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Home My WebLink About00-00230 '~ ' ~" " ,-- ','~~,,- , JONATHAN C. JAMES, Esquire Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, PA 17110 (717) 233- 4101 _I',~" ",'" <.,' 'w ;,;,"-" ",^;.:'h' . '"","''''~o''''__'' :,1 Attorney for Plaintiff ; .:';" ,l"~ ;,':"~',,;,~'- ~"', "'".':"':"" , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY; PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 And Ms. Sandra L. Knauss 6 Laurel Drive Enola, PA 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, CIVIL COMPLAINT NO. 0\ HJ0 ~ ~D ~ 1 rrr~E'l ,.,,~,~ "',, ".,,,~.' ." " ,c.""" ",;1 .: .,~' ',", ".' : :',',0.; ",._~'-'"iJb "".' "'0' "" '. ,'.:,~ .....""11, NOTICE TO DEFEND 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 the complaint and notice are served, by entering a written appearance personally or by attomey 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA TELEPHONE: 7172493166 AVISO Le han demandado a usted en la corte. 5i usted quiere defenderse de estas de estas demandas expuestas an las paginas signientes, usted tiene veinte (20) dias de plazo al partir de ia fecha de la demanda y ia notificacion. Hace falta asentar una comparencia escrita 0 en persona 0 con un abogado y entregar a la corte en forma escrita sus defensas o sus objeciones alas demandas en contra de su persona. Sea avisado que si usted no se defiende, Ie corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso 0 notificacion. Ademas, la corte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisiones de esta demanda. Usted puede perder dinero 0 sus propiedades u ostros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDlATAMENTE, SI NO TIENE ABOGADO 0 SI NO TIENE EL D1NERO SUFICIENTE DE PAGAR TAL SERVICIO. VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA TELEPHONE: 7172493166 2 ""~0:'~ ,"'". .- ,'c ,..,-',-,'. ....:~ ,~, ~'" J" _ _'. -, ^,. : ,.^- :"., ,,-'__c' , _i; "'..; ,-' . "'.'._ " JONATHAN C. JAMES, Esquire Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, PA 17110 (117) 233.4101 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. :J-.(r(r() -230 ~ ..,-~ And Ms. Sandra L. Knauss 6 Laurel Drive Enola, PA 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, COMPLAINT AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a West Shore Health and Rehabilitation Center, 770 Poplar Church Road, Camp Hill, PA 17011 by and through its attorneys, Capozzi & Associates, P.C., and avers as follows: 1. Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a West Shore Health and Rehabilitation Center, (hereafter "Facility"), is a corporation organized 3 v.' "'~~~.."'" n ~' _.'_';-";,~_ " <':"-,,"',",c.c '_;,,,, ,--x"..,;' :-., -."j,,-,_,,_, . ,,'c under the laws of the State of Pennsylvania with its registered office located at 770 Poplar Church Road, Camp Hill, PA 2. Defendant, Ms. Ellen D. Musser, ("Defendant Musser") is an adult individual residing at 770 Poplar Church Road, Camp Hill, PA 3. Defendant, Ms. Diane Knauss, ("Defendant Knauss") is an adult individual residing at 6 Laurel Drive, Enola, PA 17025 4. Facility provided nursing home care and services to Defendant Musser, since her admission on 26 April, 1996. 5. Facility continues to provide said services. 6. On information and belief, on or about the time of admission to Plaintiff Facility, Defendant Knauss presented Plaintiff Facility with a document she represented was a Power of Attorney for Defendant Musser. A true and correct copy of the document is attached hereto and marked as Exhibit "A" 7. Defendant Knauss continues to represent herself as Power of Attorney for Defendant Musser. 8. Defendant Knauss has acted as "Legal Representative" for Defendant Musser since the admission of Defendant Musser into the Facility on 27 March 1998. A true and correct copy of the Admission Agreement (hereafter "Agreement") is attached hereto and marked as Exhibit "B." 9. Defendant Knauss continues to represent that she is "Legal Representative" for Defendant Musser. 4 'ii''':i: ,.,", "I ,J-_ ," ,.i,_"h",_",C--!_~." '''-'--'-' BREACH OF CONTRACT Ellen D. Musser 10. Plaintiff hereby incorporates 11111 through 09 of the Complaint as if set forth in full. 11. On information and belief, on or about March 27, 1998, Defendant Knauss, requested Defendant Musser be admitted to Plaintiff Facility for nursing facility care and services. 12. Plaintiff Facility agreed to admit Defendant Musser. 13. Defendant Knauss signed the Agreement on or about 27 March 1998. 14. On information and belief Defendant Musser represented to Plaintiff Facility she would pay the cost of nursing home care and services directly from her own assets. 15. On information and belief Defendant Knauss represented to Plaintiff Facility that she would arrange for payment for Defendant Musser's nursing home care and services directly from Defendant Musser's assets. 16. The Facility promised to render nursing home care and services to Defendant Musser. 17. Defendant Musser promised to pay for said services. 18. Defendant Knauss promised to use the assets of Defendant Musser to pay for said services. 19. Facility did render said services to Defendant Musser. 20. Defendant Musser accepted said services. 21. Defendant Musser has not paid for the services received. 22. On information and belief, Defendant Knauss has access to Defendant Musser's financial information, including the latter's income and assets. 5 - ,~'\::Yfi "-"... .-~.~ '.". '--~-"'- "'" '. ,.-';"-,'J",_'_I,' 23. Defendant Knauss has not made the Defendant Musser's proceeds available to satisfy the debt created by the costs of Defendant Musser's nursing home care. 24. Facility has demanded payment for the care and services it provided to Defendant Musser on many occasions, but to date has not received payment. 25. An account history reflecting the current balance is attached hereto and marked as Exhibit "C." 26. On information and belief Defendant Knauss executed a partial payment agreement during or about June of 1998. See attached at Exhibit "D". 27. On information and belief Defendant Knauss has represented to Plaintiff Facility she acknowledges she has an obligation to retire any past due amounts that were owed to Plaintiff. 28. Defendant Knauss acknowledged, in executing the partial payment agreement that an arrearage existed. 29. The Agreement provides that in the event that Facility initiates and prevails in litigation against Defendants in an action arising from Defendants' failure to comply with the Agreement, Facility shall be entitled to receive reasonable attorney fees. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of $14,494.49 plus interest, attorney fees and court costs from the date of the Court's judgment. 6 /;-',~ 0'-"-- j ,,<C,', -,;--'-,,;, 'CO, .,,'-_"~__ ".~" I ;";,--, BREACH OF IMPLIED CONTRACT 30. Plaintiff hereby incorporates 11111 through 29 of the Complaint as if set forth in full. 31. Defendant Musser requested Plaintiff Facility provide Defendant Musser with nursing home care and services. 32. Plaintiff Facility agreed to provide nursing home care and services to Defendant Musser 33. Facility promised to provide Defendant Musser with nursing home care and services. 34. Defendant Musser promised to pay Facility for the nursing home care and services provided. 35. . Facility provided Defendant Musser with nursing home care and services. 36. Defendant Musser failed to pay Plaintiff Facility. 37. Plaintiff and Defendants have an implied contract for Plaintiffs provision of nursing home care and services. 38. On information and belief, Defendant Knauss requested Plaintiff Facility admit Defendant Musser to Plaintiff Facility so Defendant Musser could receive nursing home care and services. 39. Defendant Knauss promised to make the funds of Defendant Musser available to Plaintiff Facility to cover the costs of nursing home care and services provided that Plaintiff Facility render said services to Defendant Musser. 40. Plaintiff Facility did render the services to Defendant Musser. 41. Defendant Knauss did not make the assets of Defendant Musser available to cover the costs of nursing home care and services. 7 ""_""~';l _, <. v'~_,_ :'.-'.._ ,.J. ,-- -'-'~"" --.,~,-",,,, "fl/-:",-~"";.;".~,,;..,,;,-,,,,", "/1 WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of $14,494.49, plus interest, attorney fees and court costs from the date of the Court's judgment. 8 m,'i:~ I," ,"" - ," .--' ";,;.,~-, _--,,~_ ;"t-., , 'c ,~ QUANTUM MERUIT 42. Plaintiff hereby incorporates 11111 through 41 of the Complaint as if set forth in full. 43. With the Defendants' full knowledge Plaintiff provided Defendant Musser with nursing home care and services. 44. With the Defendants' agreement Plaintiff provided Defendant Musser with nursing home care and services. 45. Defendant Musser received the benefit of Plaintiff Facility's nursing services but did not arrange for payment of said services. 46. Defendant Knauss as Power of Attorney for Defendant Musser received the benefit of Plaintiff Facility's nursing services but did not arrange for payment of said services. 47. Defendants knew or should have known that Plaintiff Facility expected payment for its care and services. 48. Plaintiff Facility had a reasonable expectation of payment for provision of its care and services. 49. Defendants were unjustly and unconscionably enriched through their use of Plaintiffs nursing home care and services without providing Plaintiff with proper and agreed upon payment. WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of $14,494.49 plus interest, attorney fees and court costs from the date of the Court's judgment. 9 ~Ci"" ^ ,- '.- , < ~ - '- .. - I" "_'__ -_>'0";" " BREACH OF FIDUCIARY DUTY Sandra L. Knauss 50. Plaintiff hereby incorporates 11111 through 49 of the Complaint as if set forth in full. 51. By signing Defendant Musser's Admission Agreement as her "Legal Representative", Defendant Knauss indicated and entered into a confidential, fiduciary relationship with Defendant Musser. 52. By signing Defendant Musser's Admission Agreement as her "Legal Representative", Defendant Knauss indicated and entered into a confidential, fiduciary relationship with Plaintiff Facility. 53. By executing a Power of Attorney agreement with Defendant Musser, Defendant Knauss indicated and entered into a confidential, fiduciary relationship with Defendant Musser. 54. Defendant Knauss as "Legal Representative" for Defendant Musser had a fiduciary duty to Defendant Musser to act in Defendant Musser's best interests. 55. Defendant Knauss as "Legal Representative" for Defendant Musser had a fiduciary duty to Plaintiff Facility to act in Defendant Musser's best interests. 56. Defendant Knauss as Power of Attorney for Defendant Musser had a fiduciary duty to act in Defendant Musser's best interests. 57. Defendant Knauss as Power of Attorney for Defendant Musser had a fiduciary duty to Defendant Musser to use Defendant Musser's income and assets to serve Defendant Musser's best interests. 10 '~3ij"~~l ~,- ~,- ,--"" ~-,--,~ --- ,-' "h- I,~",,_ I" ,;. 'A';'~'_"'. ^, _~-;,.~, _~_ ';..' 58. Defendant Knauss as "Legal Representative" for Defendant Musser had a fiduciary duty to Defendant Musser to use Defendant Musser's income and assets to serve Defendant Musser's best interests. 59. Defendant Knauss acting as "Legal Representative" for Defendant Musser failed to make the income and assets of Defendant Musser available to satisfy the debt created by the costs of rendering nursing home services and care to Defendant Musser. 60. Defendant Knauss acting as Power of Attorney for Defendant Musser failed to make the income and assets of Defendant Musser available to satisfy the debt created by the costs of rendering nursing home services and care to Defendant Musser. 61. Defendant Knauss's failure as "Legal Representative" for Defendant Musser to make said income and assets of Defendant Musser available to Plaintiff Facility is a violation of her fiduciary duty to Defendant Musser. 62. Defendant Knauss's failure as Power of Attorney for Defendant Musser to make said income and assets of Defendant Musser available to Plaintiff Facility is a violation of her fiduciary duty to Defendant Musser. 63. As a result of Defendant Knauss's breach of fiduciary duty to Defendant Musser, Defendant Knauss has caused Plaintiff Facility to be damaged. 64. As a result of Defendant Musser's breach of fiduciary duty to Plaintiff Facility Defendant Knauss has caused Plaintiff Facility to be damaged. WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendant Knauss in an amount in excess of 11 /'~~;;~ , c,", .k ~_k-_ ;'~o." .~_<~ ,'", __,- ,,,,' _ $14,494.49, plus interest, attorney fees and court costs from the date of the Court's judgment.. ACTION IN ASSUMPSIT-DUTY TO SUPPORT Sandra L. Knauss 65. Plaintiff hereby incorporates 11111 through 64 of the Complaint as if set forth in full. 66. As the nursing facility providing Defendant Musser with nursing care and services, Facility had a legal duty to provide care, maintenance and assistance to her. 67. Defendant Knauss is Defendant Musser's daughter. 68. Upon information and belief, Defendant Musser's sole source of income is her Social Security benefits. 69. Defendant Musser's average monthly expenses incurred at Facility are in excess of $3600.00. 70. Upon information and belief Defendant Musser's monthly living expenses incurred at Facility significantly exceed her monthly income. 71. Upon information and belief, Defendant Knauss has sufficient financial ability to pay for some or all of Defendant Musser's maintenance and support. 72. Title 62 of the Pennsylvania Statutes Section 1973, et. seq., requires children and spouses with sufficient financial ability to pay for the care and maintenance of their indigent parents, and to provide their parents with financial assistance. 73. Upon information and belief, Defendant Musser is "indigent" within the meaning of Title 62 Section 1973. 12 >I/:<>'~51i\ w _ , . i ,. , '" '" ~,' . '"-, ~", c - -, '~ "",I WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendant Knauss in an amount in excess of $14,494.49, plus interest, attorney fees and court costs from the date of the Court's judgment. Date:~Ooo 13 ~'";'it "'~, 'r.'__~_ - ,,--k.;__"'_' , II IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. Ms. Sandra L. Knauss 6 Laurel Drive Enola, PA 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, VERIFICATION I, Jason Hershey, do hereby verify that the facts made in the foregoing document are true and correct to the best of my knowledge, inform ion and belief. I understand that any false statements therein are subject he penalti contained in Title 18 of the Pennsylvania Consolidated Statutes ecf n 4904, rating to unsworn falsification to authorities. Date: IIs)o /7 14 "';1::.7 DURABLE POWER OF ATTORNEY I, ELLEN D. MUSSER, now of 6 Laurel Drive, Enola, a resident of Cumberland County, Pennsylvania, appoint my daughter, SANDRAL. KNAUSS, my Attorney-in-Fact. SANDRA L. KNAUSS is referred to as "my Attorney-in-Fact" in this document. If and in the event that my Attorney-in-Fact predeceases me, or does not complete the duties of my true and lawful Attorney-in- Fact, then and in such event, I hereby make, constitute and appoint my son-in-law, ROBERT R. KNAUSS, as my Successor Attorney-in-Fact with all the rights and duties hereinafter stated. I intend to create Pa.C.S.A. Section 5604 Subs~~ state law). .JA 3 affecte by my subsequent a Durable Power of Attorney pursuant to 20 (or the corresponding provision of any The et;Eective date of this Power is ,19'fS-. This Power shall not be disability or incapacity. My Attorney-in-Fact is hereby given the fullest possible powers to act on my behalf, with the same powers, for all purposes, and with the same validity as I could, if personally present. Without limiting the general powers hereby already conferred, my Attorney-in-Fact shall have the following specific powers, including, but not limited to: 1. To collect and receive any money and assets to which I may be entitled; to deposit cash and checks in any of my accounts; to endorse for deposit, transfer or collection, in my name and for my account any checks payable to my order; to draw and sign checks for me and in my name, including any accounts opened by such Attorney-in-Fact in my name at any bank, savings society, money market fund or elsewhere; to receive and apply the proceeds of such checks as my Attorney-in-Fact deems best; and, to close accounts; 2. To take all lawful steps to recover, collect and receive any amounts of money now or hereafter owing or payable to me; and, to compromise and execute releases or other sufficient discharges for such amounts; 3. To make loans, secured or unsecured, in such amounts, upon such terms, with or without interest and to such ~irms corporations, and persons as my Attorney-in-Fact deems appropr~ate; .Tfl~!(l~, , ~ ,-, 'n 4, To institute, prosecute, defend, compromise, or otherwise dispose of (and to appear for me in any proceedings before any tribunal for the enforcement or for the defense of) any claim, either alone or in conjunction with other persons, relating to me or to any property of mine or any other persons; to obtain, discharge and substitute counsel and to authorize appearance of such counsel to be entered for me in any such action or proceeding; and, to compromise or arbitrate any claim in which I may be interested and for that purpose to enter into agreement or compromise or arbitration and perform or enforce any award entered pursuant to such arbitration; 5. To lease, sublet, sell, release, hire professional managers, conveyor mortgage any real property owned by me (including my residence) or in which I have an interest now or in the future, upon such terms and conditions and under such covenants as my Attorney-in-Fact shall determine, including the sale of my real estate and to sign, execute and deliver deeds and conveyances therefore; 6. To purchase or otherwise acquire any interest in and possession of real property and to accept all deeds for such property on my behalf; and, to manage, repair, improve, maintain, restore, build, or develop any real property in which I now have or may have an interest in the future; 7. To execute, deliver, and acknowledge deeds, deeds of trust, covenants, indentures, agreements, mortgages, hypothecations, bills of lading, bills, bonds, notes, receipts, evidences of debts, releases and satisfactions of mortgage, judgments, ground rents and other debts; 8. To collect, compromise, endorse, borrow against, hypothecate, release and recover any promissory note receivable, whether secured or unsecured, and any related deed of trust; 9. To buy, purchase, sell, repair, alter, manage and dispose of personal property of every kind and nature at private sale or public sale and to sign, execute and deliver assignments and bills of sale therefore; 10. To enter my safe deposit boxes and to open new safe deposit boxes; to add to and to remove any of the contents of any such safe deposit boxes; and. to close any of such boxes; 11. To borrow money for my account on whatever terms and conditions deemed advisable, including borrowing money on any insurance policies issued on my life for any purpose without any obligation on the part of such insurance company to determine the purpose for such loan or application of the proceeds, and to pledge, assign, and deliver the policies as security; 2 .~- " ~, IIft4i ,- ~ ~-.~ ^-'-, ."-;~~~2~~J'~I. . 12. To apply for and to receive any government,insurance and retirement benefits to which I may be entitled and to exercise any right to elect benefits or payment options; to terminate such benefits; to change beneficiaries or ownership of such benefits; and, to assign rights or receive cash value in return for the surrender of any or all rights I may have in life insurance policies or benefits, annuity policies, plans of benefits, mutual fund and other dividend investment plans and retirement, profit- sharing and employee welfare plans and benefits; 13. To take custody of my stocks, bonds and other investments of all kinds, to give orders for the sale, surrender or exchange of any such investments and to receive the proceeds therefrom; to sign and deliver assignments, stock and bond powers and other documents required for any such sale, assignment, surrender or exchange; to give orders for the purchase of stocks, bonds and other investments of any kind; to give instructions as to the registration thereof and the mailing of dividends and interest therefrom; and to deposit coupons attached to any coupon bonds, whether now owned by me or hereafter acquired; 14. To purchase for me United States of America Treasury Bonds of the kind which are redeemable at par in payment of federal estate taxes; to borrow money and obtain credit in my name from any source for such purpose, to make, execute, endorse and deliver promissory notes, drafts, agreements or other obligations for such bonds and, as security therefore, to pledge, mortgage and assign any stocks, bonds, securities, insurance values and other properties, real or personal, in which I may have an interest; and, to arrange for the safekeeping and custody of any such Treasury Bonds; 15. To open or maintain accounts with stockbrokers (on cash or on margin); and, to buy, sell, endorse, transfer, hypothecate and borrow against any share of stock, bonds or other securities; 16. To vote at all meetings of shareholders (whether general, regular or special) of any corporation whose shares I own, on any questions which may arise at any such meeting, and to do everything respecting such shares of stock, including the calling of meetings of directors or stockholders or making and giving consents and ratifications, and any other act which I could do if personally present, intending hereby to confer upon my Attorney-in-Fact full power and authority to do (with reference to such shares of stock) everything which I might or could do as owner of such shares; 17. To continue the operation of any business belonging to me or in which I have a substantial interest, in such manner as my Attorney-in-Fact may deem advisable or to sell, liquidate or incorporate any business (or interest therein) on such terms as my Attorney-in-Fact may deem advisable and in my best interests; 3 . ....... . 18. To procure, change, carry or cancel insu:anc: ::::~~~ kind and in such amounts as my Attorney-in-Fact deems advisable to protect from risks affecting property or persons due to liability, damage or a claim of any sort; to claim any benefits or proceeds on my behalf; and, to purchase medical insurance for any dependent of mine; 19. To join with my spouse or my spouse's estate in filing income or gift tax returns for any years for which I have not filed such returns and to consent to any gifts made by my spouse as being made one-half by me for gift tax purposes, even though such action subjects my assets to additional liabilities; 20. To prepare, sign and file federal, state and local income, gift or other tax returns of all kinds, claims for refunds, requests,for extensions of time, petitions to the United States Tax Court or other courts regarding tax matters and any and all other tax related documents, including, without limitation, receipts, offers, waivers, consents (including, but not limited to, consents and agreements under Internal Revenue Code (hereinafter IRe) Section 2032A, or its successor), powers of attorney, and closing agreements; to exercise any elections I may have under federal, state and local tax laws; and, generally to act on my behalf in all tax matters of all kinds and for all periods before all persons representing the Internal Revenue Service and any other taxing authority, including receipt of confidential information and the posting of bonds; 21. To make limited gifts, as set forth below, either outright or in trust or, in the case of minors, in accordance with the Uniform Gifts to Minors Act and, for gifts made in trust, to execute a deed of trust for such purpose designating one or more persons, including my Attorney-in-Fact, as original or successor trustees. This power includes the right to make additions to an existing trust and does not require my Attorney-in-Fact to treat the donees equally or proportionately and may entirely exclude one or more permissible donees. The pattern followed on the occasion of any such gift (or gifts) need not be followed on the occasion of any other gift (or gifts). The power to make gifts shall be limited to gifts to my brothers and sisters (whether by the whole or half blood), spouse, parents, grandparents, and lineal descendants and any organization described in IRC Section SOl (c) (3). My Attorney-in-Fact and the donee of the gift shall be responsible as equity and justice may require to the extent that a gift made by my Attorney-in-Fact is inconsistent with the prudent planning of my estate or financial management of my property, or with my known or probable intent with respect to the disposition of my estate. 22. To execute a deed of trust, persons (including my Attorney-in-Fact) trustee(s) and to transfer to the trust designating one or more as original or successor any or all property owned 4 - ~ -. - " -.1 ".",,~~;;- by me as my Attorney-in-Fact may decide, provided that the"'i;~;'~e""" . and principal of the trust shall either be distributable to me or to the guardian of my estate, or be applied for my benefit, and upon my death, any remaining balance of principal or unexpended income OI the trust shall be distributed to my estate. Furthermore, this deed of trust shall be amendable and revocable at any time by me or my Attorney-in-Fact; 23. To add at any time any or all of the property owned by me to any trust in existence for my benefit when this power was created, provided that the income and principal of the trust shall either be distributable to me or to the guardian of my estate or be applied for my benefit during my lifetime and upon my death any remaining principal and unexpended income of the trust is directed to be distributed to my estate; 24. To withdraw and receive the income or corpus of any trust over which I may have a right of withdrawal, and to request and receive the income or corpus of any trust with respect to which the trustee thereof has the discretionary power to make distributions to or on my behalf, and to execute a receipt and release or a similar document for the property so received; 25. To interests in survivorship entireties; conveyor release any contingent or expectant property, marital property rights, and any rights of incident to a j oint tenancy or a tenancy by the 26. To elect to take against the will and conveyances of my spouse after death; to disclaim any interest in property which I am required to disclaim as a result of such election; to retain any property which I have the right to elect to retain; to file petitions pertaining to the election, including petitions to extend the time for electing, and petitions for orders, decrees, and judgments; and, to take all other necessary actions to effectuate the election; 27. To release or disclaim on my behalf any interest in property acquired by intestate, testate or inter vivos transfer, including the release or disclaimer, or acquisition of any interest in property through the exercise or surrender of any right to revoke a revocable trust; 28. To renounce any fiduciary positions to which I have been or may be appointed including (but not limited to) personal representative, trustee, guardian, Attorney-in-Fact, and officer or director of a corporation or political or governmental body; and, to resign such positions in which capacity I am presently serving; 29. To have medical treatment for, consent to, the exclusive authority to give consent for such to be performed on me and to authorize, arrange wai ve and terminate any and all medical and 5 ,'c , ,.' .. . . .. ..,'.' 'f~fr'-'h,...,,,,,.,e__'''"IIIJ''-""'''''_' 7~ - I . j'''-'-.. '~~ . -' ~ "'~",,,""= ; . , ",< ,~ . I-J'l.' "t<:.i~r~"@; 1i&~Jl" ~jI;fjt~q '~~J 'f.Jt~ ' " .'.^ ; .,",~_~ ~-'--~ '.;-. :.' r~~_\~~' ~ ~'_ -}:"~!:'I;:'i:o~f,~~t~_~ _~~0~;~~:1~ ,;1..l il' ":!i^,,' ','~'" < [< ,',' ) "I J~lS'~-.'-_~f';:'-"'":o,~ 'V.' 1;;';::I,.,,,;,,"I"1.~fi'J~f'~~ii!""'IJi1'i."' . '- ",",,_.,,_-,,~. ~'~ ,~^ ""fJ",,!' ,~;,.,.r~__ ."J~""l' ~ ,v' , ~,_ _ II! , llI~iIlliIiilhIIiilliii!~IOM!uI'~"~"""' -~IStd,~i\ilii9~'~~II'i""-&~''''''''-''' J~~ ,'~ -- ~ - ~ ,~. ~, , ;' f. " '! ~ I'..... f '. "* , ~I: ; ~. . I '" "-"-c .. ~ -, "j survival procedures on my behalf, including the administration of drugs or to withhold such consent; 30. To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home, retirement home, or similar institution; and, to pay all costs for my care as my Attorney-in-Fact, based on medical advice, determined in good faith to be necessary and for my well-being; 31. To employ lawyers, investment counsel, accountants, physicians, dentists and other persons to render services to me or my estate and to pay the usual and reasonable fees and compensation of such persons for their services; and 32. To appoint and substitute under himself a substitute or successor Attorney-in-Fact for all the purposes herein described, pursuant to Pennsylvania Consolidated Statutes Title 20, Section 5602(b) (3) or the corresponding provision of subsequent state law. Accordingly, A. Except as my Atto=ey-in-Fact may waive any fees, my Attorney-in-Fact shall be entitled to receive for services actually performed hereunder his normal and customary charge for performing similar services during the time the services are performed. B. This Power of Attorney may be accepted and relied upon by anyone to whom it is presented until such person either receives written notice of revocation by me or has actual knowledge of my death; C. All actions of my Attorney-in-Fact pursuant to this Power of Attorney during my absence or any period of my disability or incapacity shall have the same effect and inure to the benefit of and shall bind me and my heirs, distributees, legal representatives, successors and assigns, as if I were present or competent and not disabled, and for the purpose of inducing anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant and agree that, if this Power of Attorney is terminated or amended for any reason, I and my heirs, distributees, legal representatives, successors and assigns will hold such party harmless for any loss suffered or liability incurred by such party while acting in accordance with this Power of Attorney prior to that party's receipt of written notice of any such termination or amendment; D. I revoke all prior General or Durable Powers of Attorney that I may have executed and I retain the right to revoke or amend this Power of Attorney and to substitute other attorneys-in-fact in place of the Attorney-in-Fact appointed herein. Amendments to this Power of Attorney shall be made in writing by me personally (not by 6 , ~_. ~.- -~ '-.-' my Attorney-in-Fact} and they shall be attached to the original of this Power of Attorney. E. I understand that this Power of Attorney is legal document. Before executing this document, explained to me the following: (1) This document provides my Attorney-in- Fact with broad powers to dispose of, sell, convey and encumber my real and personal property; an important my attorney (2) The powers granted in this Power of Attorney will become effective upon the execution of this document and will exist for an indefinite period of time unless I limit their duration by the terms of this Power or revoke this Power. These powers will continue to exist notwithstanding my subsequent disability or incapacity; and (3) I have the right to revoke or terminate this Power at any time. F. Questions pertaining to the validity, construction and powers created under this instrument shall be determined in accordance with the laws of the Commonwealth of Pennsylvania. ~GA~"Y\'~ f!u~ ~jf7Ln A "'/ ELLEN D. MUSSER (SEAL) i I , , I I i l ~ ~ ~ Ij ~ ~ " I, I I I I I I J IN WITNESS WHEREOF, and intending to be legally bound hereby, I h~ed this Power of Attorney, this 3 ~ day of () , 193:> WITNESS: 7 j -. .' " " ,"- COMMONWEALTH OF PENNSYLVANIA COUNTY OF 'D6..u-p fvv,;..... ) ) SS.: ) On this 3./tJ. day of tJf!hJ--lA.. , ll:;;: personally appeared before me, a Notary Public, in and for the said County and Commonwealth, the above-named, ELLEN D. MUSSER, who acknowledged the foregoing Power of Attorney to be her act and deed and desires the same might be recorded as such according to law. WITNESS my hand and Notarial Seal the day and year aforesaid. ~!11tuU fuIJJAJ~ Notary Public in and for the mmonwealth of Pennsylvania Notarial Seal AAnMarie BonawItz, NOlaIy P<bIic HarrisbJrg, ~in County My Commission E><Pres Dee. 9. 1995 8 ~ I IIW!'1oI...- < I '"''..''''''':'-'-''' . @, BEVERLY ENTERPRISES "-"-,;" ,,( -'~ (. ~ ,- - RESIDENT ADMISSION AGREEMENT BEVERLY ENTERPRISES BE202(7197) - , -'. ~ ,-- - ,- "'" -, ". 0" ,'~_ "'. ~, ,"," -,,,,,U;,o;,u,: ;:_~'-'W~~ Page.... 1 1 1 1 2 3 4 5 5 5 5 5 5 5 6 7 7 7 7 7 7 7 8 8 Table of Contents -Topic' ,"")\ . ~l._,~,<t~;W'f'\I> ~ ;- ~t;> n:~, <' ,~!Tlirr:,\rt ' FINANCIAL ASPECTS OF THE AGREEMENT AGENT AND/OR LEGAL REPRESENTATIVE? FINANCIAL ARRANGEMENTS · Private Residents . Applying for MedicarelMedicaid Assistance . Medicaid Residents . Medicare Residents . Payment Information - Due Dates & Obligation to Pay Timely - Failure to Pay - Fee for Returned Checks BED HOLDS . Medicaid Residents . Private and Medicare Residents PERSONAL FUNDS TERMINATION OF AGREEMENT . Right to Terminate . Personal Property of Resident Upon Discharge REFUNDS ENFORCEMENT OF THIS AGREEMENT ~ Sole Agreement . Non-Assignable Agreement RESIDENT'S RIGHTS AND RESPONSIBIliTIES NONDISCRIMINATION STATEMENT - - ------- - - ~ - - - -- -- - "'liIliIiIii~llU " I . Il"- , 0' ., ., '..~... -. ~ ,-,,,. 8 8 8 8 9 9 9 9 9 9 9 9 10 10 10 10 10 11 CONSENT FOR TREATMENT ~: O'i;1.~~!,,/:> ,~. ,~:'';~;,,;,:'-C .:; ,,,' ':' _ . Nursing Facility Services . Physician Services . Right to Refuse Treatment RESIDENT'S PERSONAL PROPERTY RESIDENT'S RECORDS . 'Confidentiality . Consent to Release by Facility . Photographs THE RESIDENT'S DUTIES . Rules and Regulations . Resident Grievances . Diet . Medications . Care of Facility's Property . Care of the Resident's Room TRANSFERS AND DISCHARGES RESIDENT RIGHTS UNDER FEDERAL LAW FACILITY POLICY REGARDING IMPLEMENTATION OF PATIENT SELF-DETERMINATION ACT 14 RESIDENT-SPECIFIC INFORMATION 15 PARTIES 15 ACKNOWLEDGEMENTS 15 NOTICES 16 MAlL 17 RESIDENT'S PHYSICIAN 17 RESIDENT TRUST FUND AUTHORIZATION 18 ADMISSION AGREEMENT SIGNATURE PAGE 19 if . ., '''"I' JOJnl'""I".~ ~,..".'.;, ,~,~'IoI";'"I-,-"'''',lt'l ,-', I ", ~ . _,;,. ;,'."..;"J..".",~--,--:..,__,. _,.,,'j! Thestaff~fJ~sFacility ,!i,1I ~~~}rh,at~ver~~ is nece~sary to answer all o.f yo.ur questi~nsabout . these topicso'''lease cpntfnl1e. tq~~tglJe~tio~,~~,Y~u beh~ve that you understand.' rk'!' , ., ,~!-.:"~}>(1g~~~1~<,;M~\}t::'" .;}-t;,l;.'f ':'~}~;lJM~,tr1;~f!bf:t:\~trf1f'k/1;--Y{i"'/", i;..',. 'J~:;t:~, ~., ' ' ,"', .' ~"; . AGENT AND/OR LEGAL REPRESENTATIVE? If the Resident is unable to make decisions for himself or herself, an Agent and/or Legal Representative may be available to make certain decisions on behalf of the Resident. These terms are defined below: . . AGENT - For the purposes of this Agreement, an Agent is a person who manages, uses, or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amount of the funds received or held by the Agent for the Resident. The Agent does not assume responsibility for payment of the costs of the Resident's care out of the Agent's personal funds. However, the Agent is contractually bound by the terms of this agreement and may become liable for failure to perform duties under the Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT FOR ADMISSION, AND AGREES TO DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR ITEMS/SERVICES PROVIDED TO THE RESI- DENT. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include the obligations of Agent to act on behalf of Resident. . LEGAL REPRESENTATIVE - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative mayor may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a durable power of attorney for health care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State law. If Legal Representative status has been conferred by a court of law, or through appointment by the Resident, verification of such status must be provided to the Facility at the time of Admission. FINANCIAL ARRANGEMENTS FEDERAL AND STATE LAWS PROHIBIT A NURSING HOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAYMENT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION, OR CONTINUED STAY IN THE FACILITY. PRNATE RESIDENTS - A Resident is considered Private (or private pay) when no State or Federal pro- gram is paying for the Resident's Room & B?ard. A private pay Resident may have private insurance or another third party which pays all or some of hIS or her charges. . Communicating Changes in Assets. It is essential for the Resident to communicate changes in the Resident's assets or resources to the Facility as soon as possible. The Facility needs to know if the Resident's privule funds are going to be depleted so that other arrangements for payment can be made. Generally, when private funds are depleted, the Resident applies for Medicaid assistance, and ~-- - ---- - -- -~ ----- -- -- - -- application processing time can be lengthy. The Facility wants to ensure that, if the Resident runs out of private monies, he or she will still be able to pay for the services provided by the Facility. . Daily Rate. The Facility's private pay daily rate is determined in part by the type of room assigned and the level of care provided to the Resident. For this reason, the rate may change if the Resident moves to a different room. The Resident agrees to pay the Facility in advance for one month's private daily rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by Medicaid or Medicare or leaves the Facility before the end of the month. The Resident will be provided with a list of supplies and services included in the Facility's daily private rate and those supplies and services which are not covered by the daily private rate for which the Resident will be separately charged. A detailed list of and charges for supplies and services not covered by the rate is maintained in the Business Office and is available for review during normal business hours. . Rate Adjustments. The Facility may occasionally need to increase the daily rate or optional service charges. If this happens, the Resident shall receive written notice of the rate adjustment. If at any time the Resident's condition requires the Facility to change the level of care, the Resident's daily rate may be changed to the new daily rate for the new level of care without prior notice, unless notice is required by State law or regulation. When a notice of a rate adjustment is received, the Resident can choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) days of the mailing. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before 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. . Private Insurance. Even when there is private insurance coverage, the Resident remains primarily responsible for paying all Facility charges. All charges not covered by the third party payor are also the responsibility of the Resident; these non-covered charges include any coinsurance and/or deductible amounts required by the third party payor, to the extent allowed under Federal and State laws. APPLYING FOR MEDICARE/MEDICAID ASSISTANCE - This Facility makes no guarantee of any kind that the Resident's care will be covered by Medicare, Medicaid, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for the Resident's potential claim for any failure to obtain such coverage. MEDICAID ASSISTANCE: With respect to applying for and receiving Medicaid (Title XIX) assistance, the Resident agrees to the following: . Communicating Asset Status/Applying Promptly for Benefits. At some future date, the Resident's assets may be reduced to a point where the Resident does not have sufficient monthly income to pay for the cost of care and services. In this case, the Resident agrees to inform the Facility immediately of the status of the Resident's assets. . Qualifying for Medicaid Assistance.If the Resident elects coverage under the Medicaid Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility for Medicaid. These actions must include, but are not limited to, taking any and all steps necessary to ensure that. the Resident's: a~sets', are, within the required limits and that these' assets remain within allowable limits for Medicaid assistance. ll.iU" ., "",-,-,~W~"., '.lll~II..llj,'- ':' ,.,,'-:""".,,- '.' ~.,--,.--,...".--.,..,," "",' ", "'." ,'''n' ""J..,;L.,J'Lli'.il.;',.i,'''~-:''j)",.,.__,~,,'_~,">~;, . Providing ~pplicat~o~, Informati~~; Tpe Resident agrees to provi~e. all inf()rmation requested for !", completion ,pf1;he lIr1edic;lid applicatien: This information must b~ provi~ed in complil!fice' with any .j; de~dlinesset by the applic!lple State/County Medicaid program. .;:, ". . -:r. . . . Keepln.g the Facility~formed. The Resident agrees to keep the Facility informed of the status and'l' , progress of the Medic~d application. The Resident agrees to provide the Facility with copies of any information related to the Medicaid application. . Transferring Assets.. IT tjIe Resident transfers assets, this transfer may disqualify the Resident for Medicaid assistance anflior caus~a discontinuance of the Resident's Medicaid benefits. The Resident acknowledges that this inay result in discharge of the Resident due to non-payment. . Continuing Payment of Facility Charges Pending Eligibility. When an application for Medicaid assistance has been filed, the Resident agrees that: - while the Resident's application is "pending," the Resident's estimated share of cost (as described in the following paragraph) shall be paid to the Facility on or before the tenth (lOth) day of each month. - once the Resident is determined to be eligible for Medicaid assistance, the amount of the Resident's share of cost shall be paid to the Facility on or before the tenth (lOth) day of each month. This monthly share of cost is determined by the State/County Medicaid Program and may be referred to as Private Portion, Share of Cost, Patient Liability, Patient Resource, etc. Any changes in resident liability will be communicated to the Facility on a timely basis. . Agent Controlling Resident's Funds. If the Resident's Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these funds for the Resident's welfare. This includes, but is not limited to, making prompt payment for care and services provided to the Resident as specified in the terms of this Admission Agreement. > . Providing Financial Information. The Resident certifies that any financial information regarding the Resident's income and assets required by the Facility and provided by the Resident is complete and accurate. MEDICAID RRSIDENTS - A Medicaid Resident is one who receives benefits from the State Medicaid Program for a majority of his or her Room & Board charges. Medicaid mayor may not cover charges for additional services/items provided by the Facility - this varies from State to State. The following apply to Medicaid Residents: . Daily Rate Payment. On admission, the Resident will be provided with a list of supplies and ser- vices that will be paid by the Medicaid program and those supplies and services not paid for by the Medicaid program, for which the Resident will be separately charged. A detailed list of and charges for supplies and services available in the Facility but not covered by the daily rate under the Medicaid program is maintaineo in the Business Office and available for review during normal busi- ness hours. 3 - -- -- -- --- ---- ----- ----- . Termination of Coverage. The Resident may remain in the Facility for as long as he or she is certi- fied eligible for Medicaid payment, or for as long as any share of cost owed by the Resident is paid as due. A Resident who remains in the Facility after Medicaid coverage has expired or been retroac- tively terminated or denied must pay Facility charges as a Private Resident. In this event, the Resident will pay based on the private rates, charges, and terms in effect at the time of service. . Resident's Share of Cost. The Medicaid program reviews the available monthly income of all per- sons requesting Medicaid assistance. Based on this review, the Medicaid program requires most Medicaid Residents to pay for a reasonable share of the cost of their care. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. If the Resident utilizes monies received from Social Security or a similar source to pay for share of cost, and the Resident fails to make prompt payment, the Facility may request direct mailing of such monies to the Facility. In some States, failure to pay the Resident's share of cost may result in the Resident's discharge. The Facility will also notify the appropriate State or Federal agency of this non-payment. MEDICARE RESIDENTS - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. The following apply to Medicare Residents: . Daily Rate Payment. On admission, the Resident shall be provided with a list of supplies and ser- vices generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of and charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. . Limited Coverage. The Resident understands that Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit peri- od. . Expiration of Benefits. Prior to admission, the Resident must be able to demonstrate the ability to pay (either privately or through Medicaid assistance) for Facility services rendered after Medicare benefits expire. When Medicare coverage expires, the Resident may remain in the Facility if private payor other payment arrangements have been made. If the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission. . Coinsurance and Deductibles. The Resident is responsible for payment of any Medicare coinsur- ance and/or deductibles. If the Resident intends to become private pay when Medicare benefits expire, the Resident agrees to pay in advance for one month's private daily rate when the Resident changes to private pay status. With the excep- tion of private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medicaid. \; 4 ; , cPAYMENTINFORMATION DUE DATES & OBLIGATION TO PAY TIMELY - Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (lOth) day of each month. Ifpayment is not received by the tenth (10th) day of each month, the account balance is considered past due or delinquent, and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum ; amount permitted by law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. The Resident recognizes that the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. FAILURE TO PAY - The Facility's due date for payments falls on the tenth of each month. If the Resident fails to make a required payment within twenty-one (21) days of the due date, the Facility may require the Resident to vacate the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth in the Resident's Rights section of this Agreement. This notice shall be considered received either on the actual date of receipt or five (5) days after mailing, whichever occurs first. FEE FOR RETURNED CHECKS - A service fee of $25.00 (twenty five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. BED HOLDS The Resident may need to be absent from the Facility temporarily for hospitalization or therapeutic leave. The Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed hold." The Resident and a family member or legal representative shall be given notice of the bed hold option at the time of hospitalization or therapeutic leave. MEDICAID RESIDENTS - If the Resident's care is paid under the Medicaid program, Medicaid may pay for a certain number of bed hold days. If the Medicaid Resident's hospitalization or therapeutic leave exceeds the bed-hold period paid under the Medicaid program, the resident may request an additional bed hold period from the Facility by agreeing to pay the applicable daily rate during the additional bed hold period. Otherwise, the Resident shall be readmit- ted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medicaid nursing services. PRIVATE AND MEDICARE RESIDENTS - Any Private or Medicare Resident may request a bed hold from the Facility. A Resident's private insurance mayor may not pay for bed holds. The Medicare program does not reimburse for bed holds, however, if the Medicare Resident is also Medicaid eligible, some Medicaid programs may pay for a certain number of bed hold days. Otherwise, a Private or Medicare Resident requesting a bed hold must pay the Facility's private daily rate for the bed being held during the bed hold period. 5 i ,,,-:;~"""""""'~~_~T-:-_.~,""""""""_",,,"' ,0" _ '~'." "., PERSONAL FUNDS The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with management of personal funds, the Facility shall assist if requested to do so in writing. At the Resident's written request, the Facility shall hold, safeguard, manage, and account for these funds. Resident personal funds deposited with the Facility shall be handled as follows: . The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility oper- ating accounts. All interest earned on the Resident's funds shall be credited to his or her account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the fol- lowing: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to main- tain all resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the residents' convenience. . The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. . The personal fund balances of Residents who receive Medicaid benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medicaid resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medicaid or SSI. .If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity as required by State law or regulation. . The Facility shall ensure the security of all personal funds deposited with the Facility. . The Facility shall not take money from a Medicare and/or Medicaid Resident's personal funds for any item or service for which payment can be made under Medicare and/or Medicaid. (If the Resident does want the Facility's assistance with managing personal funds, the Resident is required to complete and sign the RESIDENT TRUST FUND AUTHORIZATION FORM on page 18 of this Agreement.) 6 ..---.-.:'.--,.:'::,::'~7~~ ~,i' "~";;'" ::-:'.,,'...,. ~"",J~ TERMINATION .OF .AGREEMENT RIGHT TO TERMINATE - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medicaid, unless the Facility is not licensed for Medicaid. PERSONAL PROPERTY OF RESIDENT UPON DISCHARGE - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. REFUNDS - If the Resident is discharged before using full prepaid charges, the Facility shall refund the unused portion of such charges within a reasonable period of time. If the Facility is required by law to hold resident personal funds in a demand trust account, the balance of these funds shall be refunded promptly after the Resident's date of discharge. If a Resident is retroactively approved for Medicare or Medicaid benefits, previous payments made that will be covered by the Medicare or Medicaid programs will be refunded promptly in accordance with the Facility's refund policy. Contact the Facility Business Office for details on the refund policy. ENFORCEMENT OF THIS AGREEMENT SOLE AGREEMENT - This Agreement, along with any document~ attached or included by reference, is the only agreement between the Facility and parties. Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid agreement. NON-ASSIGNABLE AGREEMENT - The Resident agrees that the 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. 7 " _ n ., RESIDENT'S RIGHTS AND RESPONSIBILITIES NONDISCRIMINATION STATEMENT The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, dis- ability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among per- sons based on their sources of payment. CONSENT FOR TREATMENT NURSING FACILITY SERVICES - By signing this Agreement, the Resident consents to the Facility pro- , viding routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. Consent to routine nursing care provided by the Facility shall include con- sent for care by such trainees. PHYSICIAN SERVICES - The Resident acknowledges that he or she is under the medical care of a person- al attending physician and that the Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician, or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physi- cians are not associates or agents of the Facility, and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payor. RIGHT TO REFUSE TREATMENT - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgement of a court of law, the Resident is determined to be mentally incompe- tent to make a decision r~garding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision-maker, subject to State and Federal law. 8 ~l ,- ~, ,', , ~', -,-~"""",,""',.w_ -' ,,,,"',;;:,:<;; '. . " ,I"~ RESIDENT'S PERSONAL PROPERTY The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property/valuables which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility of all valuable property upon admission. If, at any time during the Resident's stay, new items of value are added to the Resident's possessions in the Facility, the Resident also agrees to so inform the Facility Administrator or designee. . RESIDENT'S RECORDS CONFIDENTIALITY - Information included in the Resident's medical records is confidential. Unauthorized persons shall not be allowed to review these records without the Resident's written consent, except as required or pennitted by law. CONSENT TO RELEASE BY FACILITY - The Resident authorizes the Facility to release all or any part of the Resident's medical or financial records to any person or entity which has or may have a legal or contrac- tual obligation to pay all or a portion of the costs of care provided to the Resident, induding but not limited to hospital or medical services companies, insurance companies, workers' compensation carriers, welfare funds, and/or the Resident's employer. The Resident also authorizes release of information from medical or financial records to any medical profes- sional or institution responsible for the Resident's medical or nursing care when the Resident is transferred or discharged from the Facility. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. THE RESIDENT'S DUTIES RULES AND REGULATIONS - The Resident agrees that the Facility may, to maintain orderly and eco- nomical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. It is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. RESIDENT GRIEVANCES - Residents are urged to bring any grievances concerning the Facility to the attention of the Facility Administrator or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered directly with the corporate offices. This number is 1-800-572-9981. Residents also have the right to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. 9 . . J -~~ DIET ~ The Resident understands that his or her diet is medically prescribed and, therefore, must be moni- tored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or bever- ages brought into the Facility. MEDICATIONS - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. No drugs or medications may be brought into the Facility unless they are delivered to the nurses' station. CARE OF FACILITY'S PROPERTY - To preserve the value of the Facility's property for future residents' use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for 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 ordi- nary wear and tear. CARE OF THE RESIDENT'S ROOM - The Facility encourages the Resident to have a home-like environ- ment, and will attempt to accommodate all reasonable requests to individualize resident rooms. For safety reasons, the Facility must approve any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. TRANSFERS AND DISCHARGES The Facility shall give notice to the Resident, and if known, a family member or Legal Representative of the Resident, of transfer or discharge as follows: . Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. . In cases where the safety or health of the Resident or other individuals in the Facility may be endan- gered, or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. . The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. . Notice will include information regarding the right to appeal a transfer/discharge. The Facility shall only transfer or discharge a Resident under the following conditions: . The transfer/discharge is necessary for the Resident's welfare and the Resident's needs cannot be met I in the Facility; I I . The. transfer/discharge is approp~ate beca~se the Reside~t:s health has improved sufficiently so the I ReSident no longer needs the services proVided by the FaCIlity; I . The safety of individuals in the Facility is endangered; ! . The health of individuals in the Facility would otherwise be endangered; 10 ," .. The" Resident has failed, after refsona1;lleand appropriate notice,'to PllyJor (or'to havelp~d1'under Medicare or Medicaid) a stay at the Facility; " ,--i\- . The Facility ceases to operate. RESIDENT RIGHTS UNDER FEDERAL LAW The Facility shall protect and promote the rights of each Resident, including each of the following rights: " I The Resident has a right to a dignified existence, self-determination, communication with and access to, persons and services inside and outside the Facility. 2. The Resident has a right to exercise his or her rights as a Resident of the Facility and as a citizen or resident of the United States. 3. The Resident has the right to be free of interference, coercion, discrimination, or reprisal from the Facility in exercising his or her rights. 4. The Resident has the right to be fully informed, in a language he or she can understand, of his or her total health status, including but not limited to, his or her medical condition. 5. The Resident has the right to refuse treatment and to refuse to participate in experimental research. 6. The Resident has the right to exercise his or her legal rights, including filing a grievance with the State survey and certification agency concerning Resident abuse, neglect, and misappropriation of Resident property in the Facility. 7. The Resident has the right to manage his or her financial affairs. 8. The Resident has a right to choose an attending physician. 9. The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. 10. The Resident has a right to participate in planning his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State. 11. The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records. 12. The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself Qr herself, including clinical records, within twenty-four hours. After receipt of his or her records, the Resident or Legal Representative has the right to purchase (at a cost not to exceed the community standard) photocopies of the records or any portions of them upon request and with two days advance notice to the Facility. II ~ " __J'" . , '. ;",',0 ,,,-,,,,,~,,, - ''''''''~ _" , . ____.'.,,'___"-'""- ,~~"'i:,k; ""~-,Nr"''''&;'.,;~;..l'~~. ._-,,-,-~..... . 13. The Resident may approve or refuse the release of personal and clinical records to any individual outside the Facility except when: a.The Resident is transferred to another health care institution. b.Record release is required by law or a third party payment contract. 14. The Resident has a light to voice grievances with respect to treatment or care that fails to be fur- nished, without discrimination or reprisal for voicing grievances. 15. The Resident has a right to prompt efforts by the Facility to resolve grievances, including those with respect to the behavior of other Residents. 16. The Resident has a right to examine the results of the most recent survey of the Facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the Facility. 17. The Resident has a right to receive information from agencies acting as client advocates and be afforded the opportunity to contact the agencies. 18. The Resident has a right to refuse to perform services for the Facility. 19. The Resjdent has a right to agree to perform voluntary or paid services for this Facility if he or she desires, if there is no medical reason which would contradict the pelforming of the services, and if compensation for paid services is at or above prevailing rates. 20. The Resident has the right to privacy in written communications, inclnding the right to selld and receive mail promptly that is unopened. The Resident has a right of access to stationery, postage, and writing implements at the Resident's own expense. 21. The Resident has the right to immediate access to any of the following: a. Any representative of the Secretary of the U.S. Department of Health and Human Services. b. Any representative of the State. c. The Resident's individual physician. d. The State's long -term care ombudsman. e. The agency responsible for the protection of and advocacy system for mentally ill or devel- opmentally disabled individuals. f. Subject to the Resident's right to deny or withdraw consent at any time, immediate family or other relatives of the Resident or others who are visiting with the consent of the Resident. 22. The Facility must provide reasonable access to any Resident by an entity or individual that pro- vides health, soCial, legal, or other services to the Resident, subject to the Resident's right to deny or withdraw consent at any time. . 23. The Resident has a right to have reasonable access to the private use of a telephone. 24. The Resident has a right to retAin and use personal possessions, including some furnishings and appropriate clothing, as space permits, unless to do so would infringe on the rights or health and safety of other Residents. 12 25. The Resident has a righqo share aroom.withhis or her spouse when married Residents live in the same Facility and both spouses consent to the arrangement. 26. Each Resident has a right to self-administer drugs unless the Facility interdisciplinary team has determined for a particular Resident that this practice is unsafe. 27. The Resident has a right to be free from any physical restraints imposed or psychoactive drugs administered for the purposes of discipline or convenience, and not required to treat the Resident's medical symptoms. 28. The Resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal pun- ishment and involuntary seclusion. 29. The Resident has a right to choose activities schedules and health care consistent with his or her interests, assessments, and plans of care. 30. The Resident has a right to receive advance notice of transfers or discharges of the Resident as required by law. The Resident has a right to receive notice before the Resident's room or roommate is changed. 31. The Resident has a right to organize and participate in Resident groups in the Facility, and the Resident's family has the right to meet with families of other Residents. 32. The Resident has a right to participate in social, religious, and community activities that do not interfere with the rights of other Residents. 33. The Resident has a right to reasonable accommodation of individual needs and preferences except where the health or safety of the Resident or other Residents would be endangered. 34. The Resident has a right to freedom of choice of providers in accordance with applicable law and subject to the provider's compliance with all applicable laws and reasonable rules and regulations of the Facility. 13 .--, .......,..~....-,...,'''T"''',...._---,~-~----------:-- ".,'L '_'", '_, , "' -~ 1{_',. FACILITY POLICY REGARDING IMPLEMENTATION OF PATIENT SELF-DETERMINATION ACT The foIlowing information is being provided to the Resident as a result of a Federal law which requires cer- tain health care institutions, including nursing homes, to disclose to the Resident his or her rights under Federal and State law to make decisions regarding his or her health care. This Facility recognizes the dignity and value of each Resident's life and the right of each Resident to make decisions regarding his or her care. Where a Resident is incomp'etent, this Facility recognizes the Resident's right to have these decisions made on hislher behalf by a substitute decision-maker in accordance with State law. This Facility recognizes the right of each Resident to utilize those advance directives recognized under State law and will honor advance directives developed in accordance with State law and consistent with the level of care this Facility is licensed to provide. An advance directive is a written document that states 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 are examples of advance directives. An advance directive is not necessary in order to be admitted to or to continue to reside in this Facility. However, if the Resident has an advance directive, he or she must make it known to the Facility's Administrator or designee so that it can be reviewed and made a part of his or her medical record. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Facility Administrator. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician, and attorney. ,,' , 14 )"l'",-, -----~-,,~"',,"'...,I~ - ,'", '" . . . . RESIDENT-SPECIFIC INFORMATION [~:te This Facility accepts the following types of payments: (Check all that apply.) [ ~edicare L~diCaid ~ans Administration PARTIES The parties to this Agreement are: ~R rIi vJ (Name of Facility) ELLE N (Name of Resident) 1YI(j55e!: (Name of Resident's Agent) SA-I1I'0 t(A /f/IJA fA S J (Name of Resident's Legal Representative) If a Legal Representative signs, check the Type of Legal Representative (below): [ ] Conservator of Person [ ] Guardian #urable Power of Attorney [ ] Conservator of Estate for Health Care (DPAHC) [ ] Other, specify [ ] Agent Acting Under General POA If you are signing this Agreement on behalf of the Resident, note your relationship to the resident: \~'r ReI . onship to Resident On this, de(- day of Afi,' L , 19~, the above parties agree that on the ,;2 </ day of /j (Jrf!. I L ,19 ~ the Resident shall be admitted to this Facility; As of that day, the Facility shall pro- vide the services described in this Agreement to the Resident until the date of the Resident's discharge or transfer. The Resident shall pay for the services provided by the Facility according to the terms of this Admission Agreement. ACKNOWLEDGEMENTS By signing the Admission Agreement Signature Page, the Resident/Agent/Legal Representative acknowl- edges that he or she has been given and has read this Agreement in its entirety, and all addendums. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not applicable, write N/A): 5 \.. it. 1. A list of supplies and services that are included in the Facility's private daily rate or that will be paid for by the Medicaid or Medicare programs and a list of supplies and services not included in the Facility's private daily rate or paid for by the Medicaid or Medicare programs for which the Resident will be separately charged. White - Business Office 15 Pink - Medical Records Yellow - Resident . . ~ (1) en ~. W a z ~ :::c, " i i r;::-! I f'"' rtl I "(' I [ , , , ~ (1) ?' Z 9 ~ ,~- . . . . $Li;. 2. Information about the Facility's bed hold procedures. SUi. 3. A written explanation of how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these benefits. S\.ii.. 4. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuse/theft of resident personal property in the Facility. SL\\ 5. Copies of the State Resident Rights. '.II..'" 6. A written explanation of the Facility's Rules and Regulations. SI.." 7. 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. 'ilL\(. ,,8. A copy of the facility policy regarding implementati<5'ri' of the Patient Self Determination Act and of the applicable State law. I do _ do not 0ave an advance directive. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. NOTICES Notices shall be mailed to the addressees) indicated below. The Agent and/or Legal Representative is responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provid- ed to the Resident, Agent, and/or Legal Representative. ~j"T LEGAL REPRESENTATIVE AND/OR AGENT "IJ '1>R1A Name,)--1a/i)RA KfiJAU'S') Home Phone ?Y:J--s6'1(j WorkPhone S&I-Y79,2 Street (Q LAUREL ~a City 2NfJLA State PA- Zip /'/o,J-S S<'M.;y, l/If IN OTHER PERSON TO BE NOTIFIED ~POI). Name Rr\ b-Pt? --r- )( /l"A U 55 Home Phone '/J;} -S'??o Work Phone "110 -(,,&'J8 Street (~ [4- U (lSCl-- )) C?. State P /T- Zip 1';>0 ;;LS City r' & No L 4- White - Business Office 16 Pink - Medical Records Yellow - Resident '''''',1 :;0 " rn ~ ::> - z S ~ 1(1 " r-- , t{l C :;0 " rn Z 9 MAn_ .., 'the Facility is authorized to handle the Resident's mail as follows: (Cheek P!!~ box only,) [ J All mail given directly to the R,:sidenl [ ] All mail read to the Re,:ident r] FOfl'iiard all of the Resident's mail to: [ J Give personal mail to the: Hesident; forward busilless mail to: 8' 0', ~. Q. '" g Z '" S ;C; RESIIJEN'PS l'IWSICiAN NAME: & ~ SPECIAI.:T'Y: ADDRESS: TELEPHONE: 5 , ~ ('t !' Z '? ~ Whif.'i~ - Bu'.~iness onke i 7 Pink ~ Mt~di~a! Re.cord"~ )"clIuVl" Resident --,---- IIl'1;, ,.,.,:;. ,t RESIDENT TRllST FUNl> AUTHORIZATION A Residlml Tmst Fund i~ 'In 'ImO~lnt of money hdd by the Facilily for Ih<, ResidcllI's perso""l u.s,'. (Exampks of liRe: 'l\) allow the rer;kl\~n! to pay for room and board, be.auly shop (,harges, cigarelteR, postage stamps, or other similar expenses as desired by tht, Resident,) By signing below, tbe R"s1d"nt authodz", the Fadlity to set up a trust fund in his/her name" The individual financial recordR Rhall lx, available through qmuierly statemeHts, and Oil request, to the Resident or hislh,'r Agent or Legal Representative. 'rile Resident understands that all wilhdmwals shall be authorized by the Rt,sidcnt ()," his/her Agent or 1.,e[2,31 Representative in writinif. The following persons may authorize. wit!l~ drav,;als on the R,,,jdel1t'r, behall": Name of Authorized Person Resident's Signature Witness if Resident Signed './lith a Milrk Witness if Rec,i,knt Signed with a Mark ------~.~.._~-",._.._~,-..~..._,----,-^..._.,._--_._._"'_.~--._- L::~gal RC',prescntative,~s Signature (il" applkable) ~ ~ ---,,-----,~-,_._-----------._.._,----.~, ,_..~-~--~---~,~.~ Ag("':nt ~s Signature (if applicable) Whtl~ ,.,. BllSinl;~s.'i OHke Name of .Amhorized Person Dale Dat" Date Dak Dut'" I~ Pink ",' ~'ledk'ul! R(~(:utrJ'; y c;rHo~'-\; v. Rt.~:~kktit " , .. .. ADMISSION AGREEMENT SIGNATURE PAGE Resident Date Witness if Resident Signed with a Mark Date Witness if Resident Signed with a Mark Date y Sa..,..~u. ,8. ~'Y\GVJv.:, IJ?OR Legal Representative -'\ \ ",\q(p Date -( ) Legal Representative's Telephone Number Legal Representative's Social Security No. Agent Date ( ) :C:::;r~ Ac Facility Administrator or Designee Agent's Social Security No. L;',JY~'l0 Date Note: The signatures above refer to the information contained on pages 1 through 18 of the Beverly Enterprises Admission Agreement. White - Business Office ]9 Pink - Medical Records Yellow - Resident ", ::tl fR ~. p.. g - z S r! Ii " , , \Ii '\- (- In t ~ '" z p '""" ~ C>(! :;V ,;Jan-.05-00 . . . . . " on .. e n .... - " z .... ...... ...." ...... --- . . , ...... ...... --- --- ...... '" ...... ............ .. .. . ... .. - < ~ .. --- ...... 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Tl"lomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named defendant, DEFENDANT MUSSER ELLEN D but was unable to locate Her in his bailiwick. He therefore returns the NOTICE & COMPLAINT , NOT FOUND , as to the within named DEFENDANT , MUSSER ELLEN D DEFENDANT IS DECEASED Sheriff's Costs: Docketing Not Found Return Affidavit Surcharge 6.00 5.00 .00 10.00 .00 21.00 ~~rs'/ ,~ ~..-- /' , -,8'"N$ ~ : Thomas Kline ~ Sheriff of Cumberland County CAPOZZI & ASSOCIATES 01/18/2000 SworD and subscribed to before me this .J AU"- day of 1...L ,. .., A.D. ~C1~ 1M~.~ othonotary . .\, ~-~ ~, .. . e... SHERIFF'S RETURN - REGULAR CASE NO: 2000-00230 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BEVERLY HEALTH AND REHAB VS MUSSER ELLEN D ET AL ROBERT L. FINK Sheriff or Deputy Sheriff of Cumberland County, Pensylvania, who being duly sworn according to law, says, the within NOTICE & COMPLAINT was served upon KNAUSS SANDRA the DEFENDANT , at 0016:15 HOURS, on the 14th day of January , 2000 at 6 LAUREL DRIVE ENOLA, PA 17025 by handing to ROBERT KNAUSS (HUSBAND) a true and attested copy of NOTICE & COMPLAINT together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 9.30 .00 10.00 .00 37.30 So Answers: ~~nV.t:~~ R. Thomas Kline 01/18/2000 CAPOZZI & ASSOCIATES Sworn and Subscribed to before BY~, /yt/ 2J9f / Deputy Sheriff me this ;),.J- day of .J .J,.." '''1 ,hv-r] A. D . Q~". 0 nu PL A~'-;:- rothonotary , / ~"'" ' - i _ BEVERLY HEALTH AND REHABILITATION SERVICES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2000-230 vs. MS. ELLEN D. MUSSER and MS. SANDRA L. KNAUSS, Individually and as Attorney in Fact for MS. ELLEN D. MUSSER, Defendants CIVIL ACTION - LAW NOTICE 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 New Matter, Counterclaim and Notice are servedt 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 cl.aimed in the New Matter and Counterclaim 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717)249-3166 (800) 990-9108 NOT I C I A Le han demandado a usted en la corte. si usted guiere defenderse de estas demandas expuestas en las paginas siguientes, listed tiene viente (20) dias de plazo al partir de la fecha de la demanda y la notificacion. Usted debe presenter una apariencia escrita 0 en persona 0 por abogado y archivar en la corte en forma escri ta sus defenses 0 sus obj eciones alas demandas en contra de su persona. Sea avisado gue si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso 0 notificacion y par cualquier queja 0 alivio que es pedido en la peticion de demanda, Usted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO INMEDIATAMENTE. SI NO TIENE ABOGADO 0 81 NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME FOR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSE~UIR ASISTENCIA LEGAL. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717)249-3166 (800) 990-9108 knauss\anSVler -' f BEVERLY HEALTH AND REHABILITATION SERVICES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2000-230 vs. MS. ELLEN D. MUSSER and MS. SANDRA L. KNAUSS, Individually and as Attorney in Fact for MS. ELLEN D. MUSSER, Defendants CIVIL ACTION - LAW ANSWER OF DEFENDANT SANDRA L. KNAUSS 1. Admitted. 2. Denied. Defendant Ellen D. Musser is a deceased person who died on April 16, 1999. 3. Denied. Defendant Knauss lives as is averred in this paragraph. However, her first name is Sandra and not Diane. 4. Admitted in part and denied in part. The care terminated at the death of Ms. Musser on April 16, 1999. The balance of this averment is admitted. 5. Denied. See Paragraphs 2 and 4 incorporated herein by reference. 6. Admitted. 7. Denied. Defendant Knauss hasn't represented herself as such since the demise of Ellen D. Musser, as heretofore pleaded. 8. Admitted in part and denied in part. It's denied that Ms. Knauss ever acted as the legal representative of anyone. It's admitted that she acted as the attorney-in-fact for Ms. Musser from October 3, 1995 to April 16, 1999. It's also denied that Ms. Musser was admitted on March 27, 1998. On the contrary, Ms. Musser was admitted on or about April 24, 1996. 9. Denied. See answer to Paragraphs 7 and 8. 10. No further answer required. 11. Admitted, but such request was made by Defendant Knauss acting for her principal, Ms. Musser. 14. Denied. After reasonable investigation, Defendant Knauss is f 12. Admitted. 13. Admitted. without information to form an opinion as to the truth of this averment. The same is denied and proof thereof is demanded at trial, if relevant. 15. Admitted. 16. Admitted. 17. Denied. Defendant Musser wasn't a party to this Agreement. 18. Admitted. 19. Admitted in part and denied in part. While services were provided, they were rendered in a grossly negligent and careless manner, resulting in grievous injuries suffered by Ms. Musserl all of which are more fully set forth in the Counterclaim which is part of this answer. 20. Denied. Defendant Musser wasn f t a competent person during any part of her being a patient at Plaintiff's facility, and therefore couldn't accept anything. 21. Admitted in part and denied in part. It's admitted that a balance is due to Plaintiff per their billing. It's denied that Defendant Knauss paid rrnothing". On the contrary, Defendant Knauss paid substantial sums to Plaintiff I out of Ms. Musser r s assets f for which Ms. Knauss acted as her power of attorney. 22. Denied. Defendant Knauss no longer has any of these records. 23. Admitted in part and denied in part. While Defendant Knauss has not paid to Plaintiff the full amounts invoiced to Defendant Musser, she paid to the full extent that funds were available from MS. Musser's checking account. 24. Denied. See Paragraph 21 answer, incorporated herein. 25. Admitted. - f 26. Denied. No exhibit D was attached to the Complaint. This averment is therefore denied. 27. Denied. No such representation was made. 28. Denied. Defendant Knauss has no such recollection. 29. Admitted in part and denied in part. Defendant Knauss has no recollection of such an agreement, and/or any provision as to attorney fees. WHEREFORE, Defendant Knauss requests the Court to enter judgment in her favor. 30. No further answer required. 31. Admitted. 32. Admitted. 33. Admitted. 34. Admitted (i. e., through the Agreement signed by her attorney-in- fact) . 35. Admitted. 36. Admitted in part and denied in part. Admitted only that she failed to pay the entire balance. 37. Denied. The contract is an express contract per Exhibit liB". 38. Admitted. 39. Admitted. 40. Admitted in part and denied in part. The services were negligently rendered, see Counterclaim as filed. 41. Denied. Defendant Knauss paid whatever funds of Musser that were available. WHEREFORE, the Court is requested to dismiss this County of the Complaint against Defendant Knauss. 42. The re@pective answers to these paragraphs are incorporated herein. 43. Admitted. - b T 44. Admitted. 45. Admitted. 46. Denied. Paragraph 41 answer is incorporated herein. 47. Admitted. 48. Admitted. 49. Denied. Paragraph 41 is incorporated herein. paragraph pleads a conclusion of law. WHEREFORE, the Court is requested to dismiss this Count of the Further I this Complaint. 50. The respective answers are incorporated herein. 51. Denied. This paragraph pleads a conclusion of law. 52. Denied. This paragraph pleads a conclusion of law. 53. Denied. This paragraph pleads a conclusion of law. 54. Denied. This paragraph pleads a conclusion of law. 55. Denied. Defendant Knauss was not the legal representative of Musser. 56. Denied. This paragraph pleads a conclusion of law. 57. Admitted. 58. Denied. Paragraph 55 is incorporated herein. 59. Denied. Paragraph 55 is incorporated herein. Defendant Knauss is not an attorney and is no auels legal representative. 60. Denied. Paragraph 41 is incorporated herein. 61. Denied. Paragraphs 41 and 59 are incorporated herein. 62. Denied. Paragraph 41 is incorporated herein. 63. Denied. Paragraph 41 is incorporated herein. 64. Denied. Paragraph 41 is incorporated herein. WHEREFORE, the Court is requested to dismiss this Count of the Complaint. 65. The respective paragraphs of the Answer are incorporated herein. ~ ~~~~d~..~~ illJlrtl'lIIDil_lllili"Ji\h~iIlIl~~- '.,~~~ " ." - ", ~,<",' ..4,__ """~., .", . =,.- ,<" '.~'~-'- I T . ..~. ,,,~,,~:..' ,~I 66. Admitted. 67. Admitted. 68. Admitted. 69. Admitted. 70. Admitted. 71. Denied. 72. Denied. She had no such ability. This averment pleads a conclusion of law and requires no further answer. 73. Denied. Defendant Musser is a deceased person. NEW MATTER 74. Defendant Musser died on April 16, 1999. 75. No personal representative has ever been appointed for her estate. 76. Defendant Knauss believes and thus avers that the cause of action pleaded by Plaintiff (although not in a separately numbered Count) for vicarious liability for her mother, cannot be asserted retroactively beyond the filing date of the Complaint. 77. Not only did Defendant Knauss use her mother's funds to the full extent available, to pay Plaintiff 1 s invoices, but said Defendant used a large amount of her own funds to buy and provide clothing, special food items, wine and cigarettes, all for her mother. 78. Defendant Knauss is of moderate financial means and needs and uses all of her disposable income to provide for her own support, maintenance, health and welfare. 79. The aforesaid financial condition of Defendant Knauss existed during her mother's residency at Plaintiff's facility and continues today. , . --- , , ~ . .',,1 80. Additionally, Defendant Knauss has had no disposable income during any of the period of time, since she has been constantly endeavoring to pay past due bills and keep her head above water. COUNTERCLAIM 81. Plaintiff's care for Defendant Musser at the facility was grossly negligent, in that the facility, due to lack of care and attention or negligent care and attention repeatedly allowed Defendant Musser to fallout of her bed and chair. 82. Plaintiff failed to provide proper care and maintenance and to hire employees who attended patients! including Defendant Musser, with negligent care and gross inattention. 83. By virtue of the foregoing, Defendant Musser fell out of her bed and chair repeatedly and suffered gruesome injuries, such as: a. broken right hip b. broken right wrist c. Ubiquitous bruises, contusions and hematomas resulting from falls 84. All of the foregoing injuries were a result of the Plaintiff I s negligent care of Defendant Musser, which caused her great pain and suffering. 85. By virtue of the egregious conduct and gross and repeated negligence of Plaintiff, her estate is entitled to punitive damages in addition to compensatory damages. WHEREFORE, Defendant Knauss requests the Court to enter judgment in her favor in an amount in excess of the amount requiring compulsory arbitration -;" "-i in cumberland County, and such damages are also claimed as a set-off against any liability which would otherwise be found against Defendant Knauss. YOFFE By ( ) NO M. YOFFE, E QUIRE Attorney for Defendant Sandra L, Knauss 214 Senate Avenue, Suite 203 Camp Hill, PA 17011 (717) 975-1838 Attorney ID No. 07135 knauss\answer . '--J " BEVERLY HEALTH AND REHABILITATION SERVICES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2000-230 vs. MS. ELLEN D. MUSSER and MS. SANDRA L. KNAUSS, Individually and as Attorney in Fact for MS. ELLEN D. MUSSER, Defendants CIVIL ACTION - LAW VERIFICATION I hereby state that I am an adult individual who is authorized to make this verification and that the facts set forth in the foregoing Answer, New Matter and Counterclaim are true to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. s4904 relating to unsworn falsification to authorities. Dated: .~ \ 11\ ()(.) s~ :s.~~ SANDRA L. KNAUSS knauss\answer _~IA!lt"'I' l.,,\1Mi~~""'='=""'-"G;'~~"~I~~~-'~ilkL,t,- "'-" " ^,"' ,^ ~ " . ~ >, ~- ~= ,~ ~ "- ',_k "', t~-- --,,,,,/--, ,l':({ f.'-- "--:'7 -< - ~ ". ~ { D ("" .;:::.:;- -. \.'----, [1)/----' <::::> <::::; -> 0) ~~h :;j .~1~iff ;<J'~J' _C;;-" ::',"j !'\.,J ':::J ::<? -~, ,;~~i~;? "-,, -I..J ~5R :b! ::'D "" <:- _.. (.\:) , ~ , Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 And Ms. Sandra L. Knauss 6 Laurel Drive Eno1a, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, ... w _, "," '" '.- ~ --;'1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CNIL COMPLAINT NO. 2000- 230 NOTICE TO PLEAD TO: DEFENDANT, SANDRA KNAUSS, You are hereby notified and required to file a written response to the written preliminary objections of Plaintiff, West Shore Health, within twenty (20) days from the service hereof or a judgment may be entered against you. Respectfully submitted, Date: l.-[- OJ - 2.oDo . James, Esq' e I ation # 68214 3109 North Front Street Harrisburg, P A 1711 0 (717) 233-4101 Attorneys for Plaintiff - . ~ " '_',C , ~'<h>, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000- 230 And Ms. SaIldra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, ORDER And now, upon consideration of the Preliminary Objections ofthe Plaintiff to Defendant's Counterclaim, any answer thereto and the responsive briefs of the parties, if any, it is hereby Ordered and Decreed that said Preliminary Objections are sustained and Defendant's Counterclaim is dismissed in its entirety, with prejudice. DATED ,2000. BY THE COURT: J. -., :. .' _"-,,,_.,-,,,,", ~c ~'" , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 170 II Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000- 230 And Ms. Sandra L. Knauss 6 Laurel Drive Enol<\, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, Preliminary Obiections ofthe Plaintiffto Defendant's Counterclaim AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a West Shore Health and Rehabilitation Center, 770 Poplar Church Road, Camp Hill, P A 17011 by and through its attorneys, Capozzi & Associates, P .C., preliminarily objects to Defendant's counterclaim pursuant to Pa. R.C.P. 1028 (a)(2), (3), (4) and avers as follows: 1. A copy of the Defendant's Answer, New Matter and Counterclaim is attached hereto and referenced as Exhibit "A". ~ " .--""" ,-.- - " Failure of the Pleadiug to Couform to Rule Pursuant to Pa. R.C.P.1028(a)(2) 2. Attorney Y offe has not signed the pleading. 3. Pursuant to Pa. R.C.P. 1023, the attorney of record is required to sign the Pleading. 4. Attorney Y offe, as the attorney of record is required to sign the Pleading. Wherefore the Plaintiff prays this honorable court to dismiss Defendant's pleading for failure to conform to the Pennsylvania Rules of Civil Procedure. Insufficient specificity ofthe Pleading Pursuant to Pa R.C.P. 1028(a)(3) 5. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant pmports to establish a negligence claim. 6. Defendant's paragraph 81 states a conclusion oflaw. 7. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 8. Pa. R.C.P. 1019(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 9. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 10. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant fails to state the material facts m " upon which the defendant is relying to conclude the Plaintiff is guilty of gross negligence. 11. In paragraph 82 of Defendant's Answer, New Matter and Counterclaim, which is the second paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 12. Defendant's paragraph 82 states a conclusion oflaw. 13. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 14. Pa. R.C.P. l019(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 15. In paragraph 82 of Defendant's Answer, New Matter and Counterclaim, which is the second paragraph ofthe Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 16. In paragraph 82 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant fails to state the material facts upon which the defendant is relying to conclude the Plaintiff is guilty of gross negligence. 17. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 18. Defendant's paragraph 83 states a conclusion oflaw. 19. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. M L' , .-&:::i1 20. Pa. R.C.P. 1019(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 21. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 22. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph ofthe Counterclaim, Defendant fails to state the material facts upon which the defendant is relying to conclude the Plaintiff is guilty of gross negligence. 23. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 24. Defendant's paragraph 84 states a conclusion oflaw. 25. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 26. Pa. R.C.P. IOI9(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 27. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 28. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant fails to state the material facts ~, ~- upon which the defendant is relying to conclude the Plaintiff is guilty of gross negligence. 29. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 30. Defendant's paragraph 85 states a conclusion oflaw. 31. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 32. Pa. R.C.P. lOl9(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 33. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 34. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant fails to state the material facts upon which the defendant is relying to conclude the Plaintiff is guilty of gross negligence. Wherefore the Plaintiff, West Shore Health respectfully requests this honorable court to enter judgment in favor of Plaintiff and to dismiss Defendant's counterclaim, in its entirety, with prejudice. ~ ' ' -','I II 1.1., , II 1,1 1.1 :'1 ~I 1,1 'II. Ii 1 I' II 'I I. I r I' t ;:1 35. Lel!:al Insufficiency ofthe Pleadinl!: Pnrsuant to Pa R.ep 1028(a)(4) I II II II I I I , 36. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 37. Defendant's paragraph 81 states a conclusion oflaw. 38. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 39. Pa. R.C.P. 1019(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 40. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 41. In paragraph 81 of Defendant's Answer, New Matter and Counterclaim, which is the first paragraph of the Counterclaim, Defendant fails to set forth a cause of action against the Plaintiff, West Shore Health, upon which relief may be granted. 42. In paragraph 82 of Defendant's Answer, New Matter and Counterclaim, which is the second paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 43. Defendant's paragraph 82 states a conclusion oflaw. 44. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 45. Pa. R.C.P. 1019(a) states "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. :f 46. In paragraph 82 of Defendant's Answer, New Matter and Counterclaim, which is the second paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 47. In paragraph 82 of Defendant' s Answer, New Matter and Counterclaim, which is the second paragraph of the Counterclaim, Defendant fails to set forth a cause of action against the Plaintiff, West Shore Health, upon which relief may be granted. 48. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 49. Defendant's paragraph 83 states a conclusion oflaw. 50. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 51. Pa. R.C.P. 1019(a) states, "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 52. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 53. In paragraph 83 of Defendant's Answer, New Matter and Counterclaim, which is the third paragraph of the Counterclaim, Defendant fails to set forth a cause of action against the Plaintiff, West Shore Health, upon which relief may be granted. 54. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant purports to establish a negligence claim. " 'i 'I I" " !I ! i I,! j'l , i l,' ), 11 "'I Ii I' II Ij 'i I I I I I' l '" 55. Defendant's paragraph 84 states a conclusion oflaw. 56. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 57. Pa. R.C.P. 1019(a) states, "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 58. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. 59. In paragraph 84 of Defendant's Answer, New Matter and Counterclaim, which is the fourth paragraph of the Counterclaim, Defendant fails to set forth a cause of action against the Plaintiff, West Shore Health, upon which relief may be granted. 60. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant purports to establish a negligence claim. 61. Defendant's paragraph 85 states a conclusion oflaw. 62. Defendant Knauss alleges injury to Defendant Musser only in vague terms that are unsupported by any specific reference to time, date, place or actions. 63. Pa. R.C.P. 1019(a) states, "The material facts on which a cause of action or defense is based shall be stated in a concise and summary form. 64. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant fails to state the material facts on which a cause of action or defense is based in a concise and summary form. >, . ,-- -, ~ ' ~, ',,",-- ~-"' ">>""-- - '~~' 65. In paragraph 85 of Defendant's Answer, New Matter and Counterclaim, which is the fifth paragraph of the Counterclaim, Defendant fails to set forth a cause of action against the Plaintiff, West Shore Health, upon which relief may be granted. Wherefore the Plaintiff, West Shore Health respectfully requests this honorable court to enter judgment in favor of Plaintiff and to dismiss Defendant's counterclaim, in its entirety, with prejudice. Lack of Capacity to Sue Pursuant to Pa. R.C.P. l020(a)(5) 66. On information and belief, no Estate has been opened for Defendant Ellen Musser. 67. On information and belief Defendant Sandra Knauss is not the executrix for the Estate of Ellen Musser. 68. Defendant Knauss has averred she is not the personal representative for Defendant Musser. 69. The Answer and New Matter filled by Defendant Knauss admits no personal representative for the Estate of Musser. 70. Defendant's attorney, Norman Yoffe has signed all pleadings as attorney for Defendant Sandra Knauss. 71. On information and belief Attorney Y offe is not the attorney for decedent, Defendant Ellen Musser. 72. No Answer has been filed for Defendant Musser. 73. Defendant Knauss has not alleged the nursing services delivered by Plaintiffto Defendant Musser caused Defendant Knauss hann. 74. Defendant Knauss as no standing to sue on behalf of Defendant Musser. - ."-', , ' ',j Wherefore the Plaintiff, West Shore Health respectfully requests this honorable court to enter judgment in favor of Plaintiff and to dismiss Defendant's counterclaim, in its entirety, with prejudice. Respectfully submitted, ,P.C. J a C. James, Esquire I tificat n # 68214 310 Front Street Harrisburg,PA 17110 (717) 233-4101 Attorneys for Plaintiff Beverly Health and Rehabilitation Services, Inc., d/b/a West Shore Health and Rehabilitation Date: VC-03'~ "I IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000 - 230 Ms. Sandra 1. Knauss. 6 Laurel Drive Enola, P A 17025 IndiVidually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, VERIFICATION I, Jason Hershey, do hereby verifY that the facts made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the enalties contained in Title 18 of the Pennsylvania Consolidated Statute tion 490 ,relating to unsworn falsification to authorities. Date: f#o . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000- 230 Ms. Sandra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, CERTIFICATE OF SERVICE I certify I am serving a copy of the above captioned Preliminary Objections of the Plaintiff to Defendant's Counterclaim and Plaintiff's Reply to Defendant's Answer and New Matter and Counterclaim upon the person and in the manner indicated below. Service by First-Class, U.S. Mail Return Receipt, addressed as follows: Norman Y offee, Esquire 214 Senate Avenue, Suite 203 Camp Hill, Pennsylvania 17011 Date: "1- 03. U::OQ JON THAN C. JAMES, Esquire entification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, P A 17110 (717) 233- 4101 )W; lo;,.j~HiiIl~~~~ ,,11l~,~",.. -'1 __ rr1T"",~""",....[l'li!" -'J__' ,= .,'1 _0 _"< uu ~ ..........~ ".~ .~.,' "Ill ~ """,< o C ?: -0 en mrn 2:0:1 ~:; c:tj ~t; -. ~-....-l .f :SC) )>e: ~ cc .. - . . o o .". ~o ;;0 I .;:- o ., .-, cl.~~"';'~ J] ,~ ~r~8 (:) ).., ~)~~ ,~o .,o:"rn o -.~l :> :r;! ~ --0 ::1': r.- en -....-~ ,,',_d", ~ "'. i . .. JONATHAN C. JAMES, Esquire Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, P A 1711 0 (717) 233- 4101 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000- 230 And Ms. Sandra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, Plaintiffs Reply to Defendant's Answer and New Matter and Connterclaim AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a West Shore Health and Rehabilitation Center, 770 Poplar Church Road, Camp Hill, P A 17011 by and through its attorneys, Capozzi & Associates, P .C., and avers as follows: 74. Admitted. 75. Plaintiff is unable to form a responsive pleading to this averment. Strict proof will be demanded at trial. 1 h ~'~, _ ,"'"," , >v" "0 1&;.; r . 76. Defendant's averment constitutes a conclusion oflaw to which no responsive pleading is required. To the extent Defendant Knauss purports to escape liability the averment is denied. 77. To the extent the Defendant Knauss purports to escape liability the averment is denied. Plaintiff is without sufficient knowledge to affirm or deny that Defendant Knauss used all of Defendant Musser's funds to pay Defendant Musser's nursing care and services. Plaintiff avers the past due vbalance of Defendant Musser speaks for itself. Plaintiff avers Defendant had a fiduciary duty to timely apply for Medical Assistance and did not do so which caused a substantial debt to accrue. Plaintiff avers Defendant had a duty to use all of Defendant Musser's funds to pay for her nursing and services. 78. Plaintiff cannot confirm or deny this averment. Therefore it is denied and strict proof will be demanded at trial. 79. Plaintiff cannot confirm or deny this averment. Therefore it is denied and strict proof will be demanded at trial. 80. Plaintiff cannot confirm or deny this averment. Therefore it is denied and strict proofwill be demanded at trial. WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendant Knauss in an amount in excess of $14,494.49, plus interest, attorney fees and court costs from the date of the Court's judgment. 2 , -~ ,I . 0' "' __*'_ ~_ Ii,' . . 81. Defendant's averment constitutes a conclusion of law to which no responsive pleading is required, otherwise it is denied. Strict proof will be demanded at trial. 82. Defendant's averment constitutes a conclusion oflaw to which no responsive pleading is required, otherwise it is denied. Strict proof will be demanded at trial. 83. Defendant's averment constitutes a conclusion oflaw to which no responsive pleading is required, otherwise it is denied. Strict proof will be demanded at trial that any aspect of Defendant Musser's care was negligent. With respect to Defendant Knauss's averment Defendant Musser suffered specific injuries which were the result of Plaintiff s negligence it is denied and strict proof will be demanded at trial. 84. Defendant's averment constitutes a conclusion oflaw to which no responsive pleading is required, otherwise it is denied. Strict proof will be demanded at trial that any aspect of Defendant Musser's care was negligent. 85. Defendant's averment constitutes a conclusion oflaw to which no responsive pleading is required, otherwise it is denied. Strict proof will be demanded at trial that any aspect of Defendant Musser's care was negligent. 3 . " ,k,,,,- -,'"" WHEREFORE, Plaintiff respectfully requests that the honorable Court dismiss the Counterclaim of Defendant. Plaintiff respectfully requests that the honorable court enter judgment in favor of Plaintiff and against Defendant Knauss in an amount in excess of $14,494.49, plus interest, attorney fees and court costs from the date of the Court's judgment. Date:*/~ Respectfully submitted, Jo athan C. James, Esq Id tification # 68214 9 North Front Street Harrisburg, P A 1711 0 (717) 233-4101 Attorneys for Plaintiff Beverly Health and Rehabilitation Services, Inc., d/b/a West Shore Health and Rehabilitation ";"',.-, - ~- '. ,~. '~ ,,: -, r:~ ;'11 c ;1j i' ii n i" li~ ;1 :j ! '~ 1':1 1,;1 i :~ r-'1 !:l n H ., ,] ::1 !,l II k II [I I,j II ~l 1'1 , ri ['1 II :;! 'I ::i ',\ ~~ II l'l 11 l~ l~ I ;j il i,~ lJ l~ il !j II 11 !I ~ !1 )~ il I~ I l i 4 r 1ilIIilIo..- I C> ,-, ~ ot.;...;:~_ ~' ,"1"_ -, ,0., 'i,,'! IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000 - 230 , " I I ~ :j H !I I 'i II " Ii ~ I l I 'I ~ ~ i! II [I I I I , I ! 'i I, ! I I Ms. Sandra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, VERIFICATION I, Jason Hershey, do hereby verifY that the facts made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the enalties contained in Title 18 of the Pennsylvania Consolidated Statutes tion 490 , relating to unsworn falsification to authorities. Date: r~ -"' JONA C. JAMES, Es . e Iden' cation No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, P A 1711 0 (717) 233- 4101 "I Ii II :1 q fl !'l 1,1 I' !I M ~ 1 ~'1 II j, d Ii f'j 1:1 i-l ~,j H Ii II I, ~1 r1 !! II I, Ii II ij Ii 1'1 Ii Ii " fj II " 'I I, II I' II II II I. II 'I II !I " 11 !! i1 II il " :j II I . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000- 230 Ms. Sandra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, CERTIFICATE OF SERVICE I certify I am serving a copy of the above captioned Preliminary Objections of the Plaintiff to Defendant's Counterclaim and Plaintiff's Reply to Defendant's Answer and New Matter and Counterclaim upon the person and in the manner indicated below. Service by First-Class, U.s. Mail Return Receipt, addressed as follows: Norman Yoffee, Esquire 214 Senate Avenue, Suite 203 Camp Hill, Pennsylvania 17011 Date: L( ~ 3 ' Lot> ~ j~~' ',-'ai'"~ ,,^, ,~ ~ "_~l+'.""'"""'~"~''"'''''''''''''^" - m ^' , '" ',- ,",. "'-' () C <" -tJt:C rnn---' Z::c ~~ 2>.0 ~O )>C Z =< ".~> . a Cl "" -':] "'7 ! .j:- o --'-1 ,-< ;'i,:!.J ~39 :.:J(~ ~5~ 7c::rn ~ :JJ -< ..." ::?: ::- .&:- rffi . "'" PRAECIPE FOR LISTING CASE FOR ARGUMENT TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Please list the within matter for the next Argument court. (Full Caption) Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 (Plaintiff) VS. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Ms. Sandra L. Knauss 6 Laurel Drive Enola, PA 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser (Defendant) No. 230 Civil 2000 1. Pursuant to Cumberland County Court of Common Pleas Local Rule 211.2, kindly list Plaintiff's Preliminary Objections in the above referenced matter for argument. 2. Identify counsel who will argue case: (a) for plaintiff: Address: Jonathan C. James. Esquire Capozzi & Associates, P.C. 3109 North Front Street Harrisburg, PA 17110 (b) for defendant: Address: Norman Yoffee, Esquire 214 Senate Avenue, Suite 203 Camp Hill, PA 17011 3. I will notify all Parties in writing within two days that this case been listed for argument. 4. Argument Court Date: Dated: 7/24/2000 ~, Jill" <''''Miillliililillli ,~,~ >, ~" ' '" ~~ " ,,~ ~ iIIIii- ~ _0'," (') C:) C) C a ; ~'"... gJ. gJ:} L.. - c:; ,- 2C- I'j ;>~~ ~;~,: ( c. c:: c: " ~ (i_ ) " ~'~o er'-: , -~~-, '.' ,--, ~c r:Y rn ~c ?Il 2.: ,. -I -<: c -< H r~ " "' ,.~- -- ~~, -+ , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CNIL COMPLAINT NO. 2000- 230 Ms. Sandra L. Knauss 6 Laurel Drive Errola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, PRAECIPE TO LIST WITHDRAW THE MATTER FROM ARGUMENT LIST Kindly withdraw the above captioned matter from the current argument schedule. I supply the following information to assist your office: 1. This Praecipe is filed by the Plaintiffs attorney with the consent ofthe Defendant's attorney; 2. Defendant's attorney is Norman Yoffee, Esquire, of214 Senate Avenue, Suite 203, Camp Hill, PA 17011; 3. Plaintiffs attorney is Jonathan C. James. Esquire, of Capozzi & Associates, P.C., 3109 North Front Street, Harrisburg, P A 17110. - .,. I I.. .. '" j IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A West Shore Health And Rehabilitation Center 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Plaintiff, v. Ms. Ellen D. Musser 770 Poplar Church Road Camp Hill, Pennsylvania 17011 Ms. Sandra L. Knauss 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Musser Defendants, CIVIL COMPLAINT NO. 2000- 230 CERTIFICATE OF SERVICE I certify that I am serving a copy of the Praecipe To Withdraw The Matter From Argument List, service by First- Class, U.S. Mail, postage prepaid, upon the persons indicated below: Norman Yoffee, Esquire 214 Senate Avenue, Suite 203 Camp Hill, Pennsylvania 17011 Date: gjV(/~ , { ATHAN C. JAMES, Esquire Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, P A 17110 (717) 233- 4101 ~~1lIt ~ Illitllillll"".'-"~~"""'''''''''''-" '~''''''iiiflWiJ:iltiolill/liillll'lWlli- ..1,."" '""",~';'-'''>;I""c'.','," ~_" c" "~,' - I ' .", ". '-" -^ , ~"'" . ~, ,-, ~ ,,- ,., "~' , ' ," "'1 ~ \ (') <::> 0 c: C) <- -'1"1 -Ow "'" 0--1 ~ mfl' ~ ,- 2::c: G> r;'1::D Zr". r- w::t> en ~"Fi8 ~;...-:" D' ~c.."::; 0-0 ::::JQ eo -'I~ ' " z:. ~ ("::;-:Il )>0 ':-oJ ::.;;tC) c: am 2: -j =< )> \D :n -< ..~? L