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Home My WebLink About00-01145 ..-.-....;..--'.,,..,...... COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS NOTICE OF APPEAL FROM JUDICIAL DISTRICT DISTRICT JUSTICE JUDGMENT COMMON PLEAS No. .;t~- 1I'-1S {!lOd 1EA..1:Yt. NOTICE OF APPEAL Notic.e is given that the appellant has tiled in the above Court of Common Pleas an appeal from the judgment rendered by the DistrIct Justice on the date and in the case mentioned below. NAME OF APPELLANT W.AG. OI$T. NO. OR NAME Of D.J. s eq-I-o<.. ADDRESS OF APPELLANT 31\ WA-lo IV S'\~"'-t:"T DATE OF JUDGMENT 3\ DC> CLAIM NO. ~"l -oOOb '3 bC, CV YEAR LT YEAR CITY [.1.r-<:>Y~ 'i. STATE fR ZIP CODE ;70'1"">:, C4\-e.i c.'i;vl'i~ (OEFENDANT) cn:'i~I(, f!<f~ 1 . This block will be signed ONLY when Ihis nolation is required under PA. R.C.P.J.P. No. 1008S. This notice of Appeal, when received by the District Justice, will operate as A SUPERSEDEAS to the Judgment for possession in this case. If pellant was Claimant (see PA R.C.P.J.P. No. 1001 (6)) in action before district Justice, he MUST FILE A COMPLAiNT within twenty (20) days after filing his NOTICE of APPEAL. Signature of Profhonotary or Deputy PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of form to b.e used. ONLY wheJl.ap-pellant was DEFENDANT (see PA R.C.P.J.P. No. 1001 (7) in action before District Justice. IF NOT USED, detach from f?Opy of notice of appeal to be served upon appelJee. PRAECIPE: To Prothonotary Enter rule upon tAf\f I-IIW- 4\M C1.I\IT'i..~ -Name of appeJfee(s) , appellee(s), to file a complaint in this appeai (Common Pleas No..;) ~O,..,- ~ .) within twenty (20) days after service 01 r (2'ut"L ~ RULE: To Cl\f'lt=' I.W..t. C~'1 C.'\;IV"ndL Name of appe/lee(s) -- , appellee(s) (1) You are notified thala rule i~ DJlreby entered upon you to file a complaint in this appeal within twenty(20) days after the date of service of this qJle up~n you -6y personal service or by certified or registered mail. (2) If you do not file a complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU UPON PRAECIPE. (3) ~l, The date of service of this rule if serviG~ w~,s by mail is the date of the mailing. 0fPp ~ Q - Signature of P,.. CJ.9 . Year ,,;)onc) <...... onotary or Deputy fd Date: White Green Yellow Pink Gold Prothonotary Copy Court File Copy Appelant's Copy Appellee Copy D. J. Copy Ptoth. - 76 -# ... l .". ~',-, PROOF OF SERVICE OF NOTICE OF APPEAL. AND RULE TO FILE COMPLAINT (This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing the notice of appeal. Check applicable boxes) COMMONWEALTH OF PENNSYLVANIA COUNTY OF ; ss AFFIDAVIT: I hereby swear or affirm that I served a copy of the Notice of Appeal, Common Pleas No. _ , upon the District Justice designated therein on (date of service) , year D by personal service D by (certified) (registered) mail, sender's receipt attached hereto, and upon the appellee, (name _ _ ., on . year , D by personal service D by (certified) (registered) mail, sender's receipt attached hereto. D D and further that I served the Rule to File a Complaint accompanying the above Notice of Appeal upon the appellee(s) to whom the Rule was addressed on -' year ___' D by personal service D by (certifi.ed) (registered) mail, sender's receipt attached hereto. SWORN (AFFIRMED) AND SUBSCRIBED BEFOREME THIS DAY OF _~ YEAR. Signature of offICial before whom amdaVll was made o ~ ~ ~9- ~ h~ ..or-> ~ ~~ - I ::0 ~ u ~ --0 '"'1 p:, 21- ..~ -1-. ~ ~ 1" Tilfe of official My commission expires on ,.year Signature of Affiant 0 = <:) C = " -~. ~ ..." C! r[~ -n m r:-'; ~ . .. :z ~ ~ :--2': ~.. ;-..., -- .. UJ v:J .- -< 2:S ~ c..: .-. "T, ,-. :~1 -;'( z b ("') :t> t>? Orn C -.' '7 ,::,:,-': ", - -< -;;:) 00 -< -~- _';;;OMMONWEAL TH OF PENNSYLVANIA COlJN,'{ 01=: CUMBERLAND 09-1-02 NOTICE OF JUDGMENTJTRANSCRIPT _ CIVil CASE PLAINTIFF: NAME and ADDRE;SS 'cAMP HILL CARE CENTER J 46 ERFORD ROAD CAMP HILL, PA 17011 Mag. Disl. No,; OJ Name: HOIl, ROBER'!' V. MANLOVE Add,,,,, 1901- STATE STREET CAM1>' HILL, PA L VS. r""hooo: (717) 761-0583 17011-0000 ATTORNEY DEF PRIVATE : GREG KATSHIR, ESQ. 900 MARKET ST LEMOYNE, PA 17043 "!'!. rct <" THIS IS TO NOTIFY YQU THAT: Judgment: FOR PLAINTIFF li] li] Judgment was entered for: (Name) r~'M'P lfTT.T. I"'n'Q'R ~'RflJ'TIR~ Judgment was entered against: (Name) flTFF.RT~. SHlIRON in the amount of $ 4, <;<;1 74 on: (Date of Judgment) 1 1~1/nn o Defendants are jointly and severally liable. o Damages'will be assessed on: o This case dismissed without prejudice. (Date & Time) O Amount of Judgment Subject to Attachment/Act 5 of 1996 $ Amount of Judgment $ 4.432.12 Judgment Costs $ 119.62 Interest on Judgment $ .00 Attorney Fees $ .00 Tolal $ 4,551.74 Post Judgment Credits $ Post Judgment Costs $ ------------ ------------ Certified Judgment Total $ o o Levy is sfa yed for . days or 0 generally stayed. Objection to fevy has been filed and hearing will be held: Date: " Place: . Time: ANY PARTY HAS THE RIGHT TO APPEAL~TH!JrlO DAYS AFTER THE ENTRY OF JUDGMENT BY FlUNG A NOTICE 'OF APPEAL WITH THE PROTHONOTARY/CLplk OF THE COURT gF COMMON PLEAS, CIVIL DIVISION, YOU ,MUST INCLUDE A COPY OF THI5~~~t~~ENTIT~;:s,~F,llP~FORM WIT:,~OU:.,:?TICE OF APPEAL, Jf " Date /I(t~'l;~ .' ;,//r~r{'(. ..f:"~'t..... /....~'" ~...t..'l)istrictJustice ~ f .it '-'J} .""___~ ,.1., ..;~,..; ", 0" I certify that this is a true and corre~l~y Qt,~he record of thep5'il~,e€iding{~~~~itJgthe judgmE1nt. , , ::;~' '/': ,",:: /",:"'<9~ ,..,/' I-" .;:...:. ; ,': . f " . . . ! !.: Date ~~'''':-~-'-:-~><~<,/:i~:. r?...~~"'~j lli-:." , District.i1ustice , - - ,~_"~.. r~' .~~; n_ .../.",~...~,;;. ~ ~~ '~':' '-" < My commission expires first Monday of January, AOPC 315.99 2006 ~. ~ "" " ~",... ., '~",/ .~ SE~L" ""'. -". ~~'"'' . ~. . PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This prool of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing the notice of appeal. Check applicable boxes) COMMONWEALTH OF i='ENNSYLVANIA COUNTY OF . C-u ~u : ss -'~-<---"..- .-.""'--- ,-..-, ._~_.,....._-- -_~_'h.. ".,,~--.-~_..4~;" AFFIDAVIT: I hereby swear or affirm that I served ~ copy of the Notice of Appeal, Common Pleas No. t U-/ J ~ ~"O , upon th;.pstrici Justice designated therein on (date of service) 3.J t ,yea~_~~o ~ .0 by personal servic~__~x~{~ertifj~Ur~g~!~!ed) mail, sender's receipt attached hereto. and upon the appellee, (nam" C/4i'o-....".I:tU-~ cf.;.r.1t.. _ .- . , on ~ J t . , year _20~- - . tJ by perso;'~l service" y (certified) (registered) mail, sender's receipt attached hereto. . - --.- r.:::( and further that I served the Rule to File_ a Complaint accompanying the above Notice of Appeal up.on t~e appel1ee.~ (s. to whom the Rule was addressed on '3'1 ( _, year ;?uoV . 0 by personal service Bby_'cerWi~d~ (registered) . , .- . .----. --.:, mail, sender's receipt attached hereto. I!= SWORN (AFFIRMED) AND SUB~CRIBED BEFORE ME THIS ( DAY OF ~ , YEAR. ~JO Slgnalure of Affianf () 0 ~ C C> ~ :x '-'; -ocp ::= ;;;" ~gJ = : lip ZC:: -~m ~"". 0 6'7 :s;:5 _.0 -V ::c'\"i ~(') '::0: o::D 0 5>0 ra 5'" .C .~ ~. U1 -< Tit/e%fficial My commission expires o;V~- I~ , year200o. ! Notarial Seal \ Mary McKnight, Notary Public. llemoyne Boro, Cumberland County ~~ ~o~~:s~~ ~xpires D~c. 18, 200~ _ . ''',t "~d', . '~;:,'~,~-;';"'~!1.? As~cc,atlo[l of otanes' .~ ~: ,~""f7":~I" r~: ~H~'I<,~J,~'f ~. . .... COMlJIQNWEp..L,\-\ OF PENNSYLVp..NIp.. NOTICE OF APPEAL COURT OF COMMON PLEAS FROM JUDICIAL DISTRICT DISTRICT JUSTICE JUDGMENT COMMON PLEAS No, ~ a>::;)'~ 1/t1S (!/ 0<' L '/ E/J"l .__o~__ __.,_._'-, NOTlCE'OF APPEAL Notice Is given that the appellant has filed In the above Court of Common Pleas an appeal from the judgment rendered by the District Justice on the date and in the case mentioned below. NAME OF APPELLANT .s-*~IU>~I S;,IH 1';1 <. <0/. flL, '-C J01 MAG. DJST. NO. OR NAME OF D.J, 6Q-I-O"2.. ADDRESS OF APPEllANT J;H VJ;!.l.'"totV DATE OF JUDGMENt !>"~...,, \ IN THE CASE.'9F (P..l..AINTIFF)~. CJTY i1 "'~'1 II> ~ " STATE ZJP CODE f',q 17 c l!"~ i "IiDEFENDANT) -I-: ,,' I ' VS, $\1l\-l?C'" (Tti1~1( ~Al''-f.....Jo~,J& SfGNATURP."aF APPELLANT OR HIS ATTORNE:.YOR AGENT jik--- If a6pelf~nrwas Claimant (see PA R.C.P,J.P. No~ 1001(6)} in action before disfrictJustice, he MUST FILE A COMPLAINT within twenty (20) days after filing I1is NOTICE of APPEAL \ 13-\ 00 , CLAIM NO. CV YEAR L T YEAR 'it:) CAt< F' +lit L OQCt) :3 H. [Au U,,,,,4Q. , This block will be signed ONLY when this notation is required under PA, R,C.P,J,P, No, 1008B, ' This notice of Appeal, when received by--the District Justice, will op~rate as A SUpERSEDEAS to the Judgment for possession in this case, Signature of Prothonotary or Deputy PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of form to be used ONLY when appellant was DEFENDANT (see PA R.C.P.J.P. No. 1001 (7) in action before District Justice_ IF NOT USED, detach from ~py of notice of appeal to be serVed'tipon appellee.. PRAECIPE: To Prothonotary Enter rule upon. (lit'\" t\i~l..- C~, C<{ l\IT"i.it Name of appel/eefs)' - , appene,e(~!.,.j~ tHe ~50mplaint in this appeal (Commo~ Pleas No,o:! ~O() - II"'IS' ) within twenty (20) days after service of ~~ or s';Wer ~ of judgment of non pros, <2,(.,,'( 'J-EA-m ~!1Je7 . , "r.. :," J.., 'j ....~ '\..' .." 1 l' ,S'gnatur~Qf<JPpellantorh;sattorneyoragent' " 1-,:t f' t _'t\ . t!"} ... \ f; .', RULE: To (II!"? "lit), C/I,t"l CfjOJn~ g !:..{ Name af appe-"ee(s) - - " - .... ,0'-- ._" . .. (1) 'i'Qu are ';oJiJieothat a rule is hereby entered upon you to ftle a complaint in this appeal within twenty(20) 'days after the 'date of s~rvjce of ,this rule upon you by personal servipe or by certified or registered mail. ::::> _.:'":~"''''':::~'':'~'''~:~:'.~'' - . , ' (2) If ~ou do h6t iilea complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINSTYOU ,UPONR,(iI;ECIPE." ;., ", . c,'~-& ' . . ... , (3) The elite of service oUNs rule if serv";.ce was by maills the date of the mailing, ,~ - 'rtS ~ 1 i:<: Dale: . -' ,':-, , ':.-;.;; 9 ("~ ~,. ,.: ,,~pelle.e(s) '~'. 1", , . ../.:~ear ~OO('\ ot',.'" ' " ~" " r' ,', j! ........,.... ~." ~ "' .:,;",,,,," ~,-_"",,"":"i-': . '-- ~Ih-O ,P7pc;zp>L~lJ;;-tj Signature of P.r:~"f10n9r:ry or Deputy' I White Green Yellow PinK Gold Prothonotary cti"p)'; Court File Copy Appelant's Copy Appellee Copy D, J, Copy Proth. - 76 ~. , . ~ 7099 3400 0006 0356 0246 Q\..:t.2?:_~ cj ~ ~:c> g~~ g -v.. [\- i\~ 11 ~ 'J:;~;~i ~ -;:::: 1:1~ .0:..... ~ 'i ,.. 1.:- -0: 5: ll'> :"'" ~r~c; ~. ~ J(o;~8I ., it' Wl:!;~ ,-> ;;'18 : .: tT : : at , ." j [~~ i j~l , : 8. \ \ 1 ~ ~ iai 3~ .' ~~ .2!l!. 0" Ii' " i ~ rii . ~ g " ~ . W$' ~. as. ~1t .~ '0 -. ,,~ 2~ 0'< lir <I> "?J , ~ 7099 3400 0006 0356 2776 01 .ct?; ~i' ~[&-~i~} [ '\;-$~A~i ~ -:r.. ~i Jb~i~$ - -. l:01;.:r ;0 ... '''''~' " j 110 <31"Q , ",:i!:;~ >- :~~1~~ ~ ~o~[~! -fF} ....J: ll~ ..... i i..(\~ ~: :lIl'<.'tJ j lr"~ : : Q. : : ~ j, i l i ;' Q^3 j j..... : .~ I ' m::c. ~~ @" ~" .8. ~'i? 2-~ 0'< ~i!' ~ ~ Sl.$' ~" 33 [on .,", ~., 0"- i* i1 M . ~ rii ~ 0 . , " i1 8. ~ ~ .g . . ~ -~-~_.- or--' ,> . Complete items 1, 2, and 3. Also complete item 4 if Restricted Oeti.\lery is deSired. . 'Print your name and address on the reverse so that we can return the card to you. . Attach this card to the back of the maitpiece. or on t,he front if space permits. 1. Articre Addressed to:. li~,..<otMv, ~et ~.... I~O I ~\iI:'t" S\J-f< \' CItN> l-ItLL PI+ 1,<111 . O. Is. delivery add/'ElS$ different from item 1? If YES. enter deliver; address below: 3~!CeTYPe Certifioo Mail 0 Expmss Mail Registered 0 Return Receipt for Merchandise o Insured Mail 0 C.O.D. 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Copy from service label) ']rJff ~ I/Q'Ooooff;tJ 3rtPO~~ PS Form 3811, July 1999 Domestic Return Receipt 102595-9S1.M.1789 . Complete items 1, 2. and 3. Also complete Item 4 if Restricted Delivery is desired'. . Print your name and address on the reverse so that we can return the card to you. . Attach this card to the back of the mallplece, or on the front if space permits. ,. Article Addressed to: Cw-I' fll~l- e~ ,~...~>t. '1~ ~e.Ifr;I-l> ~ D {J+I'^P ?t'lL Pit nO\ I D. ls del' dress different from item 11 If YES. enter delivery address be-low: 3. Sen.rice Type (J'" Certified Mail 0 Express Mail b Registered 0 Re-turn Receipt for Merchandise CJ Insured Malt 0 C.O.D. 4. Restricted OeIivlWy'1 (Extm Fee) 0 Yes 2. Article Number (Cop7m service labat) o9f-z,f tJO ()()(j (,,(j ;; ~tJ PS Fonn 3811, July 1999 Dom...;c ReMn Recoil>! ~ ' . . . - . I.... . . ". . . -0 ". ... . ::r ' ru c:> 1-\0........ " /},;l~M.'T I'>Io-<W< J1 on fTI c:> ~f>-.. /" .---:: -'f "' t~;;:::;;::"f'7. \ i " ~~~ """". ~1."'.' I'''>' ~ ~..,'') ,"'\ -=, \ .:; \ .... ........--.. " -;"'" "...._E::.:!l . POSlage S. ~,Ued fee Ratum Aeceipt fee ~ {E:l'ldors~etltR"GulreO) o ~s.trieted Delivery F(le C (Ectdors:~M ReQuitedl g Tau.J poSUlge & FHS $ ::2... :=r Nl,ime (pI~~se Print Cla~1 (;0 bO' compfflted by mailOr) . (T1 tl.d~~('~..c1" r""""''-''"z, _ .._.................--......-..........-. 0- .Stre;;r::APr: f./o.:-;;/p(/Soi.:"NO:........._..... . '. ..........;...;.. ~ lQt~s:~e~~:!~-.~~.~~..r.~~.:.i.........nu.."..............~.... . d 77f? 102S95.99.M.1789 ..D t" t" tu ..I1 '" fTI C U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mall Only; No fnsurance Coverage- Provided) ILL (/4/l.'i th./V Pos1ag& $ Certif((ldF/M ReturnR'GCc!pt!=H c;g fEndOl"Unlent Reoulred) C Aestficled ~livety Foe e IEndoIsernent ~equKed) C .-.TotalP~t~a.FeQ $ C :>' ,." ..- a- c:J t" '\ \' '..... ......, '! JONATHAN C. JAMES, Esquire Identification No, 68214 CAPOZZI AND ASSOCIATES, P.C 3109 North Front Street Harrisburg, PA 17110 (717) 233- 4101. ATTORNEY FOR PLAINTIFF Beverly Health And Rehabilitation Services, Inc., D/B/A Camp Hill Care Center 46 Erford Road Camp Hill, Pennsylvania 17011 Plaintiff, v. The Estate of Alice Jolms 311 Walton Street Lemoyne, P A 17043 Ms, Sharon Strebig 311 Walton Street Lemoyne, P A 17043 Individually and as Attorney in Fact for Alice Jolms Defendants, Page 1 of 22 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL COMPLAINT NO, 2000 - 1145 " c ; 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 attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. t CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, P A TELEPHONE: 7172493166 A VISO Le han demandado a usted en la corte. Si 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, Race falta asentar una comparencia escrita 0 en persona 0 con un abogado y entregar a la corte en forma escrita sus defensas 0 sus objeciones alas demandas en contra de su persona. Sea avisado que si listed 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, f LLEVE ESTA DEMANDA A UN ABOGADO INMEDlATAMENTE, SI NO TIENE AJBOGADO 0 SI NO TIENE EL DlNERO SUFICIENTE DE PAGAR TAL SERVICIO. V AYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA ClUY A DlRECCION SE ENCUENTRA ESCRlTA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUlR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY A VENUE CARLISLE, P A TELEPHONE: 7172493166 " Page 2 of 22 . 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, PENNSYL VANIA l' Beverly Health And Rehabilitation Services, Inc., D/B/A Camp Hill Care Center 46 Erford Road Camp Hill, Pennsylvania 17011 Plaintiff, v. The Estate of Alice Johns 311 Walton Street Lemoyne, P A 17043 CIVIL COMPLAINT NO. 2000 - 1145 Ms. Sharon Strebig 311 Walton Street Lemoyne, P A 17043 Individually and as Attomey in Fact for Alice Johns Defendants, K' COMPLAINT AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a Camp Hill Care Center, 46 Erford Road, Camp Hill, Pennsylvania 1701lby and through its attorneys, Capozzi & Associates, P.C., and avers as follows: 1. Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a Camp Hill Care Center, (hereafter referenced as "Plaintiff CHC"), is a corporation organized under the laws ofthe State of Pennsylvania with its registered office ,v located at 46 Erford Road, Camp Hill, P A. Page 3 of 22 .f -r.-- 2. Defendant, Ms. Alice Johns, (hereafter referenced as "Defendant Johns") is deceased. 3. Defendant Johns last address wasPlaintiffCHC facility at 46 Erford Road, Camp Hill, P A. -' 4. Defendant, Ms. Sharon Strebig, Olereafter referenced as "Defendant Strebig") is an adult individual residing at 311 Walton Street Lemoyne, PA 17043 5. Judgment was rendered against the Defendants before District Justice Manlove on January 31st. BREACH OF CONTRACT 6. Plaintiff hereby incorporates ~~ 1 through 05 of the Complaint as if set forth in full. 7. On information and belief, on or about the 23rd of April 1999, Defendant Johns requested PlaintiffCHC admit Defendant Johns for nursing care and services. 8. On information and belief, on or about the 23rd of Aprill999, Defendant Strebig, requested Plaintiff CHC admit Defendant Johns for nursing care and services. Plaintiff CHC agreed to admit Defendant Johns. ,': 9. 10. ,;' 11. 12, Defendant Strebig signed the facility's admissions agreement (hereafter referenced as the "Agreement") on or about April 23rd 1999. A true and correct copy of this Agreement is attached and referenced as Exhibit "A". Defendant Jolms signed the Agreement on or about April 23rd 1999. On information and belief, on or about the time of admission to Plaintiff CHC, Defendant Strebig presented PlaintiffCHC with a document she represented was Page 4 of 22 , ~ a Power of Attorney for Defendant Johns. A true and correct copy of the document is attached hereto and marked as Exhibit nB.n 13. On infornlation and belief Defendant Strebig represented herself to PlaintiffCHC as the Attorney- in- Fact for Defendant Johns. 14. On information and belief Defendant Strebig represented to the staff of Plaintiff CHC that she would act as "Legal Representative" for Defendant Johns. 15. PlaintiffCHC provided nursing home care and services to Defendant Johns, since her admission on or about April 24th 1999 until her discharge. 16. On information and belief Defendant Johns represented to PlaintiffCHC she would pay the cost of nursing home care and services directly from her own assets. 17, On information and belief Defendant Strebig represented to PlaintiffCHC that she would arrange for payment for Defendant Johns' nursing home care and services directly from Defendant Johns' assets in the event Defendant Johns was unable to do so. IS. Plaintiff CHC represented a promise to the Defendants that Plaintiff CHC would render nursing home care and services to Defendant Johns. 19. Facility did render said services to Defendant Johns. 20, On infonuation and belief Defendant Johns accepted said services. 21. On information and belief Defendant Johns has not paid for the services received. 22, On information and belief, Defendant Strebig has access to Defendant Johns's financial information, including the latter's income and assets. Page 5 of 22 , < 23. Defendant Strebig has not made the Defendant Johns's proceeds available to satisfY the debt created by the costs of Defendant Jolms's nursing home care. 24. Facility has demanded payment for the care and services it provided to Defendant Johns on many occasions, but to date has not received payment. 25. Defendant Johns executed a document represented as a partial payment agreement on or about November 4th 1999. A true and correct copy of same is attached and marked as Exhibit "C". 26. Defendant Strebig's signature appears on the Witness line of Exhibit "C". 27. Defendant Strebig read Exhibit "C". 28. Defendant Strebig understood Exhibit "C". 29. On information and belief Defendant Strebig has represented to Plaintiff CHC she acknowledges she has an obligation to retire any past due amounts that were owed to Plaintiff. 30. Defendant Johns acknowledged, in executing the partial payment agreement that a debt existed. 31. On information and belief staff of Plaintiff CHC explained to Defendant Strebig that Defendant Strebig would have to fill out the Medical Assistance application in order for Defendant Johns to receive Medicaid. 32. On information and belief Defendant Strebig understood she would have to fill out the Medical Assistance application in order for Defendant Johns to receive Medicaid. 33. By letter dated 13 May 1999 Defendant Strebig was placed on notice by SeniorBlue, that Defendant Johns' nursing home care would no longer be covered Page 6 of 22 'a by Medicare. A true and correct copy ofthis letter is attached and referenced as Exhibit "D". 34. On information and belief Defendant Strebig received Exhibit "D". 35. On information and belief Defendant Strebig read Exhibit "D". 36. On information and belief Defendant Strebig understood Exhibit "D". 37. On information and belief Defendant Strebig was informed Defendant Johns' stay at Plaintiff CHC would be covered by Medicaid provided the application for same was properly submitted to the Cumberland County Assistance Office (hereafter referenced as CAO) and approved by same. 38. On information and belief Defendant Strebig represented to PlaintiffCHC that Defendant Strebig understood Defendiirit Johns could not receive Medical Assistance unless and until the application for same was correctly executed, submitted to the CAO and reviewed and approved by that office. 39. On information and belief Defendant Strebig represented to PlaintiffCHC she would co-operate with the CAO in the execution of the Medical Assistance application. 40. By letter dated June 9th 1999 the CAO requested information related to the eligibility determination of Alice Johns from Defendant Strebig. Defendant Strebig was requested to deliver this eligibility information to the CAO by or before June 24th 1999. A true and correct copy of this letter is attached and referenced as Exhibit "E". Page 7 of 22 41. By this same letter dated June 9th 1999 the Cumberland County Assistance Office requested Defendant Strebig to deliver this eligibility information to the CAO by or before June 24th 1999. Please refer to Exhibit "E". 42. On information and belief Defendant Strebig.received Exhibit "E". 43. On information and belief Defendant Strebig read Exhibit "E". 44. On information and belief Defendant Strebig understood the nature of the requests contained within Exhibit "E". 45. Defendant Strebig having received, read and understood Exhibit "E" did not provide the requested information to the CAO by June 24th 1999. 46. By notice dated July 9th 1999 the CAO notified Defendant Strebig she had not provided the requested information to the CAO and that the Medical Assistance application was now more than thirty (30) days old. A true and correct copy of this notice is attached and referenced as Exhibit "F". 47. By this same notice dated July 9th 1999 the CAO informed Defendant Strebig the medical assistance application processing time was extended to forty- five (45) days. Please refer to Exhibit "F". 48. By this same notice dated July 9th 1999 the CAO informed Defendant Strebig that should she not deliver all ofthe requested information by July 22nd 1999 the Medical Assistance application would be discontinued. Please refer to Exhibit '"p". 49. On information and belief Defendant Strebig received Exhibit "F". 50. On information and belief Defendant Strebig read Exhibit "F". Page 8 of 22 51. On information and belief Defendant Strebig understood the nature of the information contained within Exhibit "F". 52. By notice dated July 22nd 1999 the CAO informed Defendant Strebig that to determine the eligibility of Defendant Johns for Medical Assistance eight (8) additional items, described, enumerated and included as an attachment to the notice must be provided to the CAO. A true and correct copy of this notice is attached and referenced as Exhibit "G". 53. By this same notice dated July 22nd 1999 the CAO informed Defendant Strebig that should she not deliver all of the requested information by August 2nd 1999 the Medical Assistance application would be discontinued. Please refer to Exhibit "0". 54. On information and belief Defendant Strebig received Exhibit "G". 55. On information and belief Defendant Strebig read Exhibit "G". 56. On information and belief Defendant Strebig understood the nature ofthe requests contained within Exhibit "G". 57. As of August II th 1999, due to Defendant Strebig's refusal to cooperate with the CAO, Defendant Johns had not yet been approved for Medical Assistance. 58. By letter dated August 12th 1999 the CAO again requested additional information, described in list form and included in the body of the letter said information related to the eligibility determination of Alice Johns, from Defendant Strebig. Defendant Strebig was requested to deliver this eligibility information to the CAO by or before September 2nd 1999. A true and correct copy ofthis letter is attached and referenced as Exhibit "H". Page 9 of 22 59. On infonnation @d belief Defendant Strebig received Exhibit "H". 60. On information and belief Defendant Strebig read Exhibit "H". 61. On information and belief Defendant Strebig understood the nature of the requests contained within Exhibit "H". 62. On infonnation and belief Defendant Strebig failed to deliver all the requested information. 63. By letter dated September 3"d 1999 the CAO again requested, from Defendant Strebig, additional information, said information related to the eligibility determination of Alice Johns, described in list form and included in the body of the letter. A true and correct copy ofthis letter is attached and referenced as Exhibit "I". 64. Defendant Strebig was requested to deliver this eligibility information to the CAO by or before September 17'h 1999. Please refer to Exhibit "I" 65. On information and belief Defendant Strebig received Exhibit "I". 66. On information and belief Defendant Strebig read Exhibit "I". 67. On information and belief Defendant Strebig understood the nature of the requests contained within Exhibit "I". 68. On information and belief Defendant Strebig failed to deliver all the requested information. 69. By letter dated September 9th 1999 the CAO again requested, from Defendant Strebig, additional information, said information related to the eligibility determination of Alice Johns, described in list form and included in the body of Page 10 of 22 the letter. A true and correct copy of this letter is attached and referenced as Exhibit "J". 70. Defendant Strebig was requested to deliver this eligibility information to the CAO by or before September l7'h 1999. Please refer to Exhibit "J". 71. On information and belief Defendant Strebig received Exhibit "J". 72. On information and belief Defendant Strebig read Exhibit "J". 73. On information and belief Defendant Strebig understood the nature of the requests contained within Exhibit"J". 74. On information and belief Defendant Strebig failed to deliver all the requested information. 75. By notice dated September 20th 1999 the CAO rejected Defendant John's application for Medical Assistance. A true imd correct copy of this letter is attached and referenced as Exhibit "K". 76. This same notice states the rejection of the Medical Assistance application is due the inability of the CAO to determine Defendant Johns' eligibility for Medical Assistance. Please refer to Exhibit "K" 77. This same notice states the CAO's inability to determine Medical Assistance eligibility is because information with regard to the transfer of property, requested from Defendant Strebig by the CAO on three separate occasions, was not made available to the CAO for review. Please refer to Exhibit "K". 78. This same notice also indicates the Defendants may reapply for Medical Assistance. Please refer to Exhibit "K". Page 11 of 22 79. 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 aUomey fees, court costs and interest. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of $4551.75 plus interest, attomey fees and court costs from the date of the Court's judgment. Page 12 of 22 BREACH OF IMPLIED CONTRACT 80. Plaintiff hereby incorporates ~~ 1 through 79 ofthe Complaint as if set forth in full. 81. Defendant Johns requested Plaintiff CHC provide Defendant Johns with nursing home care and services. 82. Plaintiff CHC agreed to provide nursing home care and services to Defendant Johns 83. Facility promised to provide Defendant Johns with nursing home care and services. 84. Defendant Johns promised to pay Facility for the nursing home care and services provided. 85. Facility provided Defendant Johns with nursing home care and services. 86. Defendant Johns failed to pay PlaintiffCHC. 87. Plaintiff and Defendants have an implied contract for Plaintiff's provision of nursing home care and services. 88. On information and belief, Defendant Strebig requested Plaintiff CHC admit Defendant Johns to PlaintiffCHC so Defendant Johns could receive nursing home care and services. 89. Defendant Strebig represented a promise to make the funds of Defendant Johns available to PlaintiffCHC to cover the costs of nursing home care and services provided that Plaintiff CHC render said services to Defendant Johns. 90. Plaintiff CHC did render the services to Defendant Johns. Page 13 of 22 91. Defendant Strebig did not make the assets of Defendant Johns available to cover the costs of nursing home care and services. 92. Defendant Strebig represented a promise to timely apply for Medical Assistance on behalf of Defendant Johns provided that Plaintiff CHC render said services to Defendant Johns. 93. PlaintiffCHC did render the services to Defendant Johns. 94. Defendant Strebig did not timely apply for Medical Assistance on behalf of Defendant Johns. 95. . As a result ofthefailure of Defendant Johns to pay privately for the costs of nursing home care and services PlaintiffCHC has been damaged. 96. As a result of the failure of Defend ant Strebig to make the funds of Defend ant Johns available to pay for the costs oJ nursing home care and services Plaintiff CHC has been damaged. 97. As a result of the failure of Defendant Strebig to timely apply for Medical Assistance on behalf of Defendant Johns P1aintiffCHC has been damaged. WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment ill favor of Plaintiff and against Defendants in an amount in excess of$4551.75, plus interest, attorney fees and court costs from the date of the Court's judgment. Page 14 of 22 QUANTUM MERUIT 98. Plaintiff hereby incorporates ~~ I through 97 of the Complaint as if set forth in full. 99. With the Defendants' full knowledge Plaintiff provided Defendant Johns with nursing home care and services. 100. With the Defendants' agreement Plaintiff provided Defendant Johns with nursing home care and services. 101. Defendant Johns received the benefit ofPlaintiffCHC's nursing services but did not arrange for payment of said services. 102. Defendant Strebig as Power of Attorney for Defendant Johns received the benefit ofPlaintiffCHC's nursing services but did not arrange for payment of said servIces. 103. Defendants knew or should have known thatPlaintiffCHC expected payment for its care and services. 104. PlaintiffCHC had a reasonable expectation of payment for provision of its care and services. 105. Defendants were unjustly and unconscionably enriched through their use of Plaintiffs nursing home care and services without providing Plaintiffwith proper and agreed upon payment. 106. Plaintiff CHC has been damaged dueto the unjust enrichment ofthe Defendants. Page 15 of 22 WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of$4551.75 plus interest, attorney fees and court costs from the date of the Court's judgment. Page 16 of 22 BREACH OF FIDUCIARY DUTY Sharon L. Strebig 107. Plaintiff hereby incorporates ~~ 1 through 106 of the Complaint as if set forth in full. 108. By signing Defendant Johns' Admission Agreement as her "Legal Representative", Defendant Strebig indicated and entered into a confidential, fiduciary relationship with Defendant Johns. 109. By signing Defendant Johns' Admission Agreement as her "Legal Representative", Defendant Strebig indicated and entered into a confidential, fiduciary relationship with Plaintiff CHC. 110. By executing a Power of Attorney agreement with Defendant Johns, Defendant Strebig indicated and entered into a confidential, fiduciary relationship with Defendant Johns. 111. Defendant Strebig as "Legal Representative" for Defendant Johns had a fiduciary duty to Defendant Johns to act in Defendant Johns' best interests. 112. Defendant Strebig as "Legal Representative" for Defendant Johns had a fiduciary duty to PlaintiffCHC to act in Defendant Johns' best interests. 113. Defendant Strebig as Power of Attorney for Defendant Johns had a fiduciary duty to act in Defendant Johns' best interests. 114. Defendant Strebig as Power of Attorney for Defendant Johns had a fiduciary duty to Defendant Johns to use Defendant Johns' income and assets to serve Defendant Johns' best interests. Page 17 of 22 115. Defendant Strebig as "Legal Representative" for Defendant Johns had a fiduciary duty to Defendant Johns to use Defendant Johns' income and assets to serve Defendant Johns' best interests. 116. Defendant Strebig acting as "Legal Representative" for Defendant Johns failed to make the income and assets of Defendant Johns available to satisfY the debt created by the costs ofrendering nursing home services and care to Defendant Johns. 117, Defendant Strebig acting as Power of Attorney for Defendant Johns failed to make the income and assets of Defendant Johns available to satisfY the debt created by the costs Qfrendering nursing home services and care to Defendant Johns. lIS. Defendant Strebig's failure as "Legal Representative" for Defendant Johns to make said income and assets of Defendant Johns available to PlaintiffCHC is a violation of her fiduciary duty to PlaintiffCHC. 119. Defendant Strebig's failure as Power of Attorney for Defendant Johns to make said income and assets of Defendant Johns available to PlaintiffCHC is a violation of her fiduciary duty to Defendant Johns. 120. As a result of Defendant Strebig's breach of fiduciary duty to Defendant Johns, Defendant Strebig has caused Plaintiff CHC to be damaged. 121. As a result of Defendant Strebig's breach of fiduciary duty to Plaintiff CHC Defendant Strebig has caused Plaintiff CHC to be damaged. Page 18 of 22 WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendant Strebig in an amount in excess of $4551.75, plus interest, attorney fees and court costs from the date of the Court's judgment.. ACTION IN ASSUMPSIT-DUTY TO SUPPORT Sharon L. Strebig 122. Plaintiff hereby incorporates 'Il'll1 through 121 of the Complaint as if set forth in full. 123. As the nursing facility providing Defendant Johns with nursing care and services, Facility had a legal duty to provide care, maintenance and assistance to her. 124. Defendant Strebig is Defendant Johns' daughter. 125. Upon information and belief, Defendant Johns' sole source of income is her Social Security benefits. 126. Defendant Johns' average monthly expenses incurred at Facility are in excess of $3600.00. 127. Upon information and belief Defendant Johns' monthly living expenses incurred at Facility significantly exceed her monthly income. 128. Upon information and belief, Defendant Strebig has sufficient fmancia1 ability to pay for some or all of Defendant Johns' maintenance and support. 129. 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 fmancial assistance. Page 19 of22 130. Upon information and belief, Defendant Johns is "indigent" within the meaning of Title 62 Section 1973. 131. Defendant Strebig should contribute to the support and maintenance of Defendant Johns. WHEREFORE, Plaintiff respectfully requests that the honorable Court enter judgment in favor of Plaintiff and against Defendant Strebig in an amount in excess of$4551.75, plus interest, attorney fees and court costs from the date of the Court's judgment. TES, P.C. JON. THAN Co JA Iden 'fication No. 6821 0221 AND ASSOC TES, P.C. 3109 North Front Street Harrisburg, PA l7JlO (717) 233- 4101 Attorneys for Plaintiff Date: 3, 2-D - 2..bl> c::> Page 20 of 22 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA 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. Johns 770 Poplar Church Road Camp Hill, Pennsylvania 17011 CIVIL COMPLAINT NO. 2000 - 1145 MS.Sh~~bn strebig 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Johns Defendants, VERIFICATION I, Susan Bertolette, business office manager for Camp Hill Care, Plaintiff, do hereby verifY that the facts made in the foregoing document are true and correct to the best of my lmowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unsworn falsification to authorities. Date:3-2.o-z.o0V ~('-~~ - Page 21 of 22 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A Camp Hill Care Center 46 Erford Road Camp Hill, Pennsylvania 17011 Plaintiff, v. The Estate of Alice Johns 311 Walton Street Lemoyne, P A 17043 CNIL COMPLAINT NO. 2000 - 1145 Ms. Sharon Strebig 311 Walton Street Lemoyne, P A 17043 Individually and as Attorney in Fact for Alice Johns Defendants, CERTIFICATE OF SERVICE I certify I am serving a copy ofthe above captioned Complaint upon the person and in the manner indicated below: Service by First-Class, U.S. Mail RetuI1l Receipt, addressed as follows: . Gregory Katshir, Esquire 900 Market Street Lemoyne, Pennsylvania 17043 Estate of Alice Johns c/o Ms. Sharon Strebig 311 Walton Street Lemoyne, P A 17043 Date: J, . 1-D. Leo 0 JONAT N C. JAMES, Esquire ation No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg,PA 17110 (717) 233- 4101 Attorney for Plaintiff Page 22 of 22 MAIL The Facility is authorized to handle the Rt?sident's mail as follows: (Check ~ box only,) [ ] All mail given directly to the Resident )>rAll mail read to the Resident .MGive personal mail to the Resident; . C "lbrward business mail to: ~Mffi1 ~ [ ] Forward all of the Resident's mail to: NAME: SPECIALTY: JLtJvYN{J J~ -S. ~5LI,,Jr , . -. ' ~ ~ J (A 17([J / , 71o! -43/7 ADDRESS: TELEPHONE: White - Business Office 17 Pink - Medical Records Yellow - Resident ::::: " ~. ~ z ~ i I I i I , ! I I I I ;;c r; ;r. Z ~ ~. fnformation about the Facility's bed hold procedures. v::: 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. / 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. ~5. 76. ~7. . Copies of the State Resident Rights. ::: co or. ;::. ~ A written explanation of the Facility's Rules and Regulations. z co 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. / 8., Acopy of the facility policy regarding implem/,:.' tion of the Patient Self Determination Act and of the applicable State law. I do _ do not . have 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. LEGAL REPRESENTATIVE AND/OR AGENT Nam~J\'1.\T(\ ~ )J\\~f) Home Phone 1/ (h:x l/ D 8 Work Phone Street 31 {LJ~ ~ City?+: ~:fM-r ~ ;:;: " :r. z ~ Stat~ Zip /10 l.j '::j OTHER PERSON TO BE NOTIFIED Nam~~'1 GIY\P~QoHomePhone 7f!';~/r-.5-~ Work Phone C--J 12'-. f+I- C' Lt" (),. S' <.>J Street '-"\.. )!PSQ,~'I ~.i(A . ny U lY\Y tate"-..''! Zip White - Business Office 16 Pink - Medical Records Yellow - Re....idclH RESIDENT-SPECIFIC INFORMATION This Facility accepts the following types of payments: (Check all that apply.) [\J'1'rivate MMedicare [\1Medicaid (~terans Administration PARTIES ?? :f. The parties to this Agreement are: ~~~C~ (Name f Facility) ;: .1 ~/ ~~~ (Name of Residen ) ~ r:- ( ] Conservator of Person ( ] Conservator of Estate ( ] Other. specify [ ] Guardian 1(i?urable Power of Attorney for Health Care (DPAHC) [ ] Agent Acting Under General POA ~ 1 (Name of Resident's Agent) (l\iame of Resident's Legal Re sentative) If a Legal Representative signs, check the Type of Legal Representative (below): If you are signing this Agreement on behalf of the Resident, note your relationship to the resident: hPa~ Re ionship to Resident On this A day of ~ ' 19..!iJ.., the above parties agree that on the d. if- day of -lX;;;)..:r.-Z--, 19"-!11the Res dent shall be admitted to this Facility. As of that day, the Facility shall pro- ~es 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. ;;:;; " :r. z ACKNOWLEDGEMENTS By signing the Admission Agreement Signature Page, the ResidentlAgent/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 Nt A): V-l. 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 YeHow - Resident :CSI D:cnT ..-----" . . ~ ,- .".' ,~ . '. '. .. --/ ------------ ,>.. . ,-- \:. '...- . ..... ...... " 4i/~: y\\ . '. 1 . ,,1<:" . ., . i . . (C" """'ja;. i ' ", .,.;: ~,~ru~. . . '.:' .i ,~~~~ ~ '. ~.';'" --.,--",,,,, U '-. "'-~ \1.;';'/ '(>~~~~ Dt\ISSlon G~:c:ct\~nT @ BEVERLY ENTERPRISES I~.t "'- :..... ' t: ..,.t ""',. <ti~" .;::<::",.:. :t3 f: RESIDENT ADMISSION AGREEMENT BEVERLY ENTERPRISES I3E:!02(7197> BEVERLY ENTERPRISES RESIDENT ADMISSION AGREEMENT Table of Contents Topic Page FINANCIAL ASPECTS OF THE AGREEMENT I AGENT AND/OR LEGAL REPRESENTATIVE? I FINANCIAL ARRANGEMENTS I . Private Residents . Applying for Medicare/Medicaid Assistance . Medicaid Residents . Medicare Residents . Payment Information - Due Dates & Obligation to Pay Timely - Failure to Pay - Fee for Returned Checks I 2 3 4 5 5 5 5 BED HOLDS 5 . Medicaid Residents . Private and Medicare Residents 5 5 PERSONAL FUNDS 6 TERMINATION OF AGREEMENT 7 . Right to Terminate . Personal Property of Resident Upon Discharge 7 7 REFUNDS 7 ENFORCEMENT OF THIS AGREEMENT 7 . Sole Agreement . Non-Assignable Agreement 7 7 RESIDENT'S RIGHTS AND RESPONSIBILITIES 8 NONDISCRIMINATION STATEMENT 8 Table of Contents (Continued) Topic Page .". ;." CONSENT FOR TREATMENT 8 . Nursing Facility Services . Physician Services . Right to Refuse Treatment 8 8 8 RESIDENT'S PERSONAL PROPERTY 9 RESIDENT'S RECORDS 9 . Confidentiality . Consent to Release by Facility . Photographs 9 9 9 THE RESIDENT'S DUTIES . Rules and Regulations . Resident Grievances . Diet . Medications . Care of Facility's Propel1y . Care of the Resident's Room 9 9 9 10 10 10 10 TRANSFERS AND DISCHARGES 10 RESIDENT RIGHTS UNDER FEDERAL LAW 11 FACILITY POLICY REGARDING IMPLEMENTATION OF PATIENT SELF-DETERMINATION ACT 14 RESIDENT-SPECIFIC INFORMATION 15 PARTIES 15 ACKNOWLEDGEMENTS 15 NOTICES 16 MAIL 17 RESIDENT'S PHYSICIAN 17 RESIDENT TRUST FUND AUTHORIZATION 18 ADMISSION AGREEMENT SIGNATURE PAGE 19 ii FINANCIAI-ASPECTS OF THE AGREEMENT The stall' of this Facility will take whatcycr time is ncccssary tf> answcr al/ of )our qucstions about these topics. Please continue to ask qucstions until you hclie\'c Ihat you understand. AGENT AND/OR LEGAL REPRESENTATIVE? If the Resident is unable to .make decisions for himself ur herself. an A~ent and/ur Lc"al Represenwti\'e may be available to make certain decisions on behalf of the Resident. These terms ar~ defined below: . AGENT -For the.purposes Oflhis Agreement. an Agent is a person \\'ho man'lges. uses. or controls funds/assets that muy be legaIly used to pay the Resi,knt's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amuunt of the funds received or held by the Agent for the Resident. The Agent dtleS not assum-" responsibility for payment of the costs of the Resident's care out of the Agent's personal funds.. However. the Agent is contrnctually bound by the terms of this agreement and may become liable for failure to perform duties llllder the Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT FOR AD/\1ISSION. AND AGREES TO DISTRIBUTE.TO THE FACILITY. FROM THE RESIDENT'S INCOl'vlE OR . . RESOURCES. PAYMENT WHEN DUE FOR ITEMS/SERVICES PROVIDED TO THE RESI- DENT. The Agent is required to produce financial documentation ~lS 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 thi, 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 attomey-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. PRIVATE RESIDENTS - A?-esident is considered Private (or private pay) \\'hen no State or Federal pro. gram is paying for the Resideni's Room &' Board. A pri\',ue pay Resident may have pri\'ate insurance or another third parly which pays all or son;e 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 private funds are going to be depleted so that other arrangements for payment can be made. Generally, when private funds are depleted. the Resident applies fc)]' Medicaid assistance. and application proces~ing time can be lengthy. The Facility wunt~ to enSllre that. if the Re,l.,idenl J"un\ nUl 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 pnrt by the type of room assigned and the level of eare provided to the Resident. For this reason. the rate may change if the Resident moves to a ditferent 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 ",'ailable 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 plior 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 pm1ies 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!I\1EDICAIDASSISTANCE - This Facility makes no guarantee of any kind that the Resident's care will be covered by Medkare, 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 immediatelv of the status of the Resident's assets. . Qualifying for Medicaid Assistancc. 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 assets are within the required limits and that these assets remain within allowable limits for Medicaid assistance. il ~ 2 Providing Applk:Jtion Infonnntio/l. The Resident agrec's \ll prm id~ all inrunnatiun requesl~d !\lr completion of the i\1~dicaid app\ka\ion. Thi:-. inrorm~l\il)n l1\U~t he pro\'ilkd in 1,;umpli<Jlh..'L' with allY deadlines set by the applicable SlatelCllllnty tckdicaid program. Keeping thc F:Jcility Informed. The R,'silknt agrecs to keep the Fac.ility inl<ll-mcd (II' the status 'lI1d progress of the Medicaid applicatiun. The Resident agn:'cs to p[,(1\'i<l" the Facility with '.l'pies (If any information related to thc Medicaid application. . Transferring Assets. If the Resident transfers ussets. this transt<:r may disqualify the Resident f\lr Medicaid assistanL'e and/(lI' cause a discontinuance of the Resident's Medic,ti<l b"nc'lits. The R"sitknt acknowledges that this may result in discharge of the Resie!ent due to nun-payment. Continuing Payment of Facility Charges Pending Eligibility. When an applie'ltion I'll[' Ivledicdid assistance has been like!, the Resident dgre6 that: while the Resident's application is "pending." th" Resident's estimated shar" of cost (as describ"d in the following paragraph) shall be paid to the Facility on or before the tenth (10th) day of each momh. - once the Resident is d"termined 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 determin"d by the State/County Medicaid Program and may be referred to as Priyme Portion. Sbare of Cost. Patient Liability. Patient Resource. etc. AllY 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 pmvided to the Resident as specified in the terms of this Admission Agreement. . Providing Financial Information. The Resident certifies tlwt any financial information regarding the Resident's income and assets required by the Facility and provided by the Resident is complete and accurate. MEDICAID RESIDENTS - A Medicaid Resident is one wbo receives benefits from tbe State Medicaid Program for a m'\iority of his or her Room & Board cbarges. Medicaid mayor may not cover charges for additional services/items provided by tbe Facility - tbis vmies from State to State. The following apply to Medicaid Residents: . Daily Rate Payment. On 'ldmission. the Resident will b" provid"d with a list of supplies and ser vices that will be paid by the Medicaid program and thos" supplies and services not paid for by th, Medicaid program. for \\'hich the Resident will be separately charged. A detailed list of and charge: for supplies and services available in the Facility but not covered by the daily rate under th, Medicaid program is mainwined in the Business Omce and available for review during normal busi ness hours. J i ~. , . Termination of Coverage. The Resident may remain in the Facility for as long as he or she is L'eni- 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 Rcsident. 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, Ba.,ed 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 Medicat'e 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 revie\\i 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 pdvately 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 anangements 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. -' I'AY:\IENT ll\fOR:\IATlON DUE DATES 8:. OBLIGATION TO PAY TIMELY - Facility charg..:' i()r ,cniees pl"O\id<,d shall b<, l1ilkd monthly to th.: Resident. ThL'st' c.h'al'ges arc due and payilbJe by the tenth (10th) day of each month. If payment is!JQ\ r.:eeiveu by the tenth (10th) day of each 1110nth. the account halanec is considered past dlle or delinquent. :lIld the Facility may adda'late charge to the Resident's account. This late <:hnrge shall be assessed on the monthly bal:lllCe at the lesser of the 1110nthly rate of 1,5'K (one anu 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 Agreemcnt. The Resident recog.nizes 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. FA1LURE TO PAY - The Facility's due date for payments falls on the tenth of each month. If the Resident fails to make a required payn1en(\\'l1hijj 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, \\hichever is greater. will be chai'ged 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 hoid 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. MEDICAJD 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 tvfedicaid 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: l) requires the services provided by the Facility; and 2) is eligible for Medicaid nursing services. PRIVATE AND MEDICARE RESJDENTS - Any Private or Medicare Resident may request a bed hole from the Facility. A Resident's piivate insurance mayor may not pay for bed holds. The Medicare progran does not reimburse for bed .holds, however. if the Medicare Resident is also Medicaid eligible, SOlD< Medicaid programs may pay for a certain number of bed hold days. Otherwise. a Private or Medical" Resident requesting a bed hold must pay the Facility's private daily rate for the bed being held during th, bed hold period. 5 !,.~ -- PERSONAL FUNDS The Resident has a right to manage 'his or her own personal funds. If the Resident wants assistance with management of personal fuhds. 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 un 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 pet!y 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 aMedicaid resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental SecUlity 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 pro\'ide 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 :lledicare 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 . TERMINA nON OF AGREEMENT RIGHT TO TERMINATE - The Facility shall not transfer or eviet the Resident solely as a result of the Resident changing his or her manner of paymei]( from Private or Me(licare to Medicaid. unless the Facility is not licensed for Medicaid. PERSONAL PROPERTY OF RESIDENT UPON DISCHARGE - The Facility shall make reasonable eff~:Jrts to safeguard the Resident's personal belongings after discnarge. The Facility, however. shall not be liable for any damage to or Joss 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 documents attached or included by reference, is the only agreement between tlie 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 tenns shall stand as a valid agreement. NON-ASSIGNABLEAG1~EEMENT -_.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 i { . 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 SERVICJ;:S -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 TREATlvllil':'T - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to beillformed 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 regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision-maker. subject to Stale and Federal law. 8 ---...._~- RESIDENT'S PERSONAL PROPERTY The Facility strongly disl:ollrages the keeping of valuable jewelry, papers. large sums of !\loney. ,'r other items considered of value in the Facility. The Fal:ility shall make reasonabh: dforU, to safeguard the Resident's property/valuables which the Resident chooses to keep in his or her possessi,m. 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 Fa,ility Administrator or designee. RESIDENT'S RECORDS CONFIDENTIALITY - Information included in the Resident's medical records is confidentiaL Unauthorized persons shall not be' al10wed to review these records with om the Resident's written consent. except as required or permitted by law. CONSENT TO RELEASE BY FACILITY - The Resident authorizes the Facility to release all or any pm1 of the Resident's medical or financial reco'rds 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. including but not limited to hospital or medical services companies, insurance companies. workers' compensation carders. welfare funds. and/or the Resident's employer. The Resident also authorizes release of infol111ation from medical or financial records to any medical profes- sional or institution responsible for the Resident's medical or" nursilfg care when the Resident is transferred or discharged fwm 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 pUlposes. 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 light 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 ;'ules 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 regulation: may be amended from time to time as the Facility may require. Any changes to the rules and regulatiom shall be given to the Resident in writing. RESIDENT GRIEVANCES - Residents are urged to bring any grievances concerning the Facility to th attention of the Facility Administrator or designee. The F:lciIity :llso offers a toll-free "Hotline" telephon' number through which grievances can be registered directly with the corporate offices. This number i 1-8'00-572-9981. Residents :lJso have the right to contact the State Facility licensing agency, the long-ten' care ombudsman. 0(' both, to register grievances against the Facility. 9 D\1O., - ,he Resident unden;tands ,hat 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 stuff regarding food or bevel': 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 ihe 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 toinarvidualize 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 in the Facility; . The transfer/discharge is appropriate because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility; . The safety of individuals in the Facility is endangered; . The health of individuals in the Facility would otherwise be endangered; I , ~J - 10 . The Re,ident has failed. after n:a,llnilblc anti appropriate notke. to pay for (or to havc paid under Mcdicare or Medicai,l) a Slay al the racililY' . The Facility ceases to l'peratc. RESIDENT RIGHTS UNDER FEDERAL LAW The Facility shall protect and promote the rights llf each Re.sident. including each of the following rights: The Resident has a right to a dignified existence. serf-determination. communicmion 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 Stmes. 3. The Resident has the right to be ti'ee of illletferellce. coercion. discrimination. or reprisal f['om the Facility in exercising his or her rights. . -1-. 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 legalzights. including filing a grievance with the State survey and certification agency conceming Resident abuse. neglect, and misappropriation of Resident prope11y 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 infonned 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 aU records pertaining to himself or 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 p0l1ions of them upon request and with two days advance notice to the Facility. 11 ' ---, 13. The Residenl 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 pany payment contract. 14. The Resident has a right 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 effo/1s 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 Resident 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 peIiomling 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, including the right to send 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 foIlowing: 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 fumishings and appropriate clothing, as space permits. unless to do so would infringe on the rights or health and safety of other Residents. i , ~ ]2 25. The Resident has a right to share a room with his or her spouse when married Residents live in the $"me Facility and both spouses consent to the arrangement. 26. Each Resident has a right to self-administer drugs unless the Facili!y 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 10 be free from verbal. sexual. physical. or menta] 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 recei\'e 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 inte1fere 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. J3 FACIUTY POLICY REGARDING IMPLEMENTATION OF PATIENT SELF-DETERMINATION ACT The following 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 Fedeml 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 incompetent. this Facility recognizes the Resident's right to have these decisions made on his/her 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 \~'ith the Resident's family. physician. and attorney. ]4 RESIDENT-SPECIFIC INFORMATION This Facility accepts the following types of payments: (C,heck all that "pply.) [ ] Private l ] Medicare [ ]Medicaid [ ]Vctcrans Administration PARTIES The parties to this Agreement are: (Name of Facility) (Name of Resident) (Name of Resident's Agent) (Name'of Resident's Legal Representative) If a Legal Representative signs, check the Type of Legal Representative (below): [ ] Conservator of Person [ ] Conservator of Estate [ ] Other, specify [ ] Guardian [ ] Durable Power of Attorney for Health Care (DPAHC) [ ] Agent Acting Under General POA If you are signing this Agreement on behalf of the Resident, note your relationship to the resident: Relationship to Resident On this _ day of , 19_, the above parties agree that on the day of . , 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/AgentlLegal 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 NI A): 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 t5 ,Pink - Medical Records Yellow - Resident z. Informarion about the Facility's bed hold procedures. 3, A written explanation of bow to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these benefits. 4. A statement explaining tbat the Resident may file a grievance with the appropriate.State Agency abo'ut resident abuse, neglect, and/or misuse/tbeft of resident personal property in the Facility. , 5~~ c:opies of the State Resident Rig!lls. 6. A written explanation of tbe Facility's Rules and Regulations. 7. If your condition warrants, you may be placed in tbe facility's Medicare-Certified Distinct ParI 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 detennined that you may be involuntarily discharged or transferred. 8. A copy of the facility policy regarding implementation of the Patient Self Determination Act and of the 'applicable State Jaw. I do _ do not _ have 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 goveming 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 tbe Resident, Agent, and/or Legal Representative. LEGAL REPRESENTATIVE AND/OR AGENT Name Home Phone Work Pbone Street City State Zip - OTHER PERSON TO BE NOTIFIED Name Home Phone \york Phone Street City State Zip '-,..- White - Business Office t6 Pink - Medicil Records Yellow - Resident iL MAIL The Facility is authorized to handle the Resident's mail as follows: (Check one box only.) [ ] All mail given directly to the Resident [ ] All mail read to the Resident [ ] Forward all of the Resident's mail to: [ ] Give personal mail to the Resident; forward business mail to: ;;; C1l to C5 C1l ~ L '" ~ RESIDENT'S PHYSICIAN NAME: SPECIALTY: ADDRESS: TELEPHONE: -' White - Business Office 17 Pink - Medica! Records Yellow - Resident . ~ , RESIDENT TRUST FUND AUTHORIZAlLUlV A Resident Tru,( Fund is un umount of money held by the Facility ftlr the Resident', persunal use. (Examples of use: To allow the resident to pay for room and boan!, beauty shop charges. cigarettes. postage stamps. or other similar expenses as de.,ired by the Residenl.) By signing below, the Resident authorizes the E\cility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on rcquest, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals shall be authorized by the Residcnt or his/her Agent or Legal Representati ve in writing. The following persons may authorize with. drawals on the Resident's behalf: Name of Authorized Person --Name 'of Authorized Person Resident's Signature ~Date' , -- > Witness if Resident Signed with a Mark Date '. - '. Witness if Resident Signed i;vitha Mark Date Legal Representative's Signature'" Date (if applicable) Agent's Signature . Date (if applicable) \Vhite - Business Office 18 Pink - Medical Recoros YeHow - Resioent "- ~ f1-' ! ' ) , I I ! ADMISSION AGREEMENT SIGNATURE PAGE Resident Witness if Resident Signed with aM.ark Witness if Resident Si'gned with -a Mark . Legal Representative -( ) . . ' Legal Representative's telephone Number Agent -< ) .... Agent's Telephone Number. Facility Administrator or Designee ,. Date' ;:<: (1; en D- <> ::l ~ Date 2 ::; :i: Date Date Legal Representative's Social S~curity 1'\0. . Date ! d ! Agent's Social Security No. Date Note: The signatures above refer to the illformatioll cOlltailled Oil pages 1 through 18 of the Beverly Ellterprises Admissioll Agreement. \Vhite - Business Office 19' Pink - Medical Records Ye!low - Resident VL..V l' V.,J I..... "''''. ..-" vv.................Uu.l .......-.v ~-'." ......, ,..,'-.~~~-~ Lemoyne. Pennsylvania 17043 (717] 763 -8133 . Fax (717) 763-9425 POWER OF ATTORNEY KNOW /ILL MEN BY 'I'HESE PRESENTS, that I, ALICE EMMA JOHNS, of COlnlllonwealth of Pennsylvania have constituted, made' and appointed, by these presents do constitute, make and appoint my daughter, SHARON L. STREBIG, Bsrny true and lawful attorney: 1. To ask, demand, sue for, recover and receive all SlJ1llS of money, debts, goods, merchandisQ, chattels, effects and things of whatsoever nature or description which are now or hereaftQr shall be or becoming owing, due, payable or belonging to me in or by any right whatsoever, and upon receipt thereof, to make, sign, execute and deliver. such receipts, releases or other discharges for the same, respectively, as she Shall think fit. 2. To deposit any monies which nay come into her hands as such attorney with any bank or banker, either in ~y or her own name, and any of such money or any other money to which I am entitled. whiCh now is or shall be so deposited to withdraw as she thinks fit; to sign mutual savings bank and federal savings and loan association withdrawal orders; to sign and endorse checks payable to my order and to draw, accept, make, endorse, discount or otherwise deal with any bills of exchange, checks, promissory notes or othQr commercial or mercantile instruments; to borrow any sum or awns of money on such blrms and with such security as she may think fit and for that purpose to execute all notes or other instrumants which may be necessary or proper; and to have access to any and all safe deposit boxes registered in my name. 1 :;r - V!:.\.r-ll-O:l "'1.1 1,J0.1.... VUl LUl...\.L.~)L\U .....nv Il.n HV. ,.., ....".........';" .-v 3. To sell, assign, transfer and dispose of any and all stockS, bon~s, including U.S. savings bonds, ,loans, mortgages or other securities rQgistered in my nane; and to collect and receive all interest and dividends due and payable to me. 4. To invest in my name in any stocks, shares, bonds, securities or other. property, real or parsonal, and to vary such investments as she may deem best ~ and to vote at meetings of shareholders or other meetings of any corporation or company and to execute any proxies or other instrument in connection therewitn. 5. To enter into and upon all and singular my real eS1:ate, and to let, manage and improve the saltle or any part thereof, and to repair or otherwise improve or alter and to insure any buildings thereon: to sell, either at public or private sale or e~change any part or parts o~ my r~al astat~ or persona~ property for such consideration and upon such terms as she shall think fit; to execute and deliver good and sufficient deeds or other instruments for the convayance or transfQr of the same with such covenants of warranty or otherwise as she shall see fit: and to give good and effectual receipts for all or any part of the purchase price or other consideration; and to mortgage, including purchase money mortgage and to execute bonds and warrants and all o'l:her instruments and documents in connection therewi th and relating thereto; and such powar shall not be in limitation of any other powers herein set forth. 6. To enter into any agreement or contract affecting my retirelllent planjbanQfits, disability plan/benefits or my retirenent 2 v....'" ~, ..." ..~. ".......................... V_IV I Jln n...... I ,I._I'-"';V~O.") j. v-: t -- ( I , wi.th my emp~oyer r present, pl:1st or future. My above namQd attornQY shall also have the power to name or change beneficiaries on any agreement, policy, contract, stock or bond or any other si~ilar document, and shall specifically be empowered to name herself as beneficiary. 7. To contract with any person' for leasing for such periods at such rents and subject to such conditions as she shall see fit, all or any of my said real estate; to let any such person into possession thereof; to execute all such leases and contracts as shall be necessary or proper in that behalf;tc give notice to quit to any tenant or occupier thereof: and to receive and recover fron all tenants and occupiers thereof or of any part thereof all rents, arrears of rents, and sums of money which now are or shall hereaf~er become due and payable in respect thereof: and also on nonpayment thereof or of any part thereof to take all necessary or proper means and proceedings for deterMining the tenancy or occupation of such tenants or occupiers, and for ejecting the tenants or occupiers and recovering the possession thereof. 8. To c:olIlntence, prosecute, discontinue or defend all actions or ctherlegal proceedings tcuching my estate cr any part whatsoever, or touching any matter in which I or my estate may be in any way concerned; to settle, co:mpromise, or sub:nit to arbitration any debt, demand or other right or matter due me or concerning my estate as she, in her sole discretion, shall deem best and for such purpose to execute and deliver ~uch releases, discharges or other 'instrUlllents as she may deem neoessary and 3 , ., 9. To execute, ackno~ledge and file federal, state ana local income tax and personal property tax returns. 10. To engage, employ and dismiss any agents, clerks, servants or other per~on~ a~ she ~ha1l deem necessary and advisable. n. To authorize my admission to a medi=1, nur:sinq, residential or similar facility, and to enter into agreements for my care. 12. To authorize medical and surgical !:"-'. A~m-es that the attorney in fact may arrange for and consent to medical., therapeutical and surgical procedures for myself, including the administration of drugs, and the authority to w{thhold or withdraw nutrition (food) or hydration (water) medically supplied by tUbe through my nose, stomach, intestines or veins. J.3. To have full access to my medical and hospital records and all information regarding my physical O~ mental health. 14. To hire and fire medical, social service an::i other support personnel responsible for my care. 15. To create a trust for nrt benElfit and to withdraw and receive income and corpus from a ~rust. 16. To renounce a fiduciary position includinq but no!: limited to reSigning any fiduciary position in which I am serving, and either file an accounting with the Court of competent jurisdiction or settle on receipt and release or other informal 4 - - ----.----- . ~--. method as the attorney-in-fact deems advisable. 17. TO erqage in insurance transactions wii:h tne pc:lNer to continue, purchase, renew, convert or terminate ~ny type. of insurance and pay premiums and collect benefits and proceeds under insurance policies, to exercise nonforfeiture provisions under insurance policies and in ge-neral to exercise all powers with respect to insurance that I could if present. 18. To receive <;lm....""",,,uL J:::snefits in:::ludin;:; the power to prepare, sign and claim or application for Social Security, unemployment, 1llilitary service or other govern1'i1ent benefits: to collect and receipt for all government benefits c~ assistance: and in general, to axercisQ all powers with respect to government benefits that! could if present. 19. In general, ~o do all other acts, deems, matters and things whatsoever in or about my estate, property and affairs and things herein, either partiCUlarly or generallY described, as fully ana effGctually to all intents and purposes as I could do in my own proper person if personally present, giVing to my said attorney ~ower to make and substitute under her an attorney or attorneys for all tne purposes herein described, hereby ratifying' and confirming all that the said attorney or substitute or substitutes shall do therein by virtue of these presents. 20 . In addi ti on to the powers and discretion herein speciallY given and conferred upon her, and notwithstanding any usage or custom to the contrary, to have the full power, right and authority to do, perforn and to cause to be done and performed all 5 uc.\j- iI-\;;:) t ~d. ..;~ ~ U:~ \'Ufl~t.r.U-ll;V v~v rl-:.h l'iU. (1 r.c:ttljl".~:.:::l r. Vi Guch acts, deeds, matters and things in connection with my property and es~ate as she shall deem reasonable, necessary and proper, as fully, effectually and absolutely as if she were the absolute owner and possessor thereof. 21. This Power of Attorney shall.become effective upon my disability or incapacity for a periOd in eXcess of twenty-tour ..: (24) hours and shall cease to bQ in effect when and if that disability or incapacity ceases. 22. I !Specifically direct that such attorney-in-fact shall not ba Subj6ct to any liability by reason of any of such attorney's decisions, acts or failures to act, all of which shall be conclusive and binding upon llle, my personal representatives, h..irs and ass;igns;. FurthQ=orQ 1 Qxcept in the case of malfeasance of office, I agree to hold such attorneys harmless, from all claims that may be made against such attorneys as a result of such attorneys' service hereunder and I agree to reimburse SUCh attorney in the amount of any damages, costs and expense that may be incurred as a result of any such Claim. 23. If, sUbsequent to the execution o.t this Power of httorney, incapacity proceedings are commenced for my estate or person, I hereby nominate SHARON L. S'XREBIG as guardian of my ..state and/or person. IP TN w.rTNESS wm::REOF, day of r1 (t\."- '2l, "" Alice EliUna I have hereunto set my hand and seal this , 1997. ...r: T~~..s- Johns !A~ 6 Signed. sea~ed, published and aOJmowledged by th.. said Alice .Emma Johns, as and for her Power of Attorney, in the presence of us. who, in her presence and in the presence of each other, at her req-..;.est, have subscribed our names hereto as witnesses. , , (1)jcr;fwv 'PJ ~~ fJZ Witness f/ 1~~ ~~ signature of Attorney-in-Fac <:23 f :.$7 . t1 Il VI f ,), r4 . .' c..!l ; 17\{} l. ,u r KG Address · Ii~, {) (!, wlrf JJ.L.1.W"J.J) /Jill ?D71 ... .' .::roo ~1 S..... Address ~y,",~ PA noL/~ ..... - \ , 7 'Y- PARTIAL PAYMENT AGREEMENT . BEVERLY EHT'EAPIUSCS AfrUL LTOh,. ) Resident Name COmr-J Hili CQ~ G.n-h~Y Facility Name. .'.- ~ -- q;,) 33 ... -Resident Number _jqsc; -Facility Number Aflu 4&>5J.IJ. . J; I-WIS -' agreeto pay my outstanding balance of I, $ . . as follows: (exact amount) Payments of $ I CD C/', per month beginning on / L., lell-, /\/OIIe./y,!1:.r and continuing on the 10th (tenth) day of each and every month thereafter until the balance as stated above is paid in full. Acceleration 1 understand and agree that if payments are not made in full by the due date, the agreement to accept partial payments on this account is cancelled. If such a default occurs, the entire outstanding balance becomes due and payable immediately. Collection Costs I agree to pay any reasonable cost incurred in the collection of this account. Costs can include but are not limited to: agency fees, court costs and attorney's fees. In the presence of:.. r )~')' j> V\.O..wYt -----<,.) \J\.Q' ':"1 Witness . ~4~ Witness Signature )/-'-/-99 Date " BE 309 (12-91) , SENIoRBlue ... .. . P.O. Box 890134 Camp Hill, PA 17089-0134 1-800-779-6962 . TOO: 1-800-779-6961 May 13, 1999 /--.-. '-- ". I Ms. Alice Johns, Jr. \ c/o Ms. Sharon Strebig ! 311 Walton St. Lemoyne, PA 17043 I r Ms. Johns. This is to inform you that SeniorBlue has determined that you are no longer eligible for continued care in a skilled nursing facility. Based upon our review of your medical condition, it does not appear that you meet Medicare guidelines for continued skilled nursing care. Skilled care must be furnished by or under the supervision of skilled personnel to assure the safety of the patient and to achieve the medically appropriate result. However, when an individual does not require skilled nursing services on a daily basis or uthe daily services could effectively be provided in an alternative setting, the services they do receive while in a skilled nursing facility are not covered. Thus your continued stay in Camp Hill Care Center will not be covered as of May 17, 1999, because you will not need skilled nursing care or skilled rehabilitation services on a daily basis in an inpatient setting. If you choose to continue your stay in Camp Hill Care Center, you will be responsible for the cost of all services provided by the facility except services covered under Part B of Medicare. Instead of care in a skilled nursing facility, we can provide the following covered services for you: home care services should you return home or an outpatient therapy evaluation. Please have your physician call our SeniorBlue Utilization Management department at 1-800-547-2273 if assistance is needed in coordinating care. If you believe the determination is not correct, you have the right to request 3."l appe,u by following the procedure listed below: 30 Day Appeal Process for Service Denials (60 Days for claims payment denials) . If you want to file an appeal which will be processed within (30/60) days, do the following: . File the request in wIjting with SeniorBlue at the following address: SeniorBlue Appeals - Grievance Committee, PO Box 890164, and Camp Hill, P A 17089-0164. ""m\"'h""'''~yd~''m"".,kh"m~''-'''~'') L~~~ Indepet dent Licensee cf the Blue Cross am Blue Shield Associatioo Ms. Alice Johns 'Iv;,,)' \')" \999 Page 2 . You can also file.!he.request in v>'fiting with an office of the Social Security Administration, or if you are a railroad annuitant, with the Railroad Retirement Board. . Fax your written request to SeniorBlue at 1-717.975-6895 or you may deliver your request in person at the following SeniorBlue site: . Camp Hill Keystone Health Plan Central 300 Corporate Center Ddve Camp Hill, PA 17011 Even though you may file your request with the Social Security Administration of Railroad Retirement Board office, that office will transfer your request to SeniorBlue to processing. SeniorBlue is responsible for processing your appeal request within 30/60 days from the date we receive your request. If we do not rule fully in your favor, we will forward your appeal request to the Health Care Financing Administration's contractor (The Center for Health Dispute Resolution) for a decision. Expedited Appeal Process We normally have 30 days to process your appeal. In some cases, you have a right to a faster 72- hour appeal. You can get a fast appeal if your health could be seriously harmed by waiting 30 days for a standard appeal. If you ask for a fast appeal, we will decide if you get a 72-hour/fast appeal. If not, your appeal will be processed in 30 days. If any doctor asks SeniorBlue to give you a fast appeal, we must give it to you. An extension up to 14 working days is permitted for a 72-hour appeal if the extension of time benefits you; for example, if you need time to provide SeniorBlue with additional information or if we need to have additional diagnostic tests completed. . The 72 hours appeals process does not apply to denials of payment. Written or oral requests can be filed by following the procedures below: . On your oral or w1~tten request, specifically state that "1 W3.'1t 3.'1 expedited appeal, fast appeal or 72 hour appeal" or "I believe that my health could be seriously harmed by waiting 30 days for a normal appeal." . To file a request orally, call 1.800-779-6962. SeniorBlue will document the oral request in writing. Ms. Alice Johns May 13. 1999 Page 3 . Or you may hanci'deiiver your request to: Camp Hill Keystone Health Plan Central 300 Corporate Center Drive Camp Hill, PA 17011 . You can fax your request to 1-717-975-6895. . If you are in a hospital or a nursing facility, you may request assistance in having your written appeal transmitted to SeniorBlue by the use ofa fax machine. . You may also file in writing with us at the following address: SeniorBlue Appeals- Grievance Committee,PO Box 890164, and Camp Hill, PA 1708'9-0164. The 72-hour review time does not begin until SeniorBlue has received your request. . You must file yourrequest within 60 days' of the date of the notice, which is May 13, 1999. We will make a decision on your appeal and notify you of it within 72 hours of receipt of your request. However, if our decision is not fully in your favor, we will automatically forward your appeal request to the Health Care Financing Administration contractor (The Center for Health Dispute Resolution), for an independent review. The Center will send you a letter with their decision within 10 working days ofreceipt of your case from SeniorBlue. Additional information that applies to both (30/60) day appeals and 72 hour appeals: Support for Your Appeal You are not required to submit additional information to support your request for services or payment for services already received. SeniorBlue is responsible for gathering all necessary medical information, however, it may be helpful to you to include additional information to clarify or support your position. For example, you may want to include in your appeal request information such as medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your primary care physician_ If your medical records from specialist physicians are not included in your medical record from your primary care physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you. SeniorBlue will provide an opportunity for you to provide additional information in person or in \vriting. Ms. Alice Johns May \3, t999 Page 4- Who May File an A_ppcal 1. You may file an appeal. 2. If you want someone to file the appeal for you: a. Give us your name, your Medicare number, and a statement, which appoints an individual as your representative. (Note: You may appoint a non-plan provider.) For example: "I [your name] appoint [name ofrepresenuitive] to act as my representative in requesting an appeal from SeniorBlue and/or the Health Care Financing Administration regarding SeniorBlue's (denial of services) or (denial of payment for services). b. Your must sign and date the statement. c. Your representative must also sign and date this statement unless he/she is an attorney. d. Include this signed statement with your appeal. 3. Non-plan providers may file an appeal if they complete a waiver of liability statement, which says they will not bill you if they lose the appeal. 4. A court appointed guardian or an agent under a health care proxy to the extent provided under state law. Help With Your Appeal If you decide to appeal and want help with your appeal, you may have your doctor, lav"yer, a friend, or someone else help you. There are several groups that can help you. You may want to contact the Pennsylvania Department of Aging, APPRISE Health Insurance Counseling Program, at 1-800-783-7067, Monday through Friday, 9:00 AM to 4:00 PM. You can also call the Medicare Rights Center toll free at l-888-HMO-9050, Monday through Thursday, 12;00 PM to 2:00 PM EST. The following are two quality complaint processes, which are separate from the appeal process described above: Peer Review Organization Complaint Process If you are concerned about the quality of the care you have received, you may also file a complaint with the local Peer Review Organization KePRO (717) 564-8288. Peer Review Organizations are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Peer Review Organization review process is designed to help stop any improper practices. , Ms. Alice Johns May 13, 1999 Page 5 SeniorBh.ie Quality Complaint Process If you have a complaint about the quality of any aspect of SeniorBlue, you may contact SeniorBlue at 1-800-779-6962. You may also file a written complaint with SeniorBlue as described in Section 5 of your Evidence of Coverage. SeniorBlue will review you complaint within the time limits described in your Evidence of Coverage. In all cases, we will review your complaint and notifY you in writing of our conclusion. This process is separate from the appeal process described above. Please call 1-800-779-6962 for additional information. If you have questions on how to file an appeal, please contact our SeniorBlue Member Services at (717) 972-0294, 1-800-779-6962 or 1-800-779-6961. tM41 Anthony D. Molinaro, Jr., MD Associate Medical Director ADM:pad ACKNOWLEDGEMENT OF RECEIPT OF NOTICE This is to acknowledge that I received this notice from SeniorBlue. I understand that my signature below does not indicate that I agree with the notice, only that I have received a copy of the notice. Verbal notification was given to Mary Artz@ the SNF & to Kay @ the PCP's office on May 13, 1999, by Cherie Adkins, RN. Signature of Beneficiary (Member) (or person acting on his/her behalf) Date cc: Camp Hill Care Center George Harhigh, DO , MAR-13-00 MON 14:28 , ':1~,~;~:i:i~f.~~~fr' ::~~~V" '7':'."..~J\'U) ..J!~4U~ ;;l,~;:i:'~~z~; < . CUMBERLAND CAD _.. FAX NO. 71724909' 9 tt.4 tHOU HiiAl..'tM OF ......""'..-._ l __ t1' I'\aK: .,_ Q1MIIIaI..AND COO1ftT A.tSDTANC& OPJIICE . 33....... . . . Drhe p.o. .. .. d. C8rilIGlI, , .1..... 11113-'" . ~^'-- ~ If'?( . ~~~A. -~~~ ~ O."J .....J7'OO ~ P,09 :z;. I^e.' 4!t ~ ...:iOA n.s Cf/C( (:e(:h'en.s. "'./03) cc: ~/-.amp\. S-fn/;;8-' tbl/ ,fol1<lriDg it_ are required to determine e1igibil:L~. ~ lfI,lrBing ,/ a... Hed,1ealAaautance. This 1nfonaation 1IJ11Bt be provided bydU-r-L ::ZLr-iff:1 in ordar to valve the face-to-face interview. If you prefer a face-to-face inrerview. please oall to schedule an appointm~nt bySv.>"'e O?/ . All requested ltem5 pertain to both tn" Nursing Home patient and oommunitY,_ Bj>OUae. Photo copies are "oceptable. Please call U you hav.. -,.. "stion or Deed help in obt:l.1ning the required information. '\ g , P "',t... )j.j-.l' J 1.) Soc1alSecurityCard(s) . )\.,"II 2.) ?-roof of date of birth .-' .J-\ f. . 3.) Medioal coverage membership cards r s.) Hedicare (red/~hite/blue tard(s) b.l Blue Cross/Blue Shield oard(s} c.) Any other health in~uranoe p1an(s) 4.) Work Histori~a (if any in tb~ past 5 years) 5.) Ver1fic~tion of 35oets/resources for th~ past 3 years (acceptable qpea of...rU~ are: cbedtl>oolr:. h&ik "t.lll:~. cop:les of it:clol(.), etar "(e) tr.. _ of resource/_e). '!, a.) Bank aCCounts (cbecking/saving8/~ney market, etc.) b.) Stocks, Bonds. or Certifieates of Depoolt c.) Christaas Club(s), Vacation Club(s), etc. d.) Trust FuQ4s e.) IRA or KEOGll (;<J n'Tri'.) 6.) ~.x returns. including 1099(s) for last 3 years 7.) V.:ciUli.ll.tiou' of 'Utles. vehlClio'regi8trar.1on (if':..o:e tbaa'ou,.....hle1it", ~ YlWse of aadI vehicle). 8.) All life insurance policies (verifical:1Dn sbould iDclude ca.pany's _. po11-cy ........r. ~e of polley, face __t of poliey wbooA ~ out. dat.. polieT vall t8k.ell oat. ownership of policy, aDd "tat_at on eurre:nt cub. ~e). 9.) Deed to burial plot(s) or statement fr~ cemetary 10.) Copy.of 5urial Trust, hurial reserve or pre-paid agreement~nclud1ng "I:a~t of .Ine..ocabU'it:f') 11.) Deed to all property (if transferred or sold vil:bia tbe last 36 ~ths .. cop,. of t:he ...... dc"d and the ....tt1_at sheet for all soU proper",.). 12.) title to mobile home 13.) Verification of any resource/asset that has bQ~n sold, traded, or ~iven away ov~r che last 36 months ,~-13-0J 110M \4: 21 CUMBEP.Lf\ND Cf\D . :;", ,-';,:-;."". '. NOTICE;JQ APPLlC~tiT ~F)"t;';~':fl;j{~...),~~)}j~?A~~; ';;~'~~~;,~'~V'}f~~:' ~ ~ ,,' ~ ~.;' . i) ~/ ,i , FPX NO. 11724909; 9 P. OS '. .v;,.:. . ~'-r:.' _ , "', ._ ~ ';;~~~t~ ~fl;!, ;~~::': '~X, , ';,~~~::.:~~;t;:: ~ >~:::::f:.tr, .~. ',', ..'~. . ':. ::;~ ", " llB'HUIe(Ta:f\ll'lI.C~ ~~~,~.eOlft:E '#-=#~ll!I"""':; : ' ''''' ',... .f.IO. . , .-'.' .' ,~. ". -' .} ,','-'f l ".\""",.-.: ,,',: " . , .,.; ,k.1tqt~~;~:~.~~1?o' i.~1W!'~'~~'~:~' ~'r'. "'~"""':".:r,"'.,~:,~:-~,~,';,1,",i".",~~,:-,_';~,"',.-""""',:,""'{',:",',:",:::,'"" 8~~:~..,~lfl:~/I\g~~~'tre:~~"',Qln<MM5t: .O.A1tbi:!aanli,~p __ ~ I,. tJ-;Y~'~;~~t~"~'Qf.' '.. ... ._, ._ '::',\~~':i';',,~':;' '.:'",. i:::rlh4'~~MIn;" ' ~&~lI\l;I OEff<<tJvCO.r." Youw;rrt'CllOCOi\ICI$ .fcntlC~lh(sJ'" . . .t:'I:J~)'OI.lri;~vvfooC~'ll1ir;:u;IIQ:,c~nf6$' ..' ,,~'rrom t.1:' OI')ltl~hI~," ______O...t:oo.oan):.,"":..."..:;'~,"-". .' '. d~f,.,~r~."'l,o;:: .~"...~$;t;,"'\"\.", ~, ~ lC: L*""".:tl~tltllL,lthori~ yO\.l.....~W.Fl"t; "1"lQflthtcJrlo'aroYO'Jrc.ant. ~' , " ~. " . . . . . . N . ' STAJolPS.' ,o'lSS~: 'SERVICE. _ _ ~E , -',..,'-',"'" Wf, , , , . '.' .,.' " .'~ ~ ,c:;"''- , , 'I" .... ~ ;.;.....v ",,,,, ...:' It.a:L' , . ~~~.,.' '~'~.).:,::..:" ~~','~ ;~~'.:' ~t:\~~_,~'':. ......, ;:~~~,~:~-~;:~pJ~~#~r,....,\>j :i1i',~ej;?~~~3(l~y i>r<ke~W U,;.;.~ (~~,'pA 'conE 125084,' (i>'>, and the 'v;,r:l.iftC'li;>'~:'9~,alf"" ','A" "" 'J, ''''""'';..,., '.;" 'I .- i:;-f'," &,.g.-..q9 -- ',' '__' '.''', ",', ," . '. .." '..' .i?t':.:- ,.;r;J. '. i.':)s.~if,~,:'tf,'l?#:p::e,s.~t~,; .. W..,.,r" ,=tend:l.ng' the a"~l1""ticnl'rOCeBB:l.ng, t~,t:Ul 45 days." . _'1:~. l!~'>:~1 t~,1>X'I>V:l 'call !>elld~ng ~" soon ~P~}ldble,.:U';ltl,,~,1 ,:Wll~,/~-h':""~~~~;. r~(/", ( - ~ . . ". . ~ ':~-,;:. . .. :- ." . . --, "".:.' . ..! ",""" '"n.,.: .....~~~,~ '.' ',. . '. Eol.R "r--I.},~J' .' tJ~.'" . '.-" "~': '. - EDl~~ . " ' " ,$' 1/./.1/ ' ,$' " , r/ /'//" ", $ /1/1/ 15 f; .II. $ i //1 ' S.~-- -- , tJ.l.L . IL'I" N.~ . . Name UNE~'EO INC "'"'Mt ' .... l;:NE''& IN(: ~ $ I/!/' $ "J/II $ 1///1/1 . 1. / /// . 1/1/1/, $ ':lI//Il, .. TOTAL GROSg MONTHLY INCOME ~ 1$' ... & NONTHLY DePENDEHT" CARE COSTS':'," . S. '.' ,,' "",' .,' : ~ . ~ , - - , ' . Name ~ . . EARN6~ IN~~LJ ': $ C ////I/!, :; /1//1 $ .~.!I 1~~S;l~~~ LY , N i'l1 '" ~ ;; FI/ 77, $ V//!ll! $ 1//////, S " S . . , :':,::',.'., .', :~::;j:{~',.:..., '<"-; :,;'::~'~:\..:'" " \',/,;, '. ! ""'" ,'l'Or....._MOHTHl.YlNCClMt .. .$ cmOss ~TMl. T'OEPEitl:JEMT Cj,'RE. COSTS $ Q~ ll"..IlfCAI. ooars :; ,T~. W~t:'f~' EI6elrit: Garoagalrl1JSh GM utlllt'; fMtWia!lOI1 011 . 0/"'" GR-CSS UTlL.llY COSTstUl1UT't $TANOAlltO. RE"rlNOll~C)E rUES lNSUftANeIi! COST OK HOMS TOr.....llI;lQ.nR ooar $. $ s $ $ li/I/I I//!// I,~!I, N.\llT1e TOT~l. OFlOSS MONTHLy' INCOME NEi MOIiiltL V (t.,'COMElNlrr SEMt-AN.NUAlI~COi.lE INCQUE UW'r I~J p7:;7; r ~/rc.e_ V OAn5" r I 70: .0 fa \1;)/\ .;:;, -/.re j; '[- I CAT I = D>O I = l- \1 I I ., " .f ,;;"'/1.1" ._,117 , Wo"il.~'~ Slg~tlJro ~~ , 7-9-99 ;)yo---;n;7 vaN Tet~p'ttOn8 ,,"urnD.e~ C(, (11(/ ~~ '" -" .. u;atL-. .-..... &_1I:lW CAlUU.M tllIlNal!l 7Il'-..o~ ~HR-13-00 tlON 14:26 , July 22, 1999 CUMBERLAND CAO FAX NO, 7172490919 P.07 162 attachment: The following is infonnat1on that is still pending and must be submitted to complete this application: I. A copy of the deed to the property. The information you sent is conccrning the loan, It does not verify ownership. The transter of the property at 832 Fishillg Creek Rd., New Cumberland is an issue and you mUSt verifY the date of the transfer 'from your Mother to you AND the fair market value of the propert}'. We discussed tIlis oyer the phone. 2. A copy of the Power of Attorney. 3_ 1he following information f'oryour Modler: socialllCCurlty card copy, date of birth verifiCation copy, medical card eopy (Scnior Blue). 4. Verification ofmcdieal insurance premhL!ll (Senior Blue). 5, Verification oflife insurance policy- date of policy, face amount of policy, current cash !ruLTender amount of polley and policy number. 6. Verification of burial reserve and burial plot. 7. Verification of 5m99 balance of any/all bank accounts with your Mothers name on. S. The application Ii!;!s sole source ofinccme as social security. The 1998 l099'r form from City Bank indicates possible SUIViviors pension. Does she get income from this? F~X NO, 7l7248~8:8 P,03 , ..~.._.c._ ~"_.,..' .,....... _' ........',H .._. "'~&~~I;:i.~~~~:;:f~::.:' ' '-, > :--.';,- ..... -"'.' .' ~ .':' ': .;,. ,', ...~.~ "$~.:.!:,..i.~~., I ';;'.,-, .'.- "'.! ''$ ~~:. ';C~:".,. ,~ ~': Name . 'N:u:,a .'.' " $ S $, ';1 .', Ii 'l// /: 5 $, 5 TOTA~ GROSll MONTH~ V-INCOI,!l;; S. GROSS MONTHLY ~EI.fOeNr.CA1ta:~:,':". ._:~i ~ , , ,'.'3:;~~';.jJ- ,"7. !"1',. i_:'.~, I 1/ tOTAl~,IiONT1iLYIHCdMr= "$' oaoss IOOIITiIl:V OEPEkDefT CAAE COSTS I $ QROSS W?~CM- COSTS ! S T~Mf'le Waler/Senaga ~c G.arbtl9~~ Gas Utility Instan~ion 011 Ottleot GROSS. UT1UTY COSTSlUTJU1Y STANDARD- 1$ 'Reto!TIMORfGAGE I So :rAXa iJr.l$V~ COST ON HOME ,TOTAl. -.ilEi.i'eIl'cO$T . ': ~ '. '. . Ii/I 'I ;. /. '/ ' , ' 'DME,b)e~r<SSI Nama '-:'*';~;'~" N(I;l':'le :.: .' ,/ TOTAl.. GROSS folONTHLV INOOloP.::: $ nET MON"THLY INCOME/NET Sa'l(.ANNUA1.INCQrJE :$ INCOME UM1T S " "'''. -,~"",". ..,.. :,,.,,,,, ..,.....".....d....... ~I ?5S"?? In 'u. ......./ D An.s- ID ::.5 /-o,rlX! S 'kei1j- CHCC ,0"" L ~~b",lJ.. Wu' ff'~Si9:'1;tll.lt!;7 .. . . - . ." ,," 1,...;!.:ld'l .0?,!fJ)/;).-717 o.!"... T...lt;tph.:J'l" l\f\itl'jb&r .., :~,~~:.;:..~i(:.}'. ':"~:~:"'?:<"~ r :r';:{.:;4,f,..;.:~.--;:.::., ~~ :; iEiW.i.;:.,..c...i.m UIYINEIIOW,' .., CNl.l!l.EPll. 1_9 111~ '117.1lIHQfl LG.; L '~ ,~it~:~~U;,1f~~~~~.J&i{b; ~~'6,;JM;&1/~t~ ~;;u;:~ I .' GU~BERLAND CAO FAX NO. 7172490919 CUMBERLM'D COUNTY ASSISTANCE OFFICE 33 Westminster Drive, P.O. Box 599 Carlisle, PA 17013 Phone (717) 240-2744 or 1-800-269-0173 August 12. 1999 P.D5 MAR-13-00 ~ON 14:24 . 'I 'f Sharon Strebig 311 Walton St. Lemoyne, P A 17043 Rc: _Camp Hill_Nursing Home record # 85548 Dear MIs Strebig, After reviewing the record and the information received, the following itoms arc still needed to determine Nursing Home Medical Assistance eligibility for ...ALICE JOHNS_. . PLEASE VERIFY VALUE OF THE PROPERTY. OK TIIE FIRST APPLICA nON, YOU HAD STATED YOU HAD MAIII,'T ATh"ED DiE PROPERTY FOR YOlJR PARfu'I/TS, PLEASE VERIFY HOW Al\,'O RECEIPTS FOR THE AMOUNTS YOU PAID. . VERIFICATION OF THE PREMIUM FOR SENIOR BLUE INSURANCE . VERIFICATION OF THE LIFE INSURANCE POLICY (COPY OF THE POLICY) . VERIFICATION OF THE BURIAL RESERVE AND BliRIAL PLOT. . DID MRS. JOHNS RECEIVE AZ,iY TYPE OF SURVIVORS :BENEFITS FROM YOUR FATHER'S PENSION THRlJ CITY BANK (JOYCE Ir\TERNA TIONAL)? . DOES MRS. JOIL"JS HAVE ANY ACTIVE BA."lK ACCOL'NTS? . WITHIN THE PAST 36 MONTIIS HAS MRS. JOIL~S CLOSED, GIVEN AWAY, SOLD OR TRA1'iSFERRED ANY ASSETS SUCH AS A HOl'.-IE, LAND, PERSONAL PROPERTY, LIFE INSURANCE POLICIES, Al'iNUITITES. BM'K ACCOUNTS, CERTIFICATES OF DEPOSIT.. STOCKS, IRA. BONDS, TRUST FUNDS, OR A . RIGHT TO DiCOME? Please provide by .-SEPTEMBER 2, 1999__ Plea-~ call if you have questions or cannot meet this deadline. Sincerely. Lynne Gordon IMe Copy: Nursing home nAR-13-0Q MON 14:23 CUMBERLRtID CRO FRX NO. 7172490919 CUMBERLAND COUNTY ASSIST A~CE OFFICE 33 \,-es;:minstcr Drive. P.O. Box 599 Ca"'i~le, PA :70)1 Phcne (717) 240-2744 Of I-H00-269-0173 September 3, 1999 P,04 1 () Sharon SU'cb;g 31l Waiton St. Lcmoync. PA 17043 Re: ALlCE JOHNS J:amp Hill_Nuf;;ing Home rccord # 85548 Dear Mrs. Srrebig, After reviewing the record and the lnfonnation !'cceived, rhe following items are still needed to dctcnnine Nursing Home Medical Assi;taucc cligibi1:ty: . PLEASE VERIFY VALVE OF HUe PROPERTY. 0:'1 THE FIRST APPLICATION, YOl; HAD STATEDYOt, HAD 1\1AlNTAIl\ED THE PROPERTY FOR YOUR PARENTS. PLEASE VERIFY HOW AND RECEIPTS FOR THE AMOliNTS YOU i' . PAID. ' . . VERIFICATION OF THE SENIOR BLUE L'<SURA.."iCE PREMIUl\-L . . VERIFICATION OF THE UFE INSURA:iCE POLICY (COpy OF THE POLICY) , . VERIFICATION OFTHE BL,UAL RESERVE AND BlJ'RH.LPLOT. . DID J\-fRS. JOHNS RECEIVE A~Y TYPE OF Sl.TRVTVORS B'Ei'OEFITS FROM YOLlt FATHER'S PENS',m; T.fHW eTn BA!\K (JOYCE L"TERNATIONAL)? . DOES MRS. JOHNS HA VE Ai\\' ACnVl: BA8KACC:OUNTS? . WITHIN THE PAST 36 3'10NTHS, HAS MHS. .JOHNS CLOSED, GIVEN A WAY, SOLD OR TRAl'iSFERRED AlW ASSETS SUCH AS A HOME, LAND, PERSONAL PROPERTY, LIFE INSrRA8CE I'OLK:.IES, Al\i'HJlTlliS, BANK ACCOUNTS, CERTIFICATES 07 DE:'C~n, 3 tDCKS, JKA. nONDS. TRUST FUNDS, OR A RlGHT TO I"'COME~ Please provide by _SEPTF.:M[\EP. : "., 19l\r. __.. ;',,))se c,al! ;,fyou havcquc~1ions or cannot meet this deadline. SlDcereiy. Lynne Gordon (Me Copy: Nursing home ~AR-13-00 ~ON 14:22 CU~BERLANl) CAO FAX NO. 7172490919 CUMBERLAND COUNTY ASSISTA..'lCE OFFICE 33 Westminster Drive, P.O. Box 599 Carlisle,FA 17013 Phone (717) 240-2744 or 1-800-269-0173 September 9, 1999 P.03 " , Sharon Strebig 3]] Walton St. Lemoyne, P A 17043 Ro: ALICE JOHNS _Camp HiJUllursing Home record # fi5548 Deal' Mrs. Strebig, After reviewing thtl record and the infoOT'..ation received, the follo\'\~ng items are still ncodtld to detamine Nursing Home Medical Ass;;13nee e1ill'bility: . . PLEASE VERIFY HOW YOU tv1AL"lTAlNED TIIE PROPERTY FOR YOD'"R PARENTS. PROVIDE COPIES OF CANCELlED CHECKS OR RECEIPTS. . PRO\tlDE VERIFICATION OF IRREVOCABLIIT ST AIEMENT ON BURIAL , RESERVE, . DOES MRS. JOHNS HAVE ."-''1Y ACTIVE BANK ACCOL1NTS? HOW DOES SHE PAY HER BILLS'? Please pt.ovide by _SEPTEMBER 17, 1999~. Please call if you have questions or cannot meet this deadline. . Sincerely, Lynne Gordon J:Me Copy: Nursing home - . FAX HO. I I , ~ 71724929:9 P,02 DE?ARTMB..T OF PIJ9LlC WE"..F;.iqS ClMa=.F..A,'I1DCOUN"'Y ,-\S$18TJ>,~;C= O;;HC~ ;'3 WES1l"M~STEP. OR 1>0 3C~~ !i99 CAr.: :" ~ f=-'" T7G'~3.""''=It. 1.~'3.~.r;O'73 (1::i240-.2';cm -, i 1.-[ ,'\.~S'ST...Iv:;'lE i '-- CHECK 8Er,:1=I; , "-"t/:( :..., ;ir,' ~1'l1W~ ."',c~ 'l~" ':>:.:;0 ~P_:::..I ..ll'"r.:..n: ,';>I. 'II,' If->': .",:0. j 0 T",_~'"", M.~r.11' ..J o,.~~;, (All;!,:'; .:::; 'r ',r,~ /J:~.' C ."1 It,... -':".0: I _. ....,.___._WM__._ ." ----e I I , i ,~ :0 'i'~\, r~,,:,~pn':;'!"J\;:~:~-..:..ji,,.. , A ~ ... ' 1;:.'tl"u",;".,.,n"~J'}:::!,\;l -..:~~'''f.::.: -' : ~r1:!"";':'=-'::"!l:S_~_~_II"',"'Q"~'~'~'_~ ; !. 'I'C"tu :r~,=' ---:..-.__ ~v_._.~ C Ir,l,..."t~1 ~,~~_;'~l""'_ ~~" _~~~::-~. _ I,(~.. ..... W,. '(C&I.~ 1::.,n;t:t."I'lL'!; nlke;'lr':">:lJ..,'\,lI~ - - :J....llheS!L'"l1.. i . FOOC. l'-J ST,l.MPS t / I ~JJRSING~;;~1 , - 5oCIA1,. Il OTI"!!:;;t I ;""':(!F-OV/C-l:':; ...JI~~";'\') THE FQU.O\\1NG ::>:=RSONS ARE 1r~CLUDcD 'iN N,\r..lE' 01 i LQ';(l cl e..", ""lrf)rl~....;:$ I YOJ ~~t.' ..X:;..Cl~~ l~ ;I1:r 1 :l1'T"l:'r.t'tC...Broy"ur~ll.r\!. oilS';;,. !.;-i C": -"L:) ~;".MP 1t::C.. (l,SS- : sJ1?v1r: L'Nl: N N(l,\lE ASST. MCH CJ< ~IAMPS :30; A%o;,T ERVI:':~ ~rl,/)"-..JO.-- ~, ==;r, ~ . ;. HIS ACTlOU HAs EEEN TA1\EN' BECAUSE Of THE FOLLOWING fACTS AND REGULATIONS 1 25. ~!I(Q.) i ~<::' {:IfI C~ / -, S. (. / l.e Ht-ClIEt."" tJ 3. ~d.":~ ('.oa<:: Q~ ;t.. fJ.JZY. ........i2>:>OU~ of a#~~ ~t ..0-'<. (j.2/U.&..<J1oL- C,,- OJ.J.ff 12) .lQ.pt-3 .\.Qt,.pt <;' .- jQ<(q tu-'- --,-,,~~C't. ().1Y'"::d rco...ci;:>n... ......-.!!'f"?/..cLvnJ- p~ c& )O'U)~ ~ vl'-"O w& IW"t. ,/.1l1';U"$ '. ~ 0.. a.;t:<.bJ-<.. ....00 ' ~:;:.Gc;(' . 1,..OC ~, / u .., I~ ,I Nine Numbg.:QT p(lr=ns~l G . S Me'l,'"',.... ="'RNECI"-CC '5 "UI,:! S; ///;// r S I'll//,/ i l;~~2~~"D.~,i1 \ r s 'j./i.','/ 1 $ li//I/i, . s V/://;" N~rntl Namt. i TOTA1. GROSS MONTHLY lr4COME GROSS MONTl-'.1. Y DEPENDENT :::~E: COSiS CROSS MEC'ICAI. COSTS IS TOTt.L.GROSS fJONTHLY INCOME G~OSS MONTH~Y DEPENDENT CA.~e COSTS ,s is TelaChO:'\c r- MEDICAL. ASSISTANCE N~mc ---1 Vi'l!erlS~wag:e - , Slf:.:et'lc ..-1 Garba~l"~::1- j G;.; 11 I L1,[ltyrr.stall2.lbr> Oil I IlolM: C;;ROSS UTlUTV caSTSlIJTI~ITY STtl,NOAAD~ RENT/MQ;;TGACi TAXES iNSURANCli. COST o:~ HOt.l& T;:)TAt.5I'\ELTER COST $ ~'/{//71 ~// /1/ ~/'/.'/', NS:Tle Nt.:rr.lolel 0: P<:lrscns'" ~~~~"'~b.t& I~ (/1/// ,$ // '$ /,1/ i Go >\SM NTH1.\' UN A1'I''I:;:) lNCOMfo S 1// ;'/ , S !5 Is is ''''The hOLt5ehotd m~y 5r,rit-:!" tetwefl'l tho aetuar t;ri/irr costs ~ll1C fIlS .standard i.it,'1!t.,: a,l1cwance ~t f'1e time of rea,;p/J2tion and one additional t.'r"e d:.Jring ~ah rw~f/!:>-Mont.i p~r"/(Jd. TOTA~ GROSS MONTHLY INCOME- L NET UONTtiL "'. INCOME/NET SE1>u.ANNUAL INCOME ! INCOME: WMIT s Is :1 /, " ~!JI./I I: S 2t' '?SS'-I'i? !e;::; r ,..-, ,.., C {~ ~J...., .;'-,Ivrvo Camp Hill Ref. and N. Heme u. - f 'r.>ct J-70 t..( ora . ~ . L C<:mp HHl, pa.,:;J.7Ql1:. ~'Y>/Y"';" '%G-td.ot'C_ , Wo.i\e:rs S~;nattJr~ ((120/'1'1 D.;lQ /-I;OD;l.690173 Teolept1"n~l'Jumbt:l' co R!iCORI~Nu~e!:R CAT L8;iAL HELP IS AVAIlABLE A,-r , ,EGA, SERVICES, iNC. 8 JAVll~E RON Co\I1L1SlE PA 1701S.:ml~ 7'17-2.43-3400 717-766.8475 [,you co not un:){Jfs~,!d O~f dsc;isJor. Ot h~v~ c!!:'ly Q!.i~tio~. contacr y:)J.J1. .\'O,i.-sr. CUEf'lT COP\, "l:');" .. 0 = 0 ? C = --n ~ --< ~.. ...!~ -00 == ~::n mr":l :::0 'r- Z.:1J "" --m ~~ "'1' 0 :-.~ 0 ::r:!Sr{ ~C') -0 6:0 ~o :Jli: -;;>"'c> ~O '-m Pc:: ~ q z ';:;! =<! :,.) :0 <J1 -< BEVERLY HEALTH AND REHABILITATION SERVICES, INC., D/B/A CAMP HILL CARE CENTER : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL COMPLAINT VS. NO. 2000-1145 THE ESTATE OF ALICE JOHNS MS. SHARON STREBIG Defendants DEFENDANT SHARON STREBIG'S ANSWER AND NEW MATTER AND NOW, comes Defendant Sharon Strebig, by and through her attorney, Gregory J. Katshir, Esquire, with the following Answer and New Matter as follows: 1. Paragraphs one (1) and two (2) of the Complaint are admitted. 2. Paragraph three (3) of the Complaint is denied. Defendants Johns last address was Manor Care, 1200 Market Street Camp Hill PA 17011. By way of further answer, Defendant Johns was discharged from Plaintiff CHC on or about May 16, 1999 and again on or about June 10, 1999. 3. Paragraphs four (4) and five (5) of the Complaint are admitted. BREACH OF CONTRACT 4. The representation set forth in Paragraphs one (1) through three (3) are incorporated herein as if the same were set forth in detail. 5. Paragraphs seven (7) through twenty (20) ofthe Complaint are admitted. By way of further answer, Defendant Johns was admitted at Plaintiff Camp Rill Care Center (CRC) on or about April 24, 1999 and was removed from the care center on or about May 14, 1999. Any and all costs for services rendered to Defendant Johns by Plaintiff CRC were paid in full up to that date. Subsequent to her removal, Defendant Johns was re-admitted to the Plaintiff CRC on or about May 17, 1999. Defendant Johns executed the Admission Agreement and was acting as her own agent. Defendant Strebig was not a party to that subsequent Admission Agreement. 6. Paragraph twenty-one (21) is admitted in part and denied in part. It is denied that Defendant Johns has not paid for any ofthe services rendered. Specifically, any and all costs associated with services rendered up to and including May 16, 1999 were paid by Defendant Johns medical insurer. Defendant Johns also entered into a Partial Payment Agreement with Plaintiff CRC after her discharge from the facility after her second stay. Defendant Johns made several payments pursuant to that Agreement up until the time of her death on December 8, 1999. 7. Paragraphs twenty-two (22) through twenty-four (24) of the Complaint are admitted. By way of further answer, Defendant Johns died on December 8, 1999. It is the belief of Defendant Strebig that Defendant Johns' estate is insolvent. 8. Paragraphs twenty-five (25) through twenty-eight (28) of the Complaint are admitted. By way of further answer, Defendant Strebig understood the agreement as meaning that any alleged debt of Defendant Johns would be paid and satisfied by Defendant Johns paying the amount of $100.00 per month. 9. Paragraph twenty-nine 29 of the Complaint is denied. At no time did Defendant Strebig represent or acknowledge that she has an obligation to pay any amounts owed to Plaintiff. 10. Paragraph thirty (30) of the Complaint attempts to set forth some type oflegal conclusion to which no responsive pleading is required. 11. Pm:agraphs thirty-one (31) and thirty-two (32) of the Complaint are admitted. By way of further answer, it is believed that Plaintiff CRC is alleging that the staff of Plaintiff spoke to Defendant Strebig on or after May 17, 1999 regarding Medicaid. 12. Paragraphs thirty-three (33) through thirty-eight (38) of the Complaint are admitted. 13. Paragraph thirty-nine (39) of the Complaint is admitted. By way of further answer, it is admitted that Defendant Strebig agreed to co-operate with CAO in the execution ofthe application, however, she had no contractual obligation or fiduciary obligation to Plaintiff to do so. 14. Paragraphs forty (40) through forty-three (43) of the Complaint are admitted. 15. Paragraphs forty-four (44) and forty-five (45) of the Complaint are specifically denied. Defendant Strebig did not understand the nature of the requests. 16. Paragraphs forty-six (46) through fifty (50) of the Complaint are admitted. 17. Paragraph fifty-one (51) ofthe Complaint is specifically denied. Defendant Strebig did not understand the nature of the information. - - - - 18. Paragraph fifty-two (52) of the Complaint is specifically denied. Exhibit "G" does not specifically indicate that the additional items must be provided to determine eligibility. 19. Paragraphs fifty-three (53) through fifty-five (55) of the Complaint are admitted. 20. Paragraph fifty-six (56) of the Complaint is denied. Defendant Strebig did not understand the nature of the requests... 21. Paragraph fifty-seven (57) of the Complaint is denied. After reasonable investigation, Defel1clant Strebig is without sufficient information to form a belief as to the truth of the averments of Paragraph fifty-seven (57) and strict proof thereof is demanded at the time of trial. 22. Paragraph fifty-eight (58) through sixty (60) of the Complaint are admitted. 23. Paragraph sixty-one (61) ofthe Complaint is specifically denied. Defendant Strebig did not understand the nature of the requests. 24. Paragraph sixty-two (62) of the Complaint is denied. After reasonable investigation, Defendant Strebig is without sufficient knowledge to determine the truth of the averments and strict proofthereofis demanded at the time of trial. 25. Paragraphs sixty-three (63) through sixty-six (66) of the Complaint are admitted. 26. Paragraph sixty-seven ofthe Complaint is specifically denied. Defendant Strebig did not understand the nature of the requests. 27. Paragraph sixty-eight (68) of the Complaint is denied. After reasonable investigation, Defendant Strebig is without sufficient knowledge to determine the truth of the averment and strict proof thereof is demanded at time of trial. 28. Paragraph sixty-nine (69) through seventy-two (72) ofthe Complaint are admitted. 29. Paragraph seventy-three (73) of the Complaint is specifically denied. Defendant Strebig did not understand the nature of the requests. 30. Paragraph seventy-four (74) of the Complaint is denied. After reasonable investigation, Defendant Strebig is without sufficient information to determine the truth of the averment and strict proof thereof is demanded at the time oftrial. 31. Paragraphs seventy-five (75) and seventy-six (76) of the Complaint are admitted. 32. Paragraph seventy-seven (77) of the Complaint is denied. The notice does not.indicate that information was requested from Defendant Strehig. Defendant Strebig's name does not appear on the notice. This notice was sent to Alice Johns at Camp Hill Ret. And N. Home, 46 Erford Road, Camp Hill PA. 33. Paragraph seventy-eight (78) of the Complaint is denied. The notice does not state that Defendants could reapply. The notice indicates that "you" may reapply. The notice was sent specifically to Defendant Johns. 34. Paragraph seventy-nine (79) of the Complaint is denied. The Agreement does not provide that the Facility would be entitled to reasonable counsel fees, court costs and interest in the event it pursues and prevails in litigation. Strict proof thereof is demanded at the time of trial. WHEREFORE, Defendant Strebig requests that this Honorable Court deny Plaintiffs Complaint and enter judgment in her favor. BREACH OF IMPLIED CONTRACT 35. The representations set forth in Paragraphs one (1) through thirty- four (34) are incorporated herein as if the same were set forth in detail. 36. Paragraphs eighty (80) through eighty-five (85) of the Complaint are admitted. 37. Paragraph eighty-six (86) of the Complaint is denied. As indicated, payment was rendered in full through May 16, 1999 and additional payments were made to Plaintiff subsequent to that date. 38. Paragraph.eighty-seven (87) of the Complaint attempts to set forth some type oflegal conclusion to whichno responsive pleading is required. 39. Paragraphs eighty-eight (88) and eighty-nine (89) of the Complaint are admitted in part and denied in part. It is admitted that Defendant Strebig requested Plaintiff admit her mother and agreed to make her mother's funds available. However, Defendant Johns was discharged from the Facility on or about May 16, 1999. All costs and expenses associated with Defendant Johns'_sJJW have been paid up to and including that date. Defendant Johns entered into a subsequent contract with Plaintiff on or about May 17, 1999. Defendant Strebig did not request admission or make promise of funds on or after that date. 40. Paragraph ninety (90) of the Complaint is admitted. 41. Paragraphs ninety-one (91) and ninety-two (92) of the Complaint are denied. Defendant Strebig is without sufficient information to form a belief as to the truth of the averments and strict proof thereof is demanded at the time of trial. 42. Paragraph ninety-three (93) ofthe Complaint is admitted. 43. Paragraph ninety-four (94) of the Complaint is denied. Defendant Strebig did timely apply for benefits. 44. Paragraphs ninety-five (95) through ninety-seven (97) attempt to set forth some type oflegal conclusion to which no responsive pleading is required. WHEREFORE, Defendant Strebig requests that this Honorable Court deny Plaintiffs Complaint and enter judgment in her favor. QUANTUM MERUIT 45. Paragraphs one (1) through forty-four (44) ofthe Complaint are incorporated herein as if:the same were set forth i~ detail. 46. Paragraph ninety-nine (99) of the Complaint is admitted. 47. Paragraph one hundred (100) of the Complaint is denied. Plaintiffs agreement is with Defendant Johns. 48. Paragraph 101 of the Complaint is denied. Defendant Johns did make arrangements for payment, including the partial payment agreement executed on November 4, 1999 and attached to the Complaint as Exhibit "C". 49. Paragraphs 102 through 106 attempt to set forth legal conclusions to which no responsive pleading is required. WHEREFORE, Defendant St;rebig requests that this Honorable Court deny Plaintiffs Complaint and enter judgement in her favor. BREACH OF FIDUCIARY DUTY 50. Paragraphs one (1) through forty-nine (49) are incorporated herein as if the same were set forth in detail. 51.Paragraphs 108 through 121 attempt to set forth some type of legal conclusion to which n,O responsive pleading is required. WHEREFORE, Defendant Strebig requests that this Honorable Court deny Plaintiffs Complaint and enter judgment in her favor. ACTION IN ASSUMPSIT - DUTY TO SUPPORT 52. Paragraphs one (1) through fifty-one (51) are incorporated herein as if the same were set forth in detail. 53. Paragraph 123 sets forth a legal conclusion to which no responsive pleading is required. 54. Paragraph 124 ofthe Complaint is admitted. By way offurther answer, Defendant Johns died on December8, 1999. 55. Paragraph 125 of the Complaint is denied. Defendant Johns died on December 8, 1999. 56. Paragraphs 126 and 127 ofthe Complaint are denied. After reasonable investigation, Defendant Strebig is without sufficient information to form a belief as to_the truth of the averments and strict proof tI:ereof is demanded at the time of trial. 57. Paragraph 128 of the Complaint is denied. Defendant Strebig does not have financial ability to pay some or any Defendant Johns maintenance and support nor does she have th,at obligation. 58. Paragraphs 129 through 130 set forth legal conclusions to which no responsive pleadings are required. WHEREFORE, Defendant Strebig requests that this Honorable Court deny Plaintiffs Complaint and enter judgment in her favor. . - NEW MATTER 59. Paragraphs one (1) through fifty-eight (58) are incorporated herein as if the same were set forth in detail. 60. On April 24, 1999 Defendant Johns was admitted to the Facility. Ms. Johns was admitted for the purposes of rehabilitation. On or about May 16, 1999, Defendant Johns was discharged from the Facility. Plaintiff CHC provided the Defendants with instructions for care upon discharge and with . Defendant Johns personal affects. 61. Up until May 17, 1999, Defendant Johns' medical insurer paid any and all costs associated with Defendant Johns' stay at the facility. 62. On or about May 17, 1999, Defendant Johns was readmitted to tp.e Facility. At the time of readmittance, Defendant Johns executed a subsequent Admission Agreement. This Agreement indicated, in the handwriting of an agent of Plaintiff, that "Resident was to be her awn boss". See attached copy of Agreement identified as "Exhibit 1". 63. Defendant Johns' readmittance was not done with the consent of Defendant Strebig nor was she a party to that subsequent agreement. 64. Defendant Johns was discharged from the facility on or about June 10, 1999. Defendant Johns died on December 8, 1999. 65.0n or about November 4, 1999, Defendant Jgp.ns, and !lat Defendant Strebig, entered into a Partial Payment Agreement wherein Defendant John.s agreed to pay monthly tawards a bill. Defendant Strebig was not a party to that Agreement. This agreement WaS entered into after Defendant Johns discharge from the Facility. 66. Defendant Jahns did make payments to Plaintiff pursuant to the Partial Payment Agreement prior to her death. tshir, Esquire r Defendant Strebig P A ID# 61967 900 Market Street Lemoyne PA 17043 (717) 763-S133 ADMISSION AGREEMENT SIGNATURE PAGE. Date ., ./ J i sident Signed with a Mark . s:. /7- 91 Date ~ '" .00 ,Q.: '" .::> ~ \ ~ l^ / ~ d- ui ice/1IL, h~~A /1 f Witness if Re'sident Signed wit a ark s: /7~ tj'q Date :z ,~ :13 ~~ , ; '(. ......". ~~..... ",..'-_.1 5-/7- 99 ,~. \.' - . -f ~~Date Legal Representative -< ) Legal Representative's Telephone Number Legal Representative's Social Security No. Agent Date -< ) Agent's Telephone Number Agent's Social Security No. Facility Administrator or Designee Date .~ '" ~ Z ? ;t&;t; tp-w -t ~ /~7 07?Y} (~ Exhibit ] Note: The signatures above refer to the information contained on pages 1 through 18 of the Beverly Enterprises Admission Agreement. White - Business Office 19 Pink - Medical Records Yellow - Resident Sent By: 717 763 9425; May-3-00 9:29AM; Page 10/11 VERIFICATION OF KNOWI"EDGE. INFORMATION AND BELIEF I verify that the facts set farth in the foregoing Answer and New Matter are true and correct to the best of my knowledge, information and belief. I understand that false averments herein are made subject to the penalties of 18 Pa. e.s. Section 4904, relating to unsworn falsification to authorities. Date: ~ay -r NOt) ~-~ I.- I A... .", Sharon Strebig . , 3 CERTIFICATION OF SERVICE I hereby certify that a true and correct copy of the foregoing Answer and New Matter was served upon the following via First Class mail, on May 5, 2000, postage prepaid as follows: Jonathan C. James, Esquire Capozzi and Associates, P.C. 3109 North Front Street Harrisburg PA 17110 Gregory J. K tshir, Esquire JONATHAN C. JAMES, Esquire Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3 I 09 North Front Street Harrisburg, PA 17110 (717) 233- 4l01. ATTORNEY FOR PLAINTWF IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A Camp Hill Care Center 46 Erford Road Camp Hill, Pennsylvania 170 I I Plaintiff, v. The Estate of Alice Johns 311 Walton Street Lemoyne, PAl 7043 CNIL COMPLAINT NO. 2000 - 1145 Ms. Sharon Strebig 311 Walton Street Lemoyne, P A 17043 Individually and as Attorney in Fact for Alice Johns Defendants, PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services Incorporated, d/b/a Camp Hill Care Center (hereafter referenced as CHC) by and through its attorneys, Capozzi & Associates, P.C., and avers as follows: 59. Defendant's averment 59 does not require a responsive pleading. 60. Admitted in part and denied in remainder. Plaintiff admits Defendant Johns was admitted to the facility on 24 April 1999 for the purposes of rehabilitation. The remainder of Defendant's paragraph 60 is denied and strict proof will be demanded at trial. Defendant Strebig removed Alice Johns from CHC pursuant to a physician's order, without the benefit of discharge planning and had Defendant Johns out of the facility for a period ofless than 24 hours. Defendant Johns was returned to CHC by representatives of the Area Office on Aging the next day, 17 May 1999. 61. Admitted in part and denied in remainder. It is admitted Defendant Johns stay at the Facility was covered by medical insurance. To the extent, if any, the 1:0 < .~ ~ . ~ .. Defendant Johns was responsible for a co-pay portion it is denied this portion was the responsibility of the insurer. 62. To the extent Defendant's paragraph 62 claims a CHC readmitted Defendant Johlls, that is a legal conclusion to which no responsive pleading is required. On 16 May 1999 Defendant Johns, pursuant to a physician's order was removed from CHC for a period oftime less than 24 hours, by Defendant Strebig, returning on 17 May 1999. To the extent Defendant's paragraph 62 claims a new agreement was executed, that is a legal conclusion to which no responsive pleading is required. Otherwise denied and strict proof will be demanded at trial. To the extent Defendant's paragraph 62 claims the words Resident was to be her own boss have any legal import what so ever under the circumstances described herein, it is denied. To the extent Defendant's paragraph 62 claims the words Resident was to be her own boss were written by an Agent of Defendant Johns, that is a legal conclusion to which no responsive pleading is required. Otherwise denied and strict proof will be demanded at trial. 63. To the extent Defendant's paragraph 63 claims a CHC readmitted Defendant Johns, that is a legal conclusion to which no responsive pleading is required. Otherwise denied and strict proof will be demanded at trial. On 16 May 1999 Defendant Johns, pursuant to a physician's order was removed from CHC for a period of time less than 24 hours, by Defendant Strebig, returning on 17 May 1999. To the extent Defendant's paragraph 63 references a "subsequent agreement", that portion of Defendant's paragraph 63 is a conclusion ofIaw to which no responsive pleading is required and is otherwise denied. The remainder of Defendant's paragraph 63 not specifically referenced above is denied and strict proof will be demanded at trial. 64. Denied. Alice Johns was discharged on June 24th 1999. Plaintiff has no knowledge of the date of Ms. Johns' passing. 65. Defendant's paragraph 65 is a conclusion of law to which no responsive pleading is required and otherwise it is denied. Strict proof will be demanded at trial. 66. Admitted to the extent partial payments were made to CHC. Additionally, on information and belief Defendant Strebig facilitated Defendant Johns' payments to CHC. On information and belief Defendant Strebig's facilitation of the payments to CHC indicates Defendant Strebig had access to Defendant Johns finances and financial information. To the extent the payments were made pursuant to an Agreement that is a legal conclusion to which no responsive pleading is required and is otherwise denied. 1- :~-,~ f ,-". ,_, + - ." ,. - . ',..1' _~ ""'~ -1" ,,,~,, " ". - r~' ,,__. _'. <-.'_ _ _ .-, WHEREFORE, Plaintiff respectfully requests that this honorable Court enter judgment in favor of Plaintiff and against Defendants in an amount in excess of$4551.75 plus interest, attorney fees and court costs from the date of the Court's judgment. Respectfully submitted, CAPOZZI AND ASSOClAT S, P.C. ~ Date: f/\tt'1 'L7..( ccJtrD ona an C. James, Esquir Ide fication # 68214 9 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff qi.,._ ''''",f'--'''''-'-'-- ,_ ~__o N y._" _', ~ _~>_ " ,~- 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. Johns 770 Poplar Church Road Camp Hill, Pennsylvania 1701 I Ms. Sandra L. Strebig 6 Laurel Drive Enola, P A 17025 Individually and as Attorney in Fact for Ms. Ellen D. Johns Defendants, VERIFICATION CIVIL COMPLAINT NO. 2000 - 1145 I, Susan Bertolette, business office manager for Camp Hill Care, Plaintiff, 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 penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unsworn falsification to authorities. b~-l{~ , Date: S-J:l-OQ 11'~.\ ",' __, _,_ _r. _ <. _ , ~ " , ""'.,-- ',' . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Beverly Health And Rehabilitation Services, Inc., D/B/A Camp Hill Care Center 46 Erford Road Camp Hill, Pennsylvania 1701 I Plaintiff, v. The Estate of Alice Johns 311 Walton Street Lemoyne, PA 17043 CNIL COMPLAINT NO. 2000- 1145 Ms. Sharon Strebig 311 Walton Street Lemoyne, PAl 7043 Individually and as Attorney in Fact for Alice Johns Defendants, CERTIFICATE OF SERVICE I certify I am serving a copy of the above captioned Plaintiff's Reply To Defendant's New Matter upon the person and in the manner indicated below: Service by First-Class, U.S. Mail Return Receipt, addressed as follows: Gregory Katshir, Esquire 900 Market Street Lemoyne, Pennsylvania 17043 Date: M4 Y 2..Lf 2-GYOD Estate of Alice Johns c/o Ms. Sharon Strebig 311 Walton Street Lemoyne, PAl 7043 JO ~.THAN C. J Identification No. 68214 CAPOZZI AND ASSOCIATES, P.C. 3109 North Front Street Harrisburg, PA I7110 (717) 233- 4101 Attorney for Plaintiff ;"~~~ ~ ,.,.,.- ." 'p , ,~ "'_,,' ow, >. ~ -. - O~. ....",.. 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