATE: dumomm" Discharge: Discharge to: Discharge Diagnoses: Reason: Name: CRUM, LINDA, Mrs. Current Location: Health Record ift _ Client #: tloup A%* WOW MmIl"m *Nft -44WAw" EXHIBIT 2 ro ro r A. r C'd o d C/) n l H H J r ttC'? O, m LEI H U7 J 13 r- C> co -- t) Id rb X, ooPCn r (D H 1 NO 3 ? co * h7 fT [?7 m ri o l N i'l .brom 1 roo 0 O u' n(D ?m ??y \ Y t* O ~ N ' cHnHN O N- 1 ro Czz x x otn3ym rnm G ' H ? n x` ?m 1 rn n???U' m n?? G? zH \ a? rn nY z ??ff n it ro rnrornrt aaro Ulromrraba0 w n n P. H-N r-a N t7 1 n t- r z ?'r*`C n n 0) Z m rt,< N 0) 0 r (D a m p W rt n x 3 Cy , ro .... ? 0 N• m " rt rt rr`G r10 N ?• H 0 rt J w t" (D m(D I I a .a ?c to J 0 ?D 0% rt O C'' w rrt rt m N O 'O r r_- ?hC'7 N 1 rpt0 rte H xK x 000 > m ?33 41 .?% n ;' C LXJ (] rt+ £viS N rtA?+•1 z iO r ° z (D (D g $ o n m EQ ' 1T1 W°° H .. .. .. .. H Lnn H y O O \ IP rKA .rl '? N 1 < CO o H H i W w \ ox0 ? to 1 ?' ? b7 \ y Cy ? 1 to N to L??iyJ W t H o m W ? t+] ?1 m 7. ' coo ? '?H OO H N N 5C b H O (Y) L ID Z, rt L=J Z \ N o Ln H rt K J N W 1 W \ Oo i%+ nro 0 z t °° ? n rn R, rr ttAl w i t-i I C •. :D 1 ri .??' K t' ? 7C 1 N ro ' o x ' ? ° n n n o V Parr O H O d N Lnnpa tn[n r?r nw? n no to rtw ntro C" W r rn roCnrta0 1.10 towrta0 w "yr?t m rt? rr'e n n m m rr?rt.? rt ty o d W~y ?? z r?O .. .. .. .. .. .. .. . .. .. H o r N co t7 m m W yQj , m r m 1 W J f'' [+7 1 rover OIn t? n rm • r ro x O tO Lo 1 NI,$ o? HW nro hi0N n mm um N N N .. m a ara ld° ? ? '° ? ? z O ro K I ?0Kn9N dd J oro $ Ww co nnnrmm n w a rororo ?• 1 rn o :3' rt ?, J 1 r o 1 ?' J J , (D rn N \ 1 w r t, o 1 01 m w w I \ I • 1 r %0 0) ON 1 N 1 I I I 1 1 tj 1 N• 0 1 W ? I 1 1 r I N• 1 n w ' 1 m o ' m o m ' at oo ; y% 1 ? I [rJ i r VERIFICATION The undersigned does hereby verify subject to the penalties of 18 PA.C.S §4904 relating to unsworn falsifications to authorities, that he/she is Yvonne Swartz , Collections Manager of Golden Living , plaintiff herein, that he/she is duly authorized to make this Verification, and that the facts set forth in the foregoing Complaint are true and correct to the best of his/her knowledge, information and belief. Date: S? o £? Yvo Swartz CERTIFICATE OF SERVICE The undersigned certifies that a true and correct copy of the within Amended Complaint in Civil Action was served on the,Fth day of August, 2008, by United States first class mail, postage pre-paid, addressed as follows: Nichole M. Walters, Esq. The Elder Law and Consumer Protection Clinic Dickinson School of Law Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 Weltman, Weinberg & Reis Co., L.P.A. arina Velter, Esquire Attorney for Plaintiff c? ? O C= -n rn CP m t;:S Nichole M. Walters, Esquire Attorney I.D. No. 84478 The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB, Plaintiff No. 07-342 V. ROBERT AND LINDA CRUM, CIVIL ACTION - LAW Defendants PRELIMINARY OBJECTIONS TO PLAINTIFF'S AMENDEDCOMPLAINT AND NOW COMES the Defendants, Robert and Linda Crum, by and through their attorneys, Nichole M. Walters, Esquire of the Elder Law and Consumer Protection Clinic of The Dickinson School of Law of The Pennsylvania State University, and sets forth as follows in support of these Preliminary Objections to Plaintiff's Amended "Complaint: The Plaintiff, Beverly Healthcare - West Shore Health and Rehab, is a company with its principal place of business located at P.O. Box 180970, Fort Smith, Arkansas 72918. 2. Plaintiff is represented by Weltman, Weinberg, & Reis, CO, L.P.A., located at 325 Chestnut Street, Suite 501, Philadelphia, PA 19106. 3. Defendants are Robert and Linda Crum, both adult individuals, residing at 416 North East Street, Carlisle, PA 17013. 4. Defendants are represented by the Elder Law and Consumer Protection Clinic of The Dickinson School of Law of The Pennsylvania State University, located at 45 North Pitt Street, Carlisle, PA 17013. 5. Plaintiff filed a Complaint against Defendant Linda Crum and Defendant Robert Crum. Plaintiff alleges that Defendant Linda Crum purportedly breached a contract because she failed to make payments on an account with the Plaintiff. Plaintiff alleges that Defendant Robert Crum owes money to Plaintiff's facility under the doctrine of necessaries. 6. Plaintiff's Complaint was served on the Defendants on January 22, 2007. 7. Defendants filed Preliminary Objections to Plaintiff's Complaint on July 3, 2008. 8. In response to Defendants' Preliminary Objections, Plaintiffs filed an Amended Complaint on August 7, 2008. PRELIMINARY OBJECTION PURSUANT TO Pa RCP 1028(a)(2) - FAILURE OF A PLEADING TO CONFORM TO LAW OR RULE OF COURT OR INCLUSION OF SCANDALOUS OR IMPERTINENT MATTER Failure to Conform to Pa RCP 1019(i) 9. Paragraphs 1 through 8 of Defendant's Preliminary Objections to Plaintiff's Amended Complaint are hereby incorporated by reference as if set forth at length. 10. Plaintiff's Amended Complaint fails to conform to a rule of law or Court in that it does not comply with Pa. R.C.P. 1019(i). 11. Pa. R.C.P. 1019(i) requires Plaintiff to attach to the Complaint the writing or material part thereof upon which the Complaint is based. 12. Plaintiff has attached what appear to be pages 11 through 15 of the Admission Agreement, however pages 1 through 10 have not been attached. 13. The pages attached by Plaintiff fail to set out any terms or conditions to which the Defendants allegedly agreed. 14. Defendant Linda Crum cannot possibly discern the terms of the written contract referred to in Plaintiff's Amended Complaint without viewing a copy of that contract. 15. Defendants cannot properly answer Plaintiff's Amended Complaint without having a complete copy of the "Resident Admission Agreement." WHEREFORE, Defendant Linda Crum respectfully requests that this Honorable Court grant Defendants' Preliminary Objections pursuant to 1028(a)(2) and require Plaintiff to produce a copy of the alleged written contract, or have its Amended Complaint dismissed with prejudice for failure to conform to Pa. R.C.P. 1019(i). PRELIMINARY OBJECTIONS PURSUANT TO Pa. R.C.P.1028(a)(3) - INSUFFICIENT SPECIFICITY IN A PLEADING 16. Paragraphs 1 through 15 of Defendant's Preliminary Objections to Plaintiffs Amended Complaint are hereby incorporated by reference as if set forth at length. 17. Plaintiff s Amended Complaint fails to state a cause of action upon which relief can be obtained. 18. Plaintiff s Amended Complaint is insufficiently specific to allow Defendants to properly answer. Defendant assumes that in Paragraphs 4 through 8 of Plaintiff s Amended Complaint, Plaintiff is purportedly alleging that Defendant Linda Crum breached a contract between Plaintiff and Defendant Linda Crum. However, the Amended Complaint fails to set forth the specific terms of the alleged contract it claims were breached. Instead, Plaintiff attached as Exhibit 1 an "Admission Agreement Signature Page" signed by Defendant Robert Crum. The Amended Complaint, together with Exhibits 1 and 2, fails to set forth any specific terms of the alleged contract. 19. Without knowing the specific terms of the contract that Plaintiff alleges was breached by Defendant Linda Crum, it is impossible for Defendant Linda Crum to form answers with regard to breach of contract allegations. 20. Plaintiff claims in Paragraphs 4 through 8 of the Amended Complaint that it is entitled to $17,518.16 for the goods and/or services which it provided to Defendant Linda Crum. The account statements provided by Plaintiff show the most recent balance of Defendant's account as $17,518.16, but it cannot be readily determined by looking at the account statement attached to the Amended Complaint that payments made on the account were properly credited to Defendant Linda Crum's account. WHEREFORE, Defendants request that this Honorable Court require the Plaintiff to amend its Complaint to: a) state a cause of action upon which Plaintiff bases its request for relief; b) specifically allege the terms of the purported contract; c) allege the specific charges (without disclosing personal information) and credits posted on Defendant Linda Crum's account to demonstrate how Plaintiff determined damages; or d) have its Amended Complaint dismissed for insufficient specificity. Respectfully submitted, Date: $ LI 0[:?_ Nichole M. Walters, Esquire The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 Attorney for the Defendants IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB, Plaintiff I No. 07-342 V. ROBERT AND LINDA CRUM, I CIVIL ACTION - LAW Defendants CERTIFICATE OF SERVICE I, Lyndsey W. Leatherman, Certified Legal Intern, certify that on this date I served the foregoing Preliminary Objections to Plaintiff's Amended Complaint by placing a true and correct copy of the same in the United States first class mail, postage prepaid, addressed as follows: Karina Velter, Esquire Weltman, Weinberg & Reis, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date: 1 Z f By: J *Lynsey W. L gatheman Certified Legal Intern Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 x -CI O. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff vs. ROBERT CRUM LINDA CRUM Defendants No. 07-342 SECOND AMENDED COMPLAINT IN CIVIL ACTION FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Karina Velter, Esquire PA I.D. #94781 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 WWR#05397059 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff vs. Civil Action No. 07-342 ROBERT CRUM LINDA CRUM Defendants NOTICE TO DEFEND NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claim set forth in the following pages, you must take action within twenty (20) days after this complaint and Notice are served, by entering a written appearance personally or by an attorney in filing in writing with the Court your defenses or objections to to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for money claimed in the Complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. AVISO LE HAN DEMANDADO A USTED EN LA CORTE. Si usted quiere defenderse de estas demanddeas expuestas en las paginas siguientes, usted tiene veinte (20) dias de plazo al partir de la fecha dela demanda y la notificacion. Hace falta asentar una comparencia escrita o en persona o con. un abogado y entregar a la corte en forma escrita sus defensas o sus objeciones a ]as demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso o notificacion. Ademas, la corte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisioner de esta demanda. usted puede perder dinero o sus propiedadas u otros drechos importantes para usted. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP: LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTA. SI NO TIENE ABOGADO O SING TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICO, VAYA EN PERSONA O LLAME FOR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ADAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. LAWYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 S BEDFORD ST CARLISLE, PA 17013 (717) 249-31665 SECOND AMENDED COMPLAINT IN CIVIL ACTION Plaintiff, Beverly Healthcare - West Shore Health and Rehab, is a corporation with offices located at P.O. Box 180970, Fort Smith, AR 72918. 2. Defendant Linda Crum is an adult individual with a last known address at 416 North East Street, Carlisle, PA 17013. 3. Defendant Robert Crum is an adult individual with a last known address at 416 North East Street, Carlisle, PA 17013. COUNTI BEVERLY V. LINDA CRUM 4. Pursuant to the Resident Admission Agreement dated June 20, 2005, and Plaintiff's Statement of Account dated July 6, 2006, and at the specific instance and request of Defendant, Linda Crum, Plaintiff provided certain goods and services to Defendant, Linda Crum, as more specifically shown by Plaintiff's Resident Admission Agreement and Statement of Account, a true and correct copy of which is attached hereto, marked as Exhibit "1" and "2" respectively, and made part hereof. Defendant received and accepted the afore-mentioned goods and services that were provided by Plaintiff. 6. The prices charged by Plaintiff were the prices that Defendant agreed to pay. 7. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and/or refused to pay the balance owed on this account.. 8. Plaintiff avers that there is a balance due and owing from Defendant in the amount of $17,518.16, as is shown by Plaintiff's Statement of Account attached hereto as afore-mentioned Exhibit "2", and made a part hereof. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Linda Crum, jointly and severally, in the amount of $17,518.16, and costs. COUNT II BEVERLY V. ROBERT CRUM 9. Plaintiff incorporates all preceding averments as if fully set forth at length herein. 10. At all times pertinent hereto, Defendant, Robert Crum, was the husband of Defendant, Linda Crum. 11. Under the doctrine of necessaries, Defendant, Robert Crum, is liable for payment of the outstanding balance for the services provided to Defendant, Linda Crum. 12. Defendant, Robert Crum, is liable to Plaintiff for payment in the amount of $17,518.16. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Robert Crum, individually, in the amount of $17,518.16, and costs. This law firm is a debt collector attempting to collect this debt for our client and any information obtained will be used for that purpose. WELTMAN, WEINBERG & REIS, CO., L.P.A. Karina Velter, Esquire PA I.D. #94781 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 215-599-1500 W WR#:05397059 EXHIBIT 1 To: BEI I i i RESIDENT ADMISSION AGREE NT ill-V2 (,W..t, To:BEI RESIDENT ADMISSION AGREEA?ENT Topic Table of Contents NONDISCRI ATION STATEMENT Pa e CONSENT FO TREATMENT 1 • Nursing Facility Services • Physici Services l • Right t Refuse Services I 1 PHOTOGRAP S 1 .. ARBPTRATIO 1 PRIVACY A NOTIFICATION STATEMENT l RESIDENT'S ERSONAL PROPERTY 2 • Safety Resident's Personal Proper • z Persona Property of Resident Upon Discharge 2 PERSONAL NDS 3 • Right t Manage Own Funds • Resides Trust Fund Authorizatio 3 n • Interest 3 • Accoun ng 3 • Medical Assistance Residents 3 Refund 3 Securit of Funds 3 3 THE RESIDE 'S DUTIES 4 • Facility' Rules and Regulations • Residen Grievances 4 • Diet 4 • Medicat ons 4 • Care of acility's property 4 ¦ Care of a Resident's Room 4 4 PROWB1T10 AGAINST THIRD PARTY GUARANTOR 4 AGENT AND/ R LEGAL REPRESENTATIVE 4 • Agent • Legal R presentative 5 5 S i To:BEI Table of Contents (Continued) PAYMENT I FORMATION 5 + Obliga i on to Pay Timely 5 • Credit and Charges 5 • Fee f Returned Checks 5 • Potentia l Personal Liability of Agent 6 " PRIVATE P RESIDENT 6 • Month y Rate 6 • Rate jusbnents 6 • Prima Responsibility for Payment 6 • Comm nicating Changes in Assets 6 • Discha ge of Resident 7 MEDICAL A SISTANCE PROGRAM RESIDENTS 7 • Applyi g for Medical Assistance 7 • Qualif ing for Medical Assistance 7 • Provid g Application Information and Keeping the Facility Informed 7 + Transf rring Assets 7 • Reside is Share of Cost 7 + Cantin ing Payment of Facility Charges Pending Eligibiliiy 8 • Daily ate Payment 8 • Termi tion of Coverage 8 • Design tion of Facility as Representative Payee 8 MEDICARE ESIDENT 8 • Medic a Coverage 8 • Limite Coverage 8 • Expira on of Benefits 8 + Coinsu ce and Deductibles 9 TRANSFERS D DISCHARGES 9 « Notice 9 • Reason for Discharge 9 BED-HOLDS 9 • Medic Assistance Residents 9 + Private Pay and Medicare Residents 9 RESIDENT'S RIGHTS AND FACILITY POLICY UNDER THO FEDERAL SELF-DETER INATION ACT 10 + Right t Make Decisions Regarding Care 10 • Right t Formulate an Advance Directive 10 r An Ad ante Directive is Not Required as a Condition of Admission Or Co n inued Stay 10 ii i To:BEI Table of Contents (Continued) CHARGES FO COPIES OF MEDICAL RECORDS rag. SOLE AGREE 10 ASSIGNA131L 10 INTEGRATIO 10 RESIDENT SP CIFIC INFORMA77OAr 10 PAYER SOUR ES 11 ACK.NOWL GEMENTS 11 NOTICES 11 MAIL 11 RESIDENTS SICIAN 12 CREDIT CA AUTHORIZATION 12 ADMISSION A REEMEAT SIGNATURE PAC 13 RESIDENT A FACIUTY ARBITRATION AGREEMENT 15 RESIDENT RI HTS UNDER FEDERAL LAW iii To:BEI WELCOME THAN YOU FOR GTIOOSING US FOR YOUR NURSIJ; G FACILITY CARE The staff of this F ity will take whatever time is necessary to answer ill of your questions about this Agreement. Befor. signing the Agreement, please continue to ask questions until you believe that you understand the Agiecinent. L NONDIS RIMINATION STAT1EMXNT - The Facility welcomes all persons in need of its services and does of discriminate on the basis of age, disability, race, 061or, national origin, ancestry, religion or sex. Ti e Facility does not discriminate among persons based on their sources of payment. D. CONSE FOR TREATMENT A. Nursing F cility Services - By sighing this Agreement, the R dent consents to the Facility attending physician. From providing routine ing and other health care services as directed by the son time to time, the F cility may participate in training programs for pers seeking licensure or certification as hea th care workers. In the course of this participation, wart may be rendered to the Resident by such 'pees under supervision as required by law. In addition, the Facility may use outside contractors to assL4t in providing routine nursing and other health we s6vices. Consent to routine nursing care provi ed by the Facility shall include consent for care by st ch trainees and contractors. B. Physician erviees - The Resident acknowledges that he or she (is under the medical care of a personal attending hysician and that the Facility provides services based on the general and specific instructions of this hysician. The Resident has a right to select his or h? own attending physician. If, however, the Resi emt does not select an attending physician or is unable to select an attending physician, an attending physi 'an may be designated by the Facility, or in accordance with State law. The Resident recognizes and agr that all physicians providing services to the Resid?rrt, including those designated by the Facility, are in ependent contractors. The Resident recognizes and hgrees that such physicians are not associates or ents of the Facility and that the Facility's liability, ffor !any physician's act or omission is limited. The Rea t shall be solely responsible for payment of all charges of any physician who renders care to the Resid in the Facility, unless the charges are covered by a third party payer. C. Right To for treatment. Tl or revocation of i the attending phy incompetent to tr made by a Legal ,efuse Services - The Resident has the right to refu Resident also has the right to be informed of the rr meet, and to be informed of alternate treatments a, dan or by judgment of a court of law, the Resident :e a decision regarding refusal of treatment, the do ,presentative or other surrogate decision maker, su treatment and to revoke consent ical consequences of such refusal fable. Where, in the opinion of determined to be mentally ion to refuse treatment may be wt to State and Federal law. III. P110TOC Resident as a mca also be used to he shall otherwise be purposes other du advance of such u APHS - The Resident agrees to allow the Facility t of identification or for health related purposes. Th locate the Resident in the event of an unauthorized apt confidential. If the Facility intends to use the pl those noted above, the Facility shall get written pei . The Resident retains the right to refuse the taking photograph or videotape the photographs or videotapes may absence from the Facility, but otograph or videotape for mission from the Resident in of a photograph at any time, IV. ARBITRATION -- The Resident acknowledges that disputes under this Agreement may be submitted to arbitr tion, if the Resident elects to do so, by signing a separate agreement executed From: rllected will be entered into the Long-Teem Care It System No. 09-70-1516. Information from this s! ices, to: (1) a congressional office fi om the record angressional office made at the request of that indi 'Justice; (4) an individual or organization for a res+ :he prevention of disease or disability, or the restoz abuse; (6) an agency of a State Government for d ided in the State; (7) another benefits program fimi fraud or abuse; (8) Peer Review Organizations to ices for preventing fraud or abuse under specific o between the parti . Agreeing to arbitration is not a condition of admission or continuing care. V. PRIVACY A NOTFICATION STATEMMNT - Skilled nursing facilities who contract with the Medicare and M 'cal Assistance Programs (hereinafter referred to as `Medical Assistance Program" or "Program") are uired to conduct comprehensive, accurate, standard}zed, and reproducible assessments of each resident's nctional capacity and health status. As of June 22,;1998, all skilled nursing and musing f Ldlities required to establish a database of resident assessment information and to electronically trf,tn9 it this information to the State. The State is then z?cquired to transmit the data to the Federal Central cc Minimum Data Set (MDS) repository of the Ceiters for Medicare and Medicaid Services. These are prote cted under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Carte s of Records. `fhe Center for Medicare and Medicaid Services is authorized to collect these datSections 1819(1), 1919(1}, 1819(b)(3XA) and 1864 of the Social Security Act. The purpose oft data collection is to aid in the administration of tht, survey and certification of Medicare/Medi Assistance long-term care facilities and to study the effectiveness and quality of care given in those fi ' sties. This system will also support regulatory, reimbursement, policy, and research functions. This stem will collect the minimum amount of personal d to needed to accomplish its stated purpose. The information c system of rocords specific circurmsta inquiry fl om the ( the Department o project related to to detect fraud or care services pro, funds or to detea functions; (9) ser You should be permits the goy Collection of the result in the loss of information to For nursing hom requested inform given in certified not submit the to VL A. Safety O valuable jewelry, Facility shall ma) chooses to keep personal properp brought to or rer To:BEI mum Data Set (LTC KIDS) m may be disclosed, under an individual in response to am aal; (2) the Bureau of Census; (3) ;h, evaluation, or epidemiological >n of health; (5) analyzing data, or iveness, and/or quality of health In whole or in part with Federal form Title M or Title XVM are that P.L. 104-643, the Computer Matching and privacy Protection Act of 1988, invent to verify information by way of computer matches. social Security Number is voluntary; however, failure to provide this information may f Medicare benefits. The Social Security Number w;ll be used to verify the association he appropriate individual. residents residing in a certified Medicare/Medical Assistance nursing facility the tion is mandatory because of the need to assess the Wectiveness and quality of care acilities and to assess the appropriateness of provided services. If a nursing home does uired data it cannot be reimbursed for any MedicarWedical Assistance services. PERSONAL PROURTY Resident's Personal Property - The Facility stroq rapers, large sums of money, or other items conside reasonable efforts to safeguard the Resident's prof i his or her possession. The Resident agrees to info upon admission. If, at any time during the Residem owed from the Resident's possessions in the Facility, discourages the keeping of I of value in the Facility. The ly/valuables, which the Resident i the Facility in writing of all stay, new items of value are re Resident also agrees to so From: To : BEI inform the Facility E*ecutive Director or designee. R. Personal P perry Of Resident Upon Discharge - The Facility hall make reasonable efforts to safeguard the Reside 's personal belongings after discharge. The Facility however, shall not be liable for any damage to or to of the Resident's property. The Facility may dispose of any property left by the Resident if not claim within thirty (30) days of discharge or transfer, orin accordance with applicable State law. VII. PERSONAL FUNDS A. Right To M sage Own Funds - The Resident has a right to in e his or her own personal funds. If the Residen wants assistance with the management of persona ds, the Facility shall assist if requested to do so i writing. B. Resident Tr st Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. i C. Interest - Th Facility shall deposit funds in excess of Fifty Dollars ($50,00) in an interest-bearing account insured by a Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. l interest earned on the Resident's funds shall be cited to the Resident's account. The Facili shall have the option of depositing funds of less than Fifty Dollars ($50.o0) in one of the following: a n n-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform a Resident as to how his or her funds are being held, The Facility's policy is to maintain all Rtsident funds in a separate account, except for a nominal an;ount maintained in a petty cash fund for the Residerit s convenience. A. Accounting The facility shall have a system that ensures a complete and separate accounting based on generally ac , cepted accounting principles, of the personal funds deposited with the Facility by each Resident or on s or her behalf. This system shall also ensure that the Resident's funds are not commingled with th Facility's funds or with any other funds besides thus Q' of other Residents. In addition to the requi quarterly accounting, the Facility shall provide indual financial records at the written request of th Resident. E. :?Acal Ass stance Residents - The personal fund balances of R? sidents who receive Medical AssistaProgant nefits must remain within a certain dollar range toiatisfy State and Federal laws. The Facility shall n a Medical Assistance Program Resident if his or er account balance is within Two Hundred Doll (5200.00) of the Federal Supplemental Security Ingomie (SSI) limit, The Facility shall also notify the esident if the account balance, in addition to the Resident's known anon-exempt assets, reachts the S I resource linniit. A, balance in excess of this limit may! cause the Resident to lose eligibility for Medi Assistance or SSI. F. Refunds - If Resident who has personal fiords deposited with the Facility expires, the Facility shall refund the Resi etrt's account balance within thirty (30) days and provide a Rill accounting of these funds to the individ probate jurisdiction administering the Resident's etate, or other entity or individual, as require by State law or regulation, Upon discharge, the balance of funds in the trust account shall be pro tly refunded in accordance with the Facility's Refutd Policy that is available for review in the Facili s Business Office, To:BEI G. Security of Funds - The Facility shall ensure the security of all pe6onal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance > rogratn Resident's personal funds for any item or service for which payment can be made under the Ptagrams. VTIL THE RES NT'S DUTIES A. Fachity's R les And Regulations - The Resident agrees that the Facility may, to maintain orderly and economi operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of th Resident. The Resident agrees to follow those tole and regulations and hereby acknowledges that h or she has been given a written copy of such rules and regulations. It is understood that the rules and lotions may be amended froth time to time as the Facility may require, Any changes to the rules and re ations shall be given to the Resident in writing. B. Resident G evanees Residents are urged to bring any grievanci concerning the Facility to the attention of the Faci Exec itive Director or desipce. The Facility aW offers a tall-free "Hotline" telephone number th- ough which grievances can be registered anonymously. This number is 1-800-572- 9981. Residents al have the right to contact the State Facility licensingi agency, the long-term care ombudsman, or ba to register grievances against the Facility. C. Diet - The ident understands that his or her diet is medically prescribed and, therefore, must be monitored by the acdity. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages br into the Facility for the Resident's benefit. I D. Medieatio - No medications or drugs may be brought upon Facility premises unless the medications or drug are labeled according to the requirements of State 6d Federal law, Packaging of medications must compatible with the Facility's medication distributiol system. All drugs or medications brough into the Facility shall be immediately delivered to the nurses' station. E. Care Of Fa ility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to u se due care to avoid damaging the Facility's property and premises. The Resident shall be responsible or repair or replacement of the Facility's property damaged or destroyed by the Resident. However the Resident shall not be, responsible for such damage as is to be, expected from ordinary wear and t ar. F. Care Of Th Resident's Room - The Facility encourages the Resident to have a home-like environment and 1 attempt to accommodate all reasonable requests toiindividualize Resident rooms. Fox safety reasons, he Facility must concur with any addition or rearrangement of fn-niture, hang of pictures, posters, o other similar activities. IX. PROHIB ON AGAINST THIRD PARTY GUAPWNTOR -1?EDERAL AND STATE LAWS PROHIBIT A TNG HOME FROM REQUIRING A THTRb PARTY GUARANTEE OF PAYMENT TO FACILITY AS A CONDITION OF ADM1<SSx N, EXPEDITED ADMISSION OR CON'T'INUE STAY IN THE FACILI'T'Y. HOWEVE14 A F CILITY MAY REQUIRE AN 1 5 INDTVIDUAL O HAS LEGAL ACCESS TO THE RESIDEN S INCOME OR RESOURCES AVAILABLE TO AY FOR FACILITY CARE TO SIGN A CONT CT, WITHOUT INCURRING PERSONAL FIN CIAL LIABILTFY FOR THE RESIDENT'S C(?STS OF CARE, TO PROVIiDI? FACILITY PA N'T` FROM THE RESIDENT'S INCOME OR RESOURCES. To:BEI X. AGENT AND/OR LEGAL REPRESENTATIVE A. Agent - Tor he purposes of this Agreement, an Agent is a personjwho manages, uses or controls fiuads/assets that ma be legally used to pay the Resident's charges or whd otherwise acts on behalf of the Resident. The Agen 's financial obligations are limited to the amount of tite funds received or held by the Agent for the Reside at. The Agent assumes no responsibility to pay for toe costs ofthe ResidenWs care out of the Agent's onal funds. However, as a necessary party to this ,Agreement, the Agent is contractually bouniAEnNT e terms of this Agreement and may become person-ally liable for failure to perform duties ane Agreement. If the Agent has control of or access to the Resident's income and/or assess, the agrees to use these finds for the Resident's welf ? e. The Agent is raquired to produce financial entation as proof of the Resident's ability to pay for charges when due and to make prompt payor care and services provided to the Resident as specified in the terms of this Agreement. THE IS REQUIRED TO SIGN THIS AGREEMENT AND AGRFXS TO DISTRIBUTE TO pACII.iTY, FROM THE RESIX?EI rs IN ME OR RESOURCES, PAYMENT WHE DUE FOR THE ITEMS/SERVICES PROVIDE, TO THE RESIDENT. Wherever this Ag ment refers to the Resident's financial obligations udder this agreement, "Resident" shall be construed to include not only the Resident, but a, o the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized u der State law as having the authority to make healthcare and/or financial decisions for the Resident. Legal Representative mayor may not be court appointed, A Legal Representative may be an attorney-ii -fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of 'n, or other person allowed to act for the Resident under State Law, If Legal Representative state has been conferred by a court of law or through appointment by the Resident, copies of documents erifyintg such status must be provided to the Facility at the time of admission. XL PAYMENT INFORMATION A. Obligation a Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These harges are due and payable by the tenth (1 Oth) day f each month or, in the case of a notice of a rate c ge, within ten (10) days of mailing of the notice. If payment is W received timely, the account balance ' considered past due and the Facility may add a late charge to the Resident's account. 'I'bis late c e shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one- f percent) or the maximum amount permitted by 1#, This We charge does not alter any obligations f the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any air uat due the Facility is grounds for discharge of the I esiderrt from the Facility. If a Resident is required o vacate for failure to pay, the Facility shall provide ?ddvance notice as set forth under the Transfer ax ? Discharge section of this Agreement. a B. Credit Card Charges - The Facility accepts MasterCard and VI$A. If the Resident would like the convenience of p aying amounts due each month through one of these pptions, the Resident must provide the needed ' ormation and authorization on the Credit Card Authorization form at the back of this Agreement. The , Resident recognizes that, unless the Resident has authorized the use of MasterCard or VISA, the Facilit does not offer credit or accept installment payments The Facility's acceptance of a partial payment does inot limit the Facility's rights under this Agreement. '. C. Fee For Ret#rned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank,lwhichever is greater, will be charged for any returneld check. To:BEI D. Potential Ittersonal Liability Of Agent -Agent (includes any I.?egal Representative serving as the Resident's Ag t) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent o any payments or funds of the Resident which are available to pay for the Resident's care, which the rn withholds, misappropriates for personal use, or o Zt, wise does not turn over to Facility for p of Resident's financial obligations under this or an amount equivalent to revenue lost by th Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re- ination process as required under this Agreement.! X11. PRTYATI*PAY RESIDED TS - A Resident is considered priv?e pay when no State or Federal program is paying or the Resident's room and board- Private Pay Aesid, nts may have private insurance or another third p*ty which pays all or some of the Resident's charges. A. Monthly .ate - The Facility's private pay monthly rate is deter niried in part by the type of room assigned- For this eason, the rate may change if the Resident moves tol a different type of room. The Resident agrees toi pay the facility, on or before the day of admission, an amount no less than the first full month's room and and charge at the private pay monthly rate. For 4h additional month's stay, the Resident agrees t pay the Facility in advance on or before the tenth (1") day of the month. Any MM WA advance p ymetrt shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Progra or leaves the Facility before the end of the month. ?n this case, the Resident shall be refunded a prorat daily room rate based on the total number of days ih the calendar month during which the stay s. The Resident will be provided with a general HO of supplies and services included in the Facility's athly private pay rate and those supplies and service] which are, not covered by the monthl'T vate y rate for which the Resident will be separately charged. A, more detailed list of charges suppli and services not covered by the monthly private pay rate is maintained in the Business Office d is available for review during normal business hour. B. Rate Adj eats - The Facility shall provide advance writteni notice of any monthly rate adjustment. How r, if at any time the Resident's condition requires t6ie Facility to change the room or level of care, the esident's monthly rate may be changed without priof notice, unless such notice is required by State aw. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement, y rate increase shall be considered as agreed to by 4 parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the R dent does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day efore the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for tic duration of the Resident's stay. C. Primary responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges the Resident remains primarily responsible for paying all Facility charges, including any charges not cov fed by a third party payer, unless expressly prohibited'by a contractual agreement between the FacU ity and payer. Non-covered c1mges may include any 10insurance and/or deductible amounts requiredlby athird party payer. D. Commu ating Changes in Assets - It is essential for the Usident to communicate to the Facility any chan in the Resident's assets or resources within ten (10) days of knowledge of the changes in financ al status. Upon request by the Facility, the Resident ihall provide the required information to th? Facility within ten days. If the Resident runs out o0private monies, it is important to locate alteniativelpayment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funs are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengoy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of bring reduced to an amount that,;, when combined with the To, BEI Resident's monthly Resident's private 1 the Resident, the Fi E. Discharge the Resident chant unless the Facility XW. MEDICAL Resident is one whc her Room & Board provided by the Fa( Assistance. A. Applying will be covered by source. The Facilii any claim relating B. Qualifying requirement is met Program, the Resid actions must include Resident's applicati appropriately spent Medical Assistance of eligibility so that C. Providing agrees to provide i application and of deadlines. The Re assets provided is communication be of the status and p any information rte eligibility re-deten ncorne, is no longer sufficient to pay for the cost of Bare and services, if the ads are exhausted during the Resident's stay, and N ?A-"caid payment is available for ,ility shall accept Medicaid payments on behalf of the Resident. T /Resident - The Facility shall not transfer or evict tee Resident solely as a result of g his or her manner of payment from Private or Medicare to Medical ,Assistance, not certified for Medical .Assistance. i ASSISTANCE PROGRAM RESIOD ENT - A I+?e cal Assistance Program receives benefits from the State Medical Assistance rogram for a majority of his or charges. The Program may or may not cover charges for additional servicestitems lity, depending on State law. Medicaid eligibility is i requirement for Medical r Medical Assistance - The Facility makes no guartatee that the Resident's we edicare, Medical Assistance, or any third party insurance or other reimbursement its agents and associates are hereby released froth any liability or responsibility for the failure to obtain such coverage. 'or Medical Assistance - The Resident should learnd, if the Medicaid eligibility the time of admission. If the Resident elects eoverfge under the Medical Assistance at agrees to act as quickly as possible to establish and maintain eligibility. These but are not limited to: (1) timely completion and submission, if applicable, of n, and (2) taking any and all steps necessary to ensue that the Resident's assets are lown and maintained within the allowable limits. Th Resident agrees that the Mice may release to the Facility any information sub?riitted by the Resident in pursuit he Facility may assist with and ascertain the status of the application process. ,pplication Information And Keeping The Facility Informed - The Resident of the information necessary for completion of the Medical Assistance Program iy subsequent Program eJigibilicty re-determinations in compliance with the Program dent certifies that any financial information regarding the Resident's income and implcte and accurate. The Resident agrees to keep ti a Facility informed of all men the Resident and the Medical Assistance agencY'? no less often than weekly and egress of the application. The Resident agrees to provide the Facility with copies of %sary for the appropriate State agency to process thF application and any later nations. g Assets - If the Resident transfers assets, this transfer may disqualify the Resident ice and/or cause a diagan 'nuance of the Resident's Program benefits. The Resident his may result in charge to the Resident for services oot paid for by the Program of the Resident due to non-payment, D. `I"ransferrir for Medical Assista acknowledges that and/or in discharge E. Residenes income of all Medi to pay for a reason Patient Liability, P; the Resident. The Resident's Share o Share of Cost - The Medical Assistance Program reiiews the available monthly al Assistance applicants. As a result, most Medical Assistance Residents are required ,ble share of the cost of their care, referred to as Shane of Cost, Private Portion, beat Resource, or similar designation. Payment of that share is the responsibility of sate can change the Resident's share of cost at its discretion. Changes in the 'Cost must be communicated to the Facility on a timely basis. To:BEI .."' F. Continain Payment of Facility Charges Pending Eligibllityl - When an application for Medical has been filed, the Resident agrees that while the Resident's application is "pending," the Resident's eati tad Share of Cost shall be paid to the Facility on or: before the tenth (14th) day of each month. Once the Resident is determined to be eligible for Medicalsistance, the Resident's Share of Cost shall be p d to the Facility on or before the tenth day of each uth. If the Resident is retroactively appr ved for Medical Assistance, previous payments mad4 by the Resident which are covered by Medial Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be re", ed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is fished by Medical Assistance, failure to pay the S> are of Cost may result in the Resident's disc a from the Facility. G. Daily 1R04 Payment - On admission, the Resident shall be provided with a list of supplies and services generally Oaid for by the Medical Assistance Program, and thole supplies and services not paid for by the Progritir for which the Resident will be separately charged. k detailed list of charges for supplies and servi available in the Facility, but not covered by the daffy rate, is maintained in the Business Office an, is available for ;review during normal business hour9. 13. Termination Of Coverage -- A Resident who remains in the F lity after Medical Assistance coverage has exp or been retroactively terminated or denied must py Facility charges as a Private Pay Resident. In t is event, the Resident shall be charged based on the private rates, charges and terms in ef'm at the time Cif service. L Desigsratl n Of Facility As Representative Payee - Resident tid Agent agree that, in the event the Resident a delinquent in payment of the share of cost Wig at- n; Resident shall arrange for the designation of the aciiity as "Representative Payee" of the Resident foE any Social Security related benefita or other ' me sources of the Resident. Payments made from r ch income sources shall be applied to the Rem 's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from Resident's funds, the Facility may also notify the'ppropriate State or Federal agency of this non yrxrerit. XIV. MEDXCA RESIDENT - A Medicare Resident is one who r?ceives benefits from the Federal Medicare Progra for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare overage - On admission, the Resident shall be provided with an oral explanation and a written list of su lies and services generally paid by the Medicare program, and those supplies and services not paid f r by the Medicare program for which the Resident v?ill be separately charged. A detailed list of c ges for supplies and services available in the Facility but not covered under the Medicare progr 1 including the daily coinsurance rate, is maintained in, the Business Office and is available for revs during normal business hours. B. Limited Coverage - Medicare coverage is established by Fed guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of ce is covered for a specified number of days (b efit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended befo , the use of all allotted days in the current benefit peu'iod, C. Expiration Of Benefits -- When Medicare coverage expires, th4 Resident may remain in the Facility if private ply or other payment arrangements have been made. if the Resident wishes to be discharged from t* Facility upon expiration of Medicare benefits, he or; she must so advise the Facility at the time of the Rodent's admission or readmission. If the Resident int?nds to become private pay when To:BEI Medicare benefits ' pine, the Resident agrees to pay in advance for one month's room and board at the private pay montht rate when the Resident changes to private pay statt s. With the exception of the private portion, if pplicable, no advance payment is required from Mc4care Residents who convert to Medical Assistanc4. D. Coinsurs4e And Deductibles - The Resident is responsible fob payment of any Medicare coinsurance and/od deductibles except as covered by the Medical Assistance Program for dually eligible residents. X.Y. TRANSFZRS AND DISCHARGES A. Notice - Oe Facility shall give notice to the Resident and, if kn a family member or Legal Representative of a Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be en at least thirty (30) days prior to the Resident's rwWs r or discharge. in cases where the safety orl heft of the Resident or other individuals in the F 'ty may be endangered or if other legal reasons ?exist, notice may be given as soon as practicable bef transfer or discharge. The reason(s) for the tirinsfer/discharge shall be provided at the time of notiof transfer/discharge. Notice will also include injl rznation regarding the right to appeal a transfer/di wge. B. Reasons fvl• Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it . necessary for the Resident's welfare and the R?ident's needs cannot be met in the Facility. The Resi ent may also be transfetred/disc ed because the Resident's health has improved suffiraently so the Resident no longer needs the services rovided by the Facility. The Resident may be tram discharged because the safety of individual in the Facility is endangered or because the health o, individuals in the Facility would otherwise be to ered. The Resident may be transferred/discharged ?ecause the Resident has failed, after reasonable appropriate notice, to pay for (or to have paid underr Medicare or Medical Assistance) a stay the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVL BED-ROTS - In the event that the Resident is ternporarily abient from the Facility for hospitalization or erapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this timi. This is known as a "bed-hold." The Resident and family member or legal representative shall'be given written notice of the bed-hold option at theltime of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid fdr under the Medical Assistance Program, the Progran may pay for a certain number of bed-hold days. if the Resident's therapeutic leave exceeds the bed-ho d period paid for under the Program, the Resident may request an additional bed-hold period from the Ta cility by agreeing to pay the applicable daily rate. Otfieerwi3cc, the Resident shall be readmitted upon the first availability of a bed in a non-private room as lc'ng as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private ra$ and Medicare Residents- Any Private Pay or IvMe4icare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program floes not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for a certain numberof bed-hold days. Otherwise, a Private Pay or Medicare Resident requesting a bed-hold must pay the Facility's prorated private monthly rate during the bed=hold period. To: BEI XVII. RESIDENbrS R><GHTS AND FACILITY POLICY UNDER THE FEDERAL SELF- DETERMINATIbN ACT A. Right To regarding ake Decisions RegardiinEg Catre -The Facility reco? aizes the right of each Resident to make decisions his or her care. Where a Resident is incompetent, the Facility recognizes the Resident's right to ?uhve these decisions made on his/her behalf by a sub$titute decision maker in accordance with State law. B. Right To )formulate An Advance Directive- The Facility recci?y kes the right of each Resident to have an adv=c4 directive and will honor advance directives devel*-d in accordance with State law and consistent with the level of care the Facility is licensed to provide. *n advance directive is a written document that stags choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will And a Durable Power of Attorney for Health Care art examples of advance directives. Questions about tin Facility's policies regarding health care decisio fi-making and/or advance directives may be presente4 to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's fannily, physician and/or attorney. C. An Advauiee Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to c ntinue to reside in the facility. However, if the Resident has an advance directive, he or she must maki it known to the Executive Director or design#e so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at th time of admission, the advance directive informationh shall be provided to fancily members or other esident representatives. However, if the Resident litter regains competency, the Facility will provi , such information directly to the Resident. XVIIL CHARGES FOR COPIES OF :MEDICAL RECORDS -T* Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charged in the Fac. lity's community. XIX. SOLE AG?MVMENT- This Agreement is the only Admission Agreement between the Facility and the parties. Changes to this Agreement are valid only if trade in writing and signed by all parties. If changes in State oi Federal law snake any part of this Agreement invalid, the remaining terms shall stand as a valid Agrecm4nt. XX. ASS1GNA0111TY -'Me right of the Resident to reside at the facility is personal and not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. XXL INTEGIRA.'i ION - The parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, promises, understa? dings, and agreements between the parties, whether written or oral, and therefore they are of no furthe j force and effect. Because this is a fully integrated ag> eemern, the only discussions, statements, represents ions, promises, understandings, or agreements that arse or will be binding on any of the parties to this Agreement or their employees, affiliates, contractq rs, agents, or representatives are those expressly setifarth in writing in this Agreement, or in other written: agreements entered into at the same time as, or subsequent to, this Agreement. To : BEI I 4 RESIDENT-SPECIFIC 1NFOR,MA`[IiON XXn. Payer Sources - This Facility accepts the following types of payments: [ ] Private ] Medicare [ ] Medical Assistance [ j Veterans Administration XXIII AC"O >gI?GEMENTS - By signing the Admission Agrejemernt Signature Page, the Resident/Agen gal Representative acknowledges that he or she has?n given and has read this Agreement in its ntirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility, ln4ial the lines below (if not applicable, write */A): 1. A fist of supplies and services that are included in the Facility's private monthly rate or th4t wilt be paid for by the Medical Assistance or Medicare programs and a list of supplies an services not included in the Facility's private monthly rate or paid for by the Medical A4istanee or Medicare programs for which the Resident will be separately charged c 2. Infbrination about the Facility's bed-hold procedures. 3. A written explanation of how to apply £or and use Medicare and Medical Assistance be*efits and how to receive funds for previous payment covered by these benefits. 4. A ement explaining that the Resident may file a grieiance with the appropriate State Ancy about resident abuse, neglect, and/or misuse/theft of resident personal property in the Facility. 5. Co'ipics of the State Resident Rights. ---6. A *,ritten explanation of the Facility's Rules and ReguWions. 7. 4di re applicable, if your condition warrants, you may bj placed in the Facility's ' e-Certified Distinct Part Unit. At some point, circumstances may occur which wilt e residing in another unit more appropriate for you. ! In that case, the Facility will such a transfer with you. Under law, you canno? be discharged from this Facility uni ss you agree or unless, following an appeal, it is determined that you may be in luntarily discharged or transferred. 9. 1 dir do not have an advance directive. 9. 1 hive been informed, both orally and in %Titing, in a lanSuage I understand, of my rights an the rules and regulations governing nay conduct and,responsibilities during my stay at thelFacility. 10. I hAve been given a copy and had an opportunity to review the Facility's Notice ofNvacy XXIV. NOIUCEI - Notices shall be mailed to the address (es) indicate! below. The Agent and/or Legal Representative ar responsible for notifying the Facility in writing of an? change of address. The Resident designates the following person(s) to be notified when and legally required notices are provided to the Resident, Agent, and/or Legal Representative. Rzv. 03/13/03 NN hik Business Office Fink - kledical Records 'Velkrw - Resident X CP col z z Q 41 2871 1 040 beverly northeast cbo RISIoeff OMRM PROFILE Lid A eft" g? Sm DO ibaA?dlw ua. w 45Os4 S,"L AIcle IdW 17-O/ t?loauT p e (3twdcw. 0 tM.dodd p VACaard )kO& NeliarGlwrtdrCwedtMir?IMdfealat Na 6MAATOLvCWOFSTAY: Q$ASO JSdW 30-INdip QLafTim DOYarNr?Te lnM& :i s r;iofnchmmv s ? CA* im uww s SWk s p s C.rncM. a a? ? Te/1 raN ACa01/M? s t«?Md.Mth?M+tai?t_, ? ,.,n..era-.e?e? A .00,ndMIbrieOwed /?? hw t h?l?l(4taeaMae Ridro? QrCw Ouc?tpra? NrsVIXIW WKaMmW,aSWAM&iaw LdxMu" 0ri rK Mbi. DdC"PdA11M ihWrMedV?be Tpyyiq„ l RECORD OF ADMISSION Wee gham Health sad Retuh Ce Name: Admiaslon DatdlYmee f/ of Admits: 1 Client fl: RacWZthdcity: CRUM, LINDA, Mts. 06122/'2005 12:09 AM 1 40173 Whise not Hbpuk o Address: Geodes: Data ollghlb: Ater M64W States: Cith:enthip: 416 EASE ST Female 4W Matriod USA fin PLanguor Pr iam" . CARLISLE, PA 17013 Engim Phone 1: •?3 momem Number: Medleam Part A: Medicate>Part 3: Phone 2: Y Ali iMM Prieanary Pay Soarte: Social Sat Modtadd: HMO/Itmtnaoce 1Mftifi/?? State: Number Primary Ina.: MEDICARE Pocky it: 4EWW1i Aath. Coutsct: Secondary W- Medicare P0&T #k a AntlL Contact: Tertiary Im.: Policy d: Auto. Contact: Resp usibte Party: Notify In case of emergency or death Nett Of Kin: Crum, Robert MARTIN, JUDY 4116 N. East Street Carlisle, PA 17013 Home: W Relationship: Homer eHlvomm ser Relationship: Office: Spouse Office: Sister Celh Cell: Next Of Kin: Next Of Kin: Home: Relationship: Home: Of& Relationship: OtRa: COL. x Cell: Pr[mary Physician: Seam, Michael, Dr. OtSce: 717-652-8766 Fax 717-545-4808 Parer: 3544 Nordt Progteas Ave.,, Hsrr *w& PA 17110, Alternate, Physician: Ofllte: Fat: Pager: Office: Fat: O ther: Pharmacy' Office: 1800 994-6337. Fax- 1800 543-08070tber: OtEce: Fat: O ther. Alkrrta: PENICILLIN Admitting Diatetosa: HOSP QUAL STAY AT: HARRIS FROM DATE: 06/06/2005 OTHER SNF STAY: Yes FROM DATE: 02/1812005 TO DATE: 04/1812005 Dheharre: Diwbwp to: Ressoa: Discbarre Dlarooses: Name: Current Location: Health Record 0: Client t. CRUM, LINDA, Mm 0285-001-2-00246-2 373 40173 To:BEI _ x f ADMSSION AGRXEMENT SIGNATURE PAGE XXVL PAR S - The parties to this Agreement are: (Name ofFad ' (Name of Restdeat) (Nape of Resid 's Agent) (Nam o Resident's Legal Representative) If the Legal Repre ntative signs the Agreement, check the Type of IA:Sal Representative (below): [ ] Conservator o Parson j ] Guardian [ j Durable Power of Attorney [ ] Agent Acting [ ] Conservator o Estate for Health Care (DPAHC) Under General CY?her, specify POA If yo ! are signing his Agreement on behalf of the Resident, note your relationship to the Resident: My tlationship t the Resident is ?2C2t1.g, On tlis -41A d, r of _ 20 he above Parties agree to be bound by the provisions of this ASreemcnt an I agree that on the ,42D-day of j t K ! • 20?, ?thc Resident shall be admitted to this F?acdity. Resiftt • 1 Date '1111" IV. &-a!q sdsjiga?- Address Resident's Social Security Number city, state, zip Resident's Telephone Number Witness if Resider Signed with a Mark Date W' s If ResidSigned with a Mark Date Lpresetaft epre c Date G P?4 Legal!Represe e's Address Legal Representative's Social Security No. Legal Representative's Telephone Number ?d z z a Rev, 03/13103 Whi - Business Office Pink - Medical Roads Yellow - ReWdwt To:BEI - Date Agent's Social Security Number Agent's Telephone Number 4c`?d sr' I Date z c? Olt n contained on pages 1 through 16 of the Admission 0 ,.,!„ * w•. a dicai Records Yellow - Resident To:BEI All cairn=ythe whole or part on the same incident, transaction, or related course of care or services provided ility to the Resident shall be arbitrated in one proceeding. A claim shall be waived and forever barr if it arose and should reasonably have boon discovered prior to the date upon which notice of arbitrati is given to the Facility or received by the Resident and such claim is not presented in the arbitration P eeding. PARTIES WAPA NG T! OF 4W BE, OR WARD DERSTAND AND AGREE THAT THIS CONTRACT CONTAINS A BINDING PROVISION WHICH MAY BE ENFORCED BY THE PARTIES, AND THAT BY ? THIS ARBITRATION AGREEMENT, THE PARTIES ARE GIVING UP A" Ft CONSTITUTIONAL RIIGNT TO HAVE ANY CLAM DECIDED IN A COURT M A JUDGE AND A JURY, AS WELL AS ANY APPEAL FROM .A DECISION DAMAGES. 9 z The ? esidant unc Agreement, (2) tl furni0hing of sen by 'tten notice thirt days, this I if the Resident is i The 4ndersigned expl? ncd to him that he/she is the agreement and a4 Data'. Signature: (Resi Witniess: If the resident is incottnpetence or foiloiving: Dat?: ??? Relationship to I t .?. hands that (1) he/she has the right to seek legal counsel concerning this Arbitration execution of this Arbitration Agreement is not a precondition to admission or to the s to the Resident by the Facility, and (3) this Arbitration Agreement may be rescinded the Facility $om the Resident within thirty days of signature. If not rescinded within itration Agreement shall remain in effect for all subsequent stays at the Facility, even charged from and readmitted to the Facility. fies that he/she has read this Arbitration Agreement and that it has been fully that he/she understands its contents, and has received a copy of the provision and dent, or a person duly authorized by the Resident or otherwise to execute this its terms. able to consent or sign this provision because of physical disability or mental a minor and an authorized representative is signing this provision, complete the ?os V1 P For facility: Rev, 05/13/03 - Business Office Pink - Medical Rocords Yellow - Rcsident To:BEI RESIDEN'T'-SPECMC INFORMATION e: in its was write = This Facility accepts ffie following types of payments: edicare [ edical Assistance [dV?s Administration ADGEMENTS - By signing the Admission Agreement Signaturc Page, the al Representative aclWowledges that he or she has been given and has read this irety, and all addenda. The Resident also acknowledges that the following vided upon or before admission by the Facility. Initial the lines below (if not A ' of supplies and services that are included in the Facility's private monthly rate or t will be paid for by the Medical Assistance or Medicare programs and a list of supplies services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged Q( __ TI-3. 4. i 6. t 8. 9. I about the Facility's bad-hold procedures. Av ben As Ag, the Co A} I ha and the I ha XXIVI NOTICES Representative are The Resident desig provided to the Re Rev. 03/13/03 Whit n explanation of how to apply for and use Medicare and Medical Assistance and how to receive funds for previous payments covered by these benefits. taut explaining that the Resident may file a grievance with the appropriate State about resident abuse, neglect, and/or misusalthdt of resident personal property in of the State Resident Rights. explanation of the Facility's Rules and Regulations. a applicable, if your condition warrants, you may be placed in the Facility's ;are-Certiticd Distinct Part Unit. At some point, circumstances may occur which will residing in another unit more appropriate for you. In that case, the Facility will is such a transfer with you. Under law, you cannot be discharged from this Facility you agree or unless, following an appeal, it is determined that you may be mtarily discharged or transferred. do not( have an advance directive. been informed, both orally and in writing, in a language I understand, of my rights rules and regulations governing my conduct and responsibilities during my stay at been given a copy and had an opportunity to review the Facility's Notice of Privacy Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal :sponsible for notifying the Facility in writing of any change of address. ites the following person(s) to be notified when any legally required notices are lent, Agent, and/or Legal Representative. - Business Office Pink -- Medical Records Yellow - Resident X z X H .Q To: BEI A- Legal Phone Work Phone[ ][ J[ }I l[ ][ J[ }[ } ? t? va 11Z& ] Stre city State Zip B. ? Other Pe on To Be Notified Honm Phone M 11 10- Work hone[ ] } NO H11 }[ if [ T- 6 _ pa -79 MD6 Strect? City Statz Zip t XXY.? MAIL - Facility is authorized to handle the Resident's mail as follows: (Check p= box only.) , All mail given ' ectly to the Resident [ All mail read to the Resident [ l 1"drward $U of be Resident's mail to, [ ] Give personal mail to the Resident; f forward business mail to: i And/Or Agent x _H z S )PHYSICIAN A. NAlia: B. SPECIALTY: t C. ArOMSS: x z 0 D. TF?FI'HC?NE: 3MSIDE TRUST FUND AUTHORIZATION - A Resident Trust Fund is an &mount of money held by the acility for the Resident's personal use. (Bxasnples of use: To allow the resident to pay for r m and boarc beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) signins below, the Rcsident authorizes the Facility to set up a trust fund in his/her name. The individ al financial records shall be available through quarterly statements, and on request, to the Resident or hi er Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/ 13103 VVhi - Business Office Pink - Medical Records Yellow - Resident To:BEI shall b?e authorized by the Resident or his/ber or Legal Representative in writing. The following perso4s may auth withdrawals on the R ent's behalf Name of Autho ' Person Name of Authorized Person Resid 's Signatu a Date Witoeo if Reddft Signed with a lc Date Logai epresentati e's Signatur Date (if apoicabie) Agents Signature jif applicable) Deft XXVJ CRED CARD AUTHORIZA ON - Facility accepts MasterCard and VISA. If Resident would hle the con enie= of paying amo due each month through one of these, please provide the neei4 informatio and authorization: } Credit Card Account # i i Expir}tion Date i 1 he+ authorize Facility to charge t e account listed above for monthly charges incurred under this Agreement: Resid#nt or Agentis Signature f Date 11the ?tesident is le to Co lit or sign this provision because of physical disability or mental inconetence or tamaor and 's provision is being signed by an authorized representative, complete the following: Date. -E--- f Relationship to Resident: Witne s: - For Ft duty: , Rev. 09113/03 Date: - Business Office Fink - Medicai Records Yellow - Resident. !A N Z h z 0 Print i Rev. 43/13/03 m N_ z w a N G p EXHIBIT 2 y C r o r as o o C!i 0 1 H O 1 a0 y m\ N n b (?D ooro 44 3 n rS . ls] F' J t+ to C7 O Nom r*t?m K I No Zi '`LT mN N 0 I Ntl 7r co f ,btaN ?' O E (n to 0 L] 0.4 nt? N ' ;d Hw r- H In 0 H O ED I! 1D m G ' 0 r4 cri 1 `? b to n b ro H a b t+ n ' A MI Kro Z rr K flt a w rt U]ro[nnaaG ?? N fKD d m~ Fn'-Rb. pi ?j ntDmw 7+ IT`CK z `CKKw wK p rt ?.. N ro ?m °xbr D- to m rtrr r?r'G N't?? Cy i F- :3 aK aw [Yz? 0 'J ?yf ?EQj 1? rt b r ON 0 rt O r[?+ W R IO N O `O N 'r?Cb $Cyd? N I to R yG ?GJ N •• 1.4 z Om b ASS J 10 co I `'tt'f W n 1 N ° ? H (AZ7r ° `O to m m m 3 0 °0 n o°N mt?]m t' H_ ni £ "d to r tn?b bdz tyo0 °o HH y 1 to C) ?D [«7 ]C F' y b W ;a O t•1 w y d I fA N K M 0 N y H o m m CCC<NJ] m i Nx as Id rS?C'd 60 Hrt tj E13 O a 0 Glib w °?° N"' 0 1 R 0 .?. m3 fn W ° R+ co n ?? R? LsJ W 1 0 K ^nJR r to O y :6 i N y M I O ° 'C o n b o ro `G .? W tot (ij ?H.. R LO 6 0 tv ' .. O ?, r 1 rn roynbabro rtw nbro d ? ?? r w? a0 Fl nKyED rt a0 W mrtprr?GKKID mRlr R?KN og µ @? H 1 fit{ . .. .. .. .. .. m n H .Z I t? 'i3 0 7C tn'C H r ?I o F+ CO to v m 0 rowM Otn 1'''0 1 rr0KNR Om L4 x Q? ty mm-40co °N Hy npo root- ? n uorrrrOK w w m r b z ?fitpKO ny 00 0 n o n F? [D n n tc w co M4 0) CO I w potato X F+ o I ? J J J I y N N O m m m 1 0 W \ I i O 1 m m 1 I , ON L 1 I I I d ' K ' O i m I r ' w I ffo W 1 o ' I m p I N I at ° ' o ? I 1 1 F-j VERIFICATION The undersigned does hereby verify subject to the penalties of 18 PA.C.S §4904 relating to unsworn falsifications to authorities, that he/she is Rita Donnelly Legal Collector of Golden Living , plaintiff herein, that she is duly authorized to make this Verification, and that the facts set forth in the foregoing Complaint are true and correct to the best of his/her knowledge, information and belief. Date: ?°? Rita onnelly CERTIFICATE OF SERVICE The undersigned certifies that a true and correct copy of the within Amended Complaint in Civil Action was served on the 28th day of August , 2008, by United States first class mail, postage pre-paid, addressed as follows: Nichole M. Walters, Esq. The Elder Law and Consumer Protection Clinic Dickinson School of Law Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 Weltman, Weinberg & Reis Co., L.P.A. K. vt??? Karina Velter, Esquire Attorney for Plaintiff ?-- ; r..? i?3 iw?„F ? :; ? -z-? _ w"j .. -n.. ? ...:, l `?,;:?` ;i `3 ?, -?.Ka BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff V. ROBERT CRUM LINDA CRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Civil Action No. 07- 342 Defendant NOTICE TO DEFEND AND CLAIM OF RIGHTS YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE CUMBERLAND COUNTY BAR ASSOCIATION 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 Nichole M. Walters T? Supreme Court No. 84478 Elder Law Clinic The Dickinson School of Law The Pennsylvania State University 150 South College Street Carlisle, Pennsylvania 17013-2899 Phone: (717) 240-5152 BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff V. ROBERT CRUM LINDA CRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Civil Action No. 07- 342 Defendant DEFENDANTS' ANSWER TO PLAINTIFF'S SECOND AMENDED COMPLAINT 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted in part and denied in part. Defendant Linda Crum received and accepted the goods and services mentioned in Paragraph 4 of Plaintiff's Second Amended Complaint upon reliance on the oral contract between Plaintiff and Defendants that Plaintiff would secure Medical Assistance for Defendant Linda Crum. 6. Denied. Defendants relied on the oral contract between Plaintiff and Defendants that Plaintiff would secure Medical Assistance for Defendant Linda Crum. Plaintiff owed Defendants a duty to exercise ordinary and reasonably prudent care while applying for medical assistance for Defendant Linda Crum. Once Plaintiff promised to secure medical assistance for Defendant Linda Crum, Plaintiff assumed responsibility for providing all the documentation required by the I County Assistance Office to support Defendant Linda Crums' application. Plaintiff breached these duties by failing to provide the County Assistance Office with all the documentation that it requested. Plaintiff also breached its duty by failing to advise Defendants to seek legal counsel experienced in Medical Assistance. Plaintiff further breached its duty to Defendants by failing to advise Defendants to seek legal counsel experienced in Medical Assistance appeals after Defendant Linda Crum's Medical Assistance Application was denied. 7. Admitted in part and denied in part. Defendants have not paid the balance owed on this account because they have insufficient funds to do so. Further, Defendants relied on the oral contract between Plaintiff and Defendants whereby Plaintiff agreed to secure Medicaid for Defendant Linda Crum. 8. Defendants lack sufficient knowledge to form an answer to this averment. Plaintiff claims that it is entitled to $17,518.16 for goods and/or services which it provided to Defendant Linda Crum. The account statements provided by Plaintiff show the most recent balance of Defendants' account as $17,518.16, but it cannot be readily determined by looking at the account statement attached to the Amended Complaint that payments made on the account were properly credited to Defendant Linda Crum's account. 9. Defendants incorporates all preceding answers as if fully set fort at length. 10. Admitted. 11. Denied. Robert Crum is not liable for payment of the outstanding balance because Plaintiff and Defendants entered into an oral contract whereby Plaintiff agreed to secure Medical Assistance for Defendant Linda Crum. Plaintiff 2 breached this contract by failing to secure Medical Assistance for its services and subsequently suing Defendants through this action. 12. Denied. Robert Crum is not liable for payment in the amount of $17,518.16 because Plaintiff and Defendants entered into an oral contract whereby Plaintiff agreed to secure Medical Assistance for Defendant Linda Crum. Plaintiff breached this contract by failing to secure Medical Assistance for its services and subsequently suing Defendants through this action. Also, Plaintiff claims that it is entitled to $17,518.16 for-goods and/or services which it provided to Defendant Linda Crum. The account statements provided by Plaintiff show the most recent balance of Defendants' account as $17,518.16, but it cannot be readily determined by looking at the account statement attached to the Amended Complaint that payments made on the account were properly credited to Defendant Linda Crum's account. COUNTERCLAIM I- NEGLIGENCE IN FILING MEDICAL ASSISTANCE APPLICATION 13. The preceding Paragraphs of Defendants' Answers are hereby incorporated by reference as if set forth at length. 14. Plaintiff orally promised Defendants that they would file the Medical Assistance Application for Defendant Linda Crum. 15. Plaintiff did not advise Defendants to seek legal counsel who was experienced in Medical Assistance planning. 3 16. Plaintiff owed Defendants a duty to exercise ordinary care when filing the Medical Assistance Application for Defendant Linda Crum. 17. Once Plaintiff promised to secure medical assistance for Defendant Linda Crum, Plaintiff assumed responsibility for providing all the documentation required by the County Assistance Office to support Defendant Linda Crums' application. 18. Plaintiff breached the duty to exercise ordinary care in filing the Medical Assistance pplication for Defendant Linda Crum because of its failure to provide all the information and documentation requested by the County Assistance Office to support Defendant Linda Crum's Medical Assistance application.. 19. Plaintiff breached the duty to exercise ordinary care because Plaintiff failed to inform Defendants that their Medical Assistance application was denied. 20. Plaintiff breached the duty to exercise ordinary care by failing to advise Defendants to seek legal counsel who was experienced in Medical Assistance planning, and by failing to advise Defendants to seek legal counsel experienced in Medical Assistance appeals after Defendant Linda Crum's Medicaid Application was denied. 21. Plaintiff s failure to adequately file the proper information with the County Assistance Office was negligent and detrimental to Defendants. 22. Plaintiff s failure to inform Defendants that their Medical Assistance application was denied was negligent and detrimental to Defendants. 23. Plaintiff's failure to advise Defendants to seek legal counsel experienced in Medical Assistance was negligent and detrimental to Defendants. WHEREFORE, Defendant prays: 4 (a) that damages be reduced to an amount commensurate with Plaintiff's contributory negligence; (b) that the court dismiss the case with prejudice; (c) such other relief as the Court may deem proper and necessary. COUNTERCLAIM II- FAILURE TO MITIGATE DAMAGES 24. The preceding Paragraphs of Defendants' Answer and Counterclaims are hereby incorporated by reference as if set forth at length. 25. Plaintiff entered into an oral contract with Defendants and agreed to secure Medical Assistance for Defendant Linda Crum. 26. Plaintiff failed to provide all the information and documentation requested by the County Assistance Office needed to support Defendant Linda Crum's Medical Assistance application and her application was subsequently denied. 27. Plaintiff failed to mitigate its damages because Plaintiff did not advise Defendants to seek legal advice for assistance in completing the Medical Assistance application. 28. Plaintiff failed to mitigate its damages because it did not provide to the County Assistance Office all the information and documentation requested by the County Assistance Office to support Defendant Linda Crum's Medical Assistance application. 29. After learning that Defendant Linda Crum's Medical Assistance application was denied, Plaintiff failed to advise Defendants to seek legal advice from an attorney experienced in handling Medical Assistance appeals, thus failing to mitigate its damages. 30. Plaintiff's damages would have been reduced had Plaintiff given the County Assistance Office all the information and documentation the County Assistance Office requested to support Defendant Linda Crum's Medical Assistance application. 31. Plaintiff's damages would have been reduced if Plaintiff had advised Defendants to seek legal counsel that is experienced in Medical Assistance planning. 32. Plaintiff's damages would have been reduced if Plaintiff had advised Defendants to seek legal counsel experienced in Medical Assistance appeals after Defendant Linda Crum's Medicaid Application was denied. WHEREFORE, Defendant prays: (a) that the amount of damages be reduced to an amount that accounts for Plaintiff's failure to mitigate its damages; (b) that the court dismiss the case with prejudice; (c) such other relief as the Court may deem proper and necessary. COUNTERCLAIM III- BREACH OF CONTRACT 33. The preceding Paragraphs of Defendant's Answer and Counterclaims are hereby incorporated by reference as if set forth at length. 34. Plaintiff and Defendants entered into an oral contract whereby Plaintiff agreed to secure Medical Assistance for Defendant Linda Crum. 35. Plaintiff breached the contract by failing to secure Medical Assistance payment for its services and subsequently suing Defendants through this action. 6 36. As a result of Plaintiffs breach of the oral contract, Defendant Linda Crum did not receive Medical Assistance coverage and the Defendants are forced to bear the resultant financial burden. WHEREFORE, Defendant prays: (a) it be restored to the position Defendant would have been in had Plaintiff satisfied its obligation to Defendant to secure Medical Assistance; (b) that the court dismiss the case with prejudice; (c) such other relief as the Court may deem proper and necessary. Respectfully submitted, Date: 2-,S,/ 06 6 By:/Yhfde!L? WldM,., Nichole M. Walters Supreme Court ID Number 84478 The Elder Law and Consumer Protection Clinic 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 7 VERIFICATION I verify that the statements made in the undersigned document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Date: Date: OBERT CRUM LINDA CRUM r-? ? ?) ? s? 4;? cz? - ? _._;, ? '-, ^ N --,; F.a ?. ...j = ? , r ? 4 r •a-"? a ? „? ,?._ IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY HEALTHCARE WEST SHORE HEALTH AND REHAB Plaintiff ROBERT CRUM LINDA CRUM V. Civil Action No. 07- 342 Defendant CERTIFICATE OF SERVICE I, Nichole M. Walters, Esq., certify that on September 26, 2008, I served the foregoing Defendants' Answer to Plaintiff's Second Amended Complaint by placing a true and correct copy of the same in the United States first class mail, postage prepaid, addressed as follows: Karina Velter, Esquire WELTMAN, WEINBERG & REIS CO., L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date: °J 1.2 orb By: GJa j,&t d Nichole M. Walters f, e_ Elder Law Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 3 }' '1""? `. ?^' ` . i1 1 '?? '_. ? ?^'G"4. x' -'t ??- ? .A ?.... f ? ? Nichole M. Walters The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff V. ROBERT CRUM LINDA CRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Civil Action No. 07- 342 Defendant NOTICE OF PRAECIPE TO ENTER JUDGMENT BY DEFAULT TO: Michael J. Dougherty, Esq. Weltman, Weinberg & Reis, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date of Notice: October 23, 2008 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 Respectfully Submitted, Dated: T Tania Klam Nichole M. Walters, Esq. Certified Legal Intern Supreme Court Number 84478 The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA V. ROBERT CRUM LINDA CRUM Civil Action No. 07- 342 Defendant CERTIFICATE OF SERVICE I, Tania Klam, certify that on October 23, 2008, I served the foregoing Notice of Praecipe to Enter Judgment By Default by placing a true and correct copy of the same in the United States first class mail, postage prepaid, addressed as follows: Michael J. Dougherty, Esq. Weltman, Weinberg & Reis, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date: l d v 8 By: --7ai4. a Tania Klam, Certified Legal Intern The Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 C-0 r Co zli 6 s WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire I.D. No. 76046 325 Chestnut Street, Suite 1120 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File # 05397059 Attorney for Plaintiff(s) BEVERLY HEALTHCARE- } WEST SHORE HEALTH AND REHAB } vs. } } } ROBERT AND LINDA CRUM } Cumberland County Court of Common Pleas NO. 07-342 ANSWER TO COUNTERCLAIM COUNTI 13. Plaintiff hereby incorporates the averments of its Complaint as if full set forth at length herein. 14. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 15. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 16. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 17. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 18. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 19. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 20. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 21. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 22. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 23. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. WHEREFORE, Plaintiff respectfully requests that Defendant's counterclaim be dismissed with prejudice. COUNT II 24. Plaintiff hereby incorporates the averments of its Complaint as if full set forth at length herein. 25. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 26. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 27. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 28. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 29. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 30. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 31. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 32. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. WHEREFORE, Plaintiff respectfully requests that Defendant's counterclaim be dismissed with prejudice. COUNT III 33. Plaintiff hereby incorporates the averments of its Complaint as if full set forth at length herein. 34. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. 35. Denied. Defendants' averment is a conclusion of law to which no responsive pleading is required. 36. Denied. Defendant's averment is a conclusion of law to which no responsive pleading is required. As way of further response, after reasonable investigation, Plaintiff is without sufficient information to form a belief as to the truth or falsity of Defendant's averment. Strict proof of same is therefore required at time of trial. WHEREFORE, Plaintiff respectfully requests that Defendant's counterclaim be dismissed with prejudice. NEWMATTER 1. Defendants' counterclaim fails to state claim upon which relief can be granted. 2. Defendants have failed to mitigate damages. 3. Defendants fail to set forth a viable claim for damages. 4. Plaintiff did not owe and/or did not breach any duty to Defendants. WHEREFORE, Plaintiff respectfully requests that Defendant's counterclaim be dismissed with prejudice. WELTMAN, WEINBE G & REIS CO., L.P.A. By Michael J. Dougherty, Esquire Attorney for Plaintiff VERIFICATION I, Michael J. Dougherty, Esquire, attorney for the Plaintiff(s) do hereby swear and affirm that the averments in the attached Reply to Counterclaim and New Matter are true and correct to the best of my knowledge, information and/or belief. These averments are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Mic el J. Dougherty Date n WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire I.D. No. 76046 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File # 05397059 Attorney for Plaintiff(s) BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB CUMBERLAND COUNTY COURT OF COMMON PLEAS VS. ROBERT CRUM LINDA CRUM No.: 07-342 CERTIFICATE OF SERVICE TO THE PROTHONOTARY: On October 22, 2008 Plaintiff, Beverly Healthcare - West Shore Health and Rehab, served its Answer to Defendant's Counterclaim with New Matter upon the following party/parties in the above-captioned matter via USPS First Class mail, postage-prepaid: Nichole M.Walters, Esq. The Elder Law and Consumer Protection Clinic Dickinson School of Law Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 WEL By Attorney for & REIS CO., L.P.A. Esquire ra v L" o M v a; _?7 ? t T1 -CA ' CJ t Q BEVERLY HEALTHCARE- WEST SHORE HEALTH AND REHAB Plaintiff V. ROBERT CRUM LINDA CRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Civil Action No. 07- 342 Defendant DEFENDANT'S RESPONSE TO PLAINTIFF'S NEW MATTER 1. Denied. Plaintiff s averment is a conclusion of law to which no responsive pleading is required. Strict proof of same is therefore required at time of trial. 2. Denied. Plaintiff s averment is a conclusion of law to which no responsive pleading is required. Strict proof of same is therefore required at time of trial. 3. Denied. Plaintiffs averment is a conclusion of law to which no responsive pleading is required. Strict proof of same is therefore required at time of trial. 4. Denied. Plaintiffs averment is a conclusion of law to which no responsive pleading is required. Strict proof of same is therefore required at time of trial. Respectfully submitted, Nichole M. Walters-, The Elder Law and onsumer Protection Clinic 45 North Pitt Street Carlisle, PA 17013 (717) 240-5152 ... _ ?.. ..... .44 Y .. ' ......i .,,,: ?? F'... IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY BEVERLY HEALTHCARE - WEST SHORE HEALTH AND REHAB, Plaintiff V. ROBERT AND LINDA CRUM, No. 07-342 CIVIL ACTION - LAW Defendants CERTIFICATE OF SERVICE I, Tania Klam, Certified Legal Intern, certify that I served the foregoing Defendant's Response to Plaintiff s New Matter, by placing a true and correct copy of the same in the United States first class mail, postage prepaid, addressed as follows: Michael J. Dougherty, Esq. Weltman, Weinberg & Reis, CO, L.P.A. 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Date: 0 By: ?c+ I Tania Klam Certified Legal Intern Elder Law and Consumer Protection Clinic The Dickinson School of Law The Pennsylvania State University 45 North Pitt Street Carlisle, PA 17013 2 WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire I.D. No. 76046 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File # 05397059 } BEVERLY HEALTHCARE - } WEST SHORE HEALTH AND REHAB } vs. } } ROBERT CRUM and LINDA CRUM I, Ic t; j ILA .,0 ?X Attorney for Plaintiff(s) 2010 AN40 lh, to: 13 Cumberland County Court of Common Pleas NO. 07-342 PRAECIPE TO DISMISS WITH PREJUDICE TO THE PROTHONOTARY: Kindly dismiss Plaintiff, Beverly Healthcare-West Shore Health and Rehab's action against Defendants, Robert and Linda Crum, and Defendants, Robert and Linda Crum's counterclaim against Plaintiff, Beverly Healthcare-West Shore Health and Rehab, with prejudice. WELTMAN, WEINBEfiZO& REIS,00., Ik.P.A. Michael Dougherty, Esquire Attorn or-P*6fiff By By "..rt.e, -M _ C4pJ- ,& Nichole M. Walters ;Esquire Attorney for D?few?ant