HomeMy WebLinkAbout03-0212
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 03 -.;2/~
C/O l L
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually, and as Legal
Representative of June R. Esworthy, Deceased
Defendant
NOTICE
You have been sued in Court. If you wish to defend against the claims set forth in the following
pages, you must take action within twenty (20) days after this Complaint and Notice is served, by
entering a written appearance, personally of by attorney, and filing in waiting 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 document, or for any other
claim or relief requested by he Plaintiff. You may lose money or property or other right 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
TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la corte. Si used quaere defensas de esas demandas expuestas en las
paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en
la corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra de su persona.
Sea avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra
used sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de
demanda. Used puede perder dinero 0 sus propiedades 0 otros derechos importantes para used.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO
o SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA
o LLAME POR TELEFONO A LA OFlCINA CUY A DIRECCION SE ENCUENTRA ESCRIT A
ABA)O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 1 701 3
Telephone (717) 249-3166
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. O~ -~;l.. t2~u~L~
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually, and as Legal
Representative of June R. Esworthy, Deceased
Defendant
COMPLAINT
AND NOW, this
day of
, 2002, comes the Plaintiff, HCR
Manor Care, by and through its attorney, Amy F. Wolfson, Esquire, and the law firm of
Wolfson & Associates, P.C, and files the within Complaint and in support avers as follows:
1 . Plaintiff, HCR Manor Care, is a health care provider qualified to conduct
business in the Commonwealth of Pennsylvania with offices and/or a place of business
situate at 1 700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1 701 1.
2. Defendant, Patricia Reed, is an adult individual with a last known address of
22 Connell Drive, Cumberland County, Pennsylvania 1 701 1.
3. Defendant, Patricia Reed, is the daughter of June R. Esworthy, Deceased
(hereinafter referred to as "Decedent").
4. That Decedent was a health care resident at Plaintiff's health care facility
prior to her death on or about May 1 I, 2001.
S. That on or about May 4, 1999, Decedent executed a Durable Power of
Attorney appointing Defendant as her attorney-in-fact. A true and correct copy of the
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Durable Power of Attorney is attached hereto, incorporated herein and marked as Exhibit
i llA".
6. That the said Power of Attorney authorized the Defendant to apply for the
admission of Decedent into a health care facility and enter agreements for the care of
Decedent. See Exhibit "A", page 2, number (19), previously identified and incorporated
herein.
7. That on or about February 20, 200 I, Defendant applied for the residency
of Decedent at Plaintiff's health care facility and represented herself to be the Responsible
Party for Decedent. A true and correct copy of the Application for Residency is attached
hereto, incorporated herein and marked as Exhibit "B".
8. That on or about March 20, 2001, Defendant executed an Admission
Agreement, on behalf of Decedent, which Agreement outlined various terms of residential
health care services to be provided by Plaintiff and the rights and obligation of the Resident
and her Responsible Party therefor. A true and correct copy of the Admission Agreement
is attached hereto, incorporated herein and marked as Exhibit "C".
9. That from February 20, 2001 through May 1 I, 200 I, Decedent was a
health care resident of Plaintiff, where she received various necessary residential health care
services and health care treatment by Plaintiff as agreed pursuant to the Admission
Agreement. An itemization of said services is attached hereto, incorporated herein and
marked as Exhibit "D".
1 O. That Defendant did agree to assume and accept responsibility for the debt to
be incurred by Decedent in the event that she breached her duties under the Admission
2
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Agreement and she further agreed to provide timely payment from Decedent's income or
resources for the fees and charges. See Exhibit "C", Section I, generally and see
Paragraphs 1 .03 and 1.10; and Section II, generally and specifically Paragraphs 2.01,
2.02, and 2.05, previously identified and incorporated herein.
1 1. That Defendant did agree to assume and accept responsibility for the
application for any available government program benefits and/or third party payor
benefits as indicated under the Admission Agreement. See Exhibit "C", Section I,
Paragraphs 1.05, 1.06, 1.08, 1.09 and 1.10; and Section II, generally and specifically
Paragraphs 2.01,2.02,2.04 and 2.05, previously identified and incorporated herein.
12. That Defendant applied for medical assistance benefits on behalf of Decedent
as agreed pursuant to the Admission Agreement but failed to complete the application
process.
13. As a direct result of the Defendant's failure to complete the application
process, medical assistance benefits for Decedent were denied, as indicated in
correspondence from the Pennsylvania Department of Public Welfare (hereinafter "DPW")
dated June 5, 2001 and July 5, 200. True and correct copies ofthe DPW's Notices to
Applicant dated June 5, 2001 and July 5, 2001 are attached hereto, incorporated herein
and collectively marked as Exhibit "E".
1 4. That Defendant breached her duties under the Admission Agreement when
she failed to cooperate and complete the DPW medical assistance application process.
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15. That Defendant agreed to be personally liable for failure to cooperate in
applying for medical assistance benefits. See Exhibit "C", Section II, Paragraph 2.05,
previously identified and incorporated herein.
16. That Defendant breached her duties under the Admission Agreement when
she failed to remit timely payment on behalf of Decedent.
1 7. That as a result of Defendant's failure to perform as provided pursuant to the
Admission Agreement, Decedent incurred a debt in the amount of Thirteen Thousand
Seven Hundred Seventy-Four and 66/100 ($13,774.66) Dollars. See Exhibit "D",
previously identified and incorporated herein.
18. Despite Plaintiff's reasonable and repeated demands for payment, Defendant
has failed, refused and continues to refuse to pay all sums due and owing on the account
balance of June R. Esworthy, Deceased, all to the damage and detriment of the Plaintiff.
1 9. Plaintiff has made numerous requests to Defendant as the Legal
Representative and/or Responsible Party for Decedent, demanding that the sums due and
owing to Plaintiff be paid, and Defendant has ignored her contractual and fiduciary
obligation to pay necessary and appropriate bills and obligations for Decedent.
20. That Plaintiff submitted to Defendant a copy of the itemization of services
accurately showing all debits and credits for transactions with Plaintiff.
2 1 . That Defendant did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendant.
22. As of the date of the within Complaint, the balance due, owing and unpaid
on Decedent's account as a result of said charges is the sum of Thirteen Thousand Seven
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Hundred Seventy-Four and 66/100 ($13,774.66) Dollars. See Exhibit "E" as
previously identified and incorporated herein by reference.
23. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff
is entitled to receive and Defendant agreed to pay all court costs and reasonable attorney's
fees if the account is referred to an attorney for collection. See Exhibit "C", previously
identified and incorporated herein.
24. Plaintiff has retained the services of the law firm of Wolfson & Associates,
P.c. in the collection of the amounts due from Defendant.
25. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's
fees from the law office of Wolfson & Associates, P.c., in the collection of the amounts
due and owing by Defendants, incident to the within action, and Plaintiff shall continue to
incur such attorney's fees throughout the conclusion of the proceedings in the amount of
thirty percent (30%) of the principal balance due and owing to the Plaintiff by the
Defendant.
26. That the amount of attorney's fees which represents thirty percent (30%) of
the principal amount due and owing is the sum of Four Thousand One Hundred Thirty-
Two and 40/100 ($4,132.40) Dollars.
27. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
28. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
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WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter judgment in favor of Plaintiff and against Defendant, Patricia Reed,
I Individually, and as legal representative of June R. Esworthy, Deceased, in the amount of
Thirteen Thousand Seven Hundred Seventy-Four and 66/100 ($13,774.66) Dollars, plus
reasonable attorney fees in the amount of Four Thousand One Hundred Thirty-Two and
40/100 ($4,132.40) Dollars, the costs of this action, and such other relief as the Court
deems proper and just.
Respectfully submitted,
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VERI FICA liON
I, Michelle Thureson, being the Senior Financial Consultant for HCR Manor Care,
verify that the statements made in the foregoing Complaint are true and correct to the best
of my information and belief. I understand that false statements herein are made subject to
the'penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities.
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HCR MANOR CARE
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Michelle Thureson
Senior Financial Services Consultant
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EXHIBIT "A"
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0," .p\;;oa\...'Q":hy,J~n\S,99
~
POWER OF ATTORISI'EY
(A Durable Power of Attorney)
I, JUNE R. ESWORTHY, of Lower Allen Township, Cumberland County,
Commonwealth of Pennsylvania, hereby appoint my daughter, PATRICIA J.
REED, as my true and lawful attorney-in-fact to act in, manage, and
conduct all my estate and all my affairs, and for that purpose for me
and in my name, place, and stead, and for my use and benefit, and as
my act and deed, to do and execute, or to concur with persons jointly
interested with myself therein in the doing or executing of all or any
of the following acts, deeds, and things to the fullest extent possi-
ble as provided in Chapter 56 of the Pennsylvania Probate, Estates and
Fiduciaries Code as presently in effect and as hereinafter amended or
in any statutory provisions which may hereafter be substituted there-
fore:
(1) To engage ~n real property transactions. My attorney-in-
fact shall have the power to sell and convey all of my real property,
and any interest or right therein, upon such terms as my attorney
shall think proper.
(2) To engage in tangible personal property transactions.
(3) To engage ~n stock, bond and other securities transactions.
(4) To engage in banking and financial transactions.
(5) To enter safe deposit boxes.
(6) To engage in insurance transactions.
(7) To engage in retirement plan transactions 0
(8) To handle interests in estates and trusts, including the
power to claim the family exemption to the same extent as I personally
could do under the provisions of Sections 3121-3126 of the Probate,
Estates and Fiduciaries Code, or any similar provisions then in
effect,
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(9) To pursue claims and litigation.
(10) To receive government benefits.
(11) To pursue tax matters.
(12) To borrow money.
(13) To create a trust for my benefit.
(14) To make additions to an existing trust for my benefit.
(15) To claim an elective share of the estate of my deceased
SpOUSe.
(16) To disclaim any interest in property.
(17) To renounCe fiduciary positions.
(18) To withdraw and receive the income or corpus of a trust.
(19) To authorize my admission to a medical, nursing, residential
or similar facility and to enter into agreements for my care.
(20) To authorize medical and surgical procedures.
(21) To carryon any business interest owned by me for whatever
period of time deemed proper, including the power to do any and all
things deemed necessary or appropriate, including the power to incor-
porate any unincorporated business; to vote any ~nd all shares of
stock owned by me in any such business; to borrow ana to pledge assets
owned by me as security for such borrowing; to assent to, join in, or
vote in favor of or against any merger, reorganization, voting trust
plan, or similar action, and to delegate discretionary duties with
respect thereto; to delegate all or any part of the sUPervision,
management and operation of the business to such person or persons as
may be selected; and to close out, liquidate, or sell the business at
such time and upon such terms as shall seem best. My attorney-in-fact
shall not be held to personal liability for shrinkage of income or
loss of capital value that may be incurred in the course of the
operation of the business, except loss that may result from willful
misconduct.
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(22) To engage and dismiss agents, co~nsel, and employees,
(23) To enter into, perform, modify, extend, cancel, compromise,
enforce, or otherwise act with respect to any contract of any sort
whatsoever.
GIVING AND GRANTING unto my said attorney-in-fact full power and
authority to do and perform all and every act, deed, matter, and thing
whatsoever in and about my estate, property, and affairs as fully and
effectually to all intents and purposes as I might or could do in my
own proper person if personally present, the above specially enumer-
ated powers being in aid and exemplification of the full, complete,
and general power herein granted and not in limitation or definition
thereof; and hereby ratifying all that my said attorney-in-fact shall
lawfully do or CaUSe to be done by virtue of these presents.
AND I hereby declare that any act or thing lawfully done here-
under by my said attorney-in-fact shall be binding on myself, and my
heirs, legal and personal representatives, and assigns.
This Power of Attorney shall continue In force and may be
accepted and relied upon by anyone to whom it is presented despite my
purported revocation of it or my death, until actual written notice of
such event is received by such person. In the event of my incom-
petency or incapacity, from whatever cause, this Power of Attorney
shall not thereby be revoked but shall thereupon become irrevocable
during the period of my incompetency or incapacity, and may be
accepted and relied upon by anyone to whom it is presented despite
such incompetency or incapacity, subject only to it becoming void and
of no further effect only upon receipt by such person either of (1)
written evidence of the appointment of a 9uardia~ (or similar
fiduciary) of my estate following adjudication of incompetency or
incapacity, or (2) written notice of my death. This Power of Attorney
shall not be affected by my subsequent disability or incapacity.
In the event any court declares that I have become incompetent or
incapacitated, I hereby state I prefer that no guardian of my estate
or person be appointed so that my affairs may be conducted under this
general durable power of attorney, but if the Court proceeds to
appoint a guardian of my estate or person then under the authority
granted to me in Section 5604(c) (2) of the Probate, Estates and
Fiduciaries Code I hereby nominate as such guardian of the estate or
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of my person the person or persons who is or are then serving under
this general durable power of attorney.
My attorney-in-fact hereby shall be entitled to reasonable
compensation for services performed hereunder as well as to reimburse-
ment for all reasonable costs and expenses actually incurred in carry-
ing out any agent's duties and responsibilities hereunder. The
attorney-in-fact acting under this power of attorney shall not be
liable for any acts of commission or omission performed in good faith
and s~all be liable only for deliberate and intentional defalc~tion.
of
IN WITNESS WHEREOF, I have hereunto set my hand this
~l1i ' 1999.
;I
day
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:__;{I-z.& {-. . 1....
? JUNE R. ESWORTHY
COMMONWEALTH OF PENNSYLVANIA:
SS.
COUNTY OF CUMBERLAND
On the
\(
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I 1999, before me, the
day of
subscriber, a Notary Public, personally appeared the above named JUNE
R. ESWORTHY, and in due form of law acknowl~dged the foregoing Power
of Attorney to be her act and deed and desired the same to be recorded
as such.
Witness my hand and Notarial Seal
the day and year aforesaid.
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NOTARIAL SI:Al
DAVID H. STOlE, NoIlIy.Publle
New~ Bero. CunierIIrlii Co
t.4y Commission &pires Nov. 9. 2002 .
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EXHIBIT "B"
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TI).apply for a~on'(1 our. Nursing Center, please complete the following qnesdOUllaire. sign, and
retUrD it to the Ad~ons ornc~ .~ appU~tion will. become a part of the "Admissiou Agreement"
audsbouJd be completed in its el:Idrety. All information will be beld in coafidenee. The complete
m.edical histot.'YllDd pbysicalenmiuatiOI1rea<s~ be reco.rded OQ another dOQlment.
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Name of Prospective ResidentlPatient: :J;. t"\ P
. Date of Birth: l.,. a\ '':''9.
Address: ~Q (ILl ('("It .\1 t)r; u c...
Oine 2) Cn M 9 '1-\: l' I () ~ 1/I?J 11
Marital Status: Married. Widowed
IfManied or Widowed, Name of Spouse
Social Security No: I es ~'16 /..,/6 7 Medicare No:
~()JIuiUrance:Provjder
ID No: . .Group No:
Insurance is: Primary
Other Insurance: Provider ......'
m No: Group No:
Insurance is: Primary Secondary
C:='(00"(",~
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Telephone No.: q 7,<::;. 6c;,-17
Single -----.
Policy No.
Co-insurance
Policy No.
Co-insurance
Name ofInquu-et:~oA, i c- ~'o-- RdGd
Address:Q Q. (1(J('f\f,l/ Drtll"l" . . .
Oine 2) Cr>. mp J.:j.;/I,,14 I}O lJ
Other persons to contact in case of emergency:
Name:
..::.' AddresS:.
(line 2)
Relationship: Do.u.qhlel' / Po
Telephone No.:~ 7,1), 6 6, A{ '7
Other Phone No.: 7'71~ ":?~1'1
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. Relationship:
..-:';::-:::'~Te1eiihone No:
Other Phone No.:
Bow did you hear about
Personal Referral
Hospital ,~
'. Physician .' .
Other Professional
MailingfBrochure
OtherNursing Ctr.
Nursing Center?
~ewspaper~agaUne
. TelevisioD/Radio
Yellow' PageS .
. Health Dept,:,
. SeminarlEvent
Assisted Living Ctr.
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t,~J~;-{m);~. <'>>C ~ ?;.it" ::f'J~:r :"."'; ,~-;.~~ :,,'~t~.>~rf,~\/':'<;d"'~ l;:t?":;tt~I;}:~*1Ft;::'-'\ ~ ,tftljX':::( (' I ,*'4,~ ~~ tJ;f' x "R .1 <:0;,,~/.;.:)>',:i:' _0. ....' V' f-:,:ip:8Jpz11'y:*
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~~rm1tl.:.~)gg~~;JTrt'-' ,'~;:)~~:rri} ~V'i, ~,~ ,(~:tj;;~ ~,,~ ;~~.z ~ ~~~:\, :;#1.\<(J'~ [;.-i ~ ~ :::'$'."'- ~ iJ>' ~ ~ ,'t~ ~':>.\1X<~$"'J<;'~/'fJl;;;'h'~;;~j'j ;,A..,' :>; ~"/'.,.(lA'}~~
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Mother~s,M,a~den.JIij'a~.~: .' f'!..rr>.r'-t- .' '^~ rf'.,h"re-.(".
Father's Name: ,>.(~ \C.Cl'.I"IC" . (.l...(..( c\ .'. .
PI2.ceofBirth:City:A \\/1 "+-1">,:,:("\ County
Church Preference (Optional): A."c.~ ("\~,' I'i ....in.vh ""Ie. f\
Preferred Ambulance Company (Optional): Name J...OWU' (:%.]1 -I, t')
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Diagnosis: m,J +: Ole m4 e..Jotr\r.......
Current Primary Physician: "1'hCl'Y\c. ~ c.) () u. "7
Physician to follow at. Facility:
Telephone No.:
Telephone No.:
TeJj...uli. about the ResidentlPatient (please check all that aHply) .
:::::='Menwlyalert. ~ADlbu1atory ". ..---confined to bed-
_Slightly forgetful
_Confused
_Walks with assistance
_Continent
V'1ncontinent
_Eats without assistance
_Requires assistance with
eating
Admission desired on:
Residentlpatieut currently at: l...felf I ,~p: r-; *'
If hospital: Date admitted ,::2, - I I - 6 \ Admitted from 1-1 <I rn-c..
Where has the resident/patient lived in the last 60 days?: De.(Aq ,,~e("' I ~ Ho m:L
~1~i~z~~:~~~.t;ii~1T~~~T:r:;5:Si;'L~~5k~~(:r~:0Y0:I;;::"~:^:;n ' :2:'.;~;~;::~2~<~~
The facility requires that a source of payment by identified to pay for the RcsidentlPatient's care.
A persOn, other thm the r~deDt,.m.aY wish to be fmanciaUy respoDSible for the .tost of the care
("guarantor"). 'ndacllity does not ~quil"C a "gu3rantor". ... ... ..... " . : .
Name of the "Guarantor":
,..:.. . ,
Address:':",:.:.~: :':'.,.',~::~" . ..
TdephoneNo.: Work No.: Other No.:"
(This person(s) rn.ust alsoeomplete the "Guar2D!~r" infoi'IDa:~OD and sign the application.)
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Bas a trust fund been established for the ResidentlPatient?: _Yes ~No
Has a Power of Attorney been. conftn'ed on the person(s )to be fmancially responsible,
....>:or: ~n tile pe~on(s) w:h4)!I'ill.adon ~~~f.orthe..resident ("Responsible Party")?:
. .. ?yes ~NoHYeS;'pleaseprciVide . 'copy: .. .' ,.~. .' .:' . ',,",. '.
Has a)egal guardian beeJiappoiJIted by a court? _Yes. ~-No
. '.". If yes; please provide a copy. .
Bas a Burial Trust,been established?:. ~.es _No
'. ".IfYeS;wi~Wbo~?:' .!'., .....c,....
'.' Uno,who.is the p~ererred funUaJ. s.ervicefor the ResidentlPatient's family?:
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EXHIBIT "c"
HeR ilt/anor Care
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Care, the Resident, and the
Legal Representative, for the purpose of providing for the rights and responsibilities of the parties
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
Center: HCR Manor Care Camp Hill
Resident: (~ d 4-<.-<A..-lh ti(f
Legal Representative: ~f}11L-U~~ If p t7&",.
Admission Date: '" J,/ cJ.O / 0 I Deposit: .$ ~-~/4
Term: This Agreement shall begin On the day the Resident enters the Center and end on
the day the Resident is discharged.
I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT
1.01 Room and Board Rate. For the basic services provided for in Section 301, the
Resident agrees to pay the applicable Room and Board Rate set forth on Attaclunent A hereto.
The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room
and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (IOu,) day
of each month, The Resident shall be responsible for the Room and Board Rate for the day of
admission as well as the day of discharge. This Section shall not apply if the Resident is covered
under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care
Organization (see Section 1.06),
1.02 Ancillarv Charges. The Resident further agrees to pay to the Center all charges for
additional medical, therapeutic, or personal care services or supplies that may be requested by the
Resident, ordered by the attending physician, or provided in the Resident's Plan of Care, The
Center reserves the right to charge for personal care items of the Resident if necessary for the
well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and
a current ancillary charge list is maintained at the Center's business office for review during
regular business hours. A.nciIIary Charges shall be included in the Resident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(101ll) day of the month.
1 V<=:0 ' d
9vl18v8 01 68[L L[L LIL
3~~) ~ON~W ~~ 9v:ll <=:00<=: 90 Nnr
1.03 Late Pavments. Accounts not paid in full within thirty (30) days of billing shall be
subject to a service charge equal to the highest legal rate of interest permitted by State law as set
forth in Attachment A on the past due balance each month until such time as the balance due is
paid in full. Should the Resident's account for any reason be turned over for collection, the
Resident agrees to pay the Center's collection costs, including attorney's fees.
1.04 Indeoendent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Resident's attending physician for any health Or
personal program in accordance with the terms of the program.
1.05 Governmental Pro~rams. If the Resident is eligible for coverage under any
governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and
the Center participates in such program, the Center shall accept payments under such program in
accordance with the terms of the program on the contract the Center has with the program. The
Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according
to the same terms and;conditions applicable to private pay residents, The Resident must comply
with all program requirements. In the event the Resident's coverage under the governmental
program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay
residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: X Medicare, X Medicaid and/or _VA.
Medicare may pay for some or all of the Resident's care, If Medicare agrees to pay for the
Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident
also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable
charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative
agree to pay any required deductible, any required co-insurance, and any non-covered services
according to the same terms and conditions applicable to private pay residents. For Medicaid, see
Attachment L for additio~al information. The Resident and/or Legal Representative are
responsible for applying for Medicaid, If the Resident receives Medicaid, most of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of the Room and Board Rate from their monthly income.
The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this
Agreement, the contribution amount as determined and periodically adjusted by the State and/or
local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the
contribution amount, the Center may take such legal action as necessary, including requesting a
court to order such payment.
1. 06 Third Panv Pavors and Managed Care Or~anizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organi:4ation ("HlYI0"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident shall be responsible for any co-payments, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents, If the Center has
not executed a provider agreement with the Resident's third party payor, the Center
2
,1/[0' d
9v,,8v8 01 68[6 6[6 6'6
3~~J ~ON~W ~~ 9v:" c00c 90 Nnr
will bill the Resident's third party payor as a service, but the Resident remains liable for charges
not paid Or covered by that third party payor including charges not paid within a reasonable
period of time.
1.07 Private Pav Resident. The Resident andlor Legal Representative acknowledge that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident has not been detennined to be eligible for Medicaid.
The Resident and/or Legal Representative agree to notify the Center promptly if there is.
insufficient income or assets to meet the financial obligations to the Center Or to make prompt
application to Medicaid for benefits, The Resident and/or Legal Representative agree to notify
the Center in writing when application to Medicaid is made, The Resident and/or Legal
Representative agree to cooperate fully in applying for Medicaid and in the eligibility
detennination process. If the Resident is no longer able to pay for care at the Center and the
Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to
discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook
and State and federa11aws,
1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal
Representative to notifY the Center and to provide any needed information regarding all third
party payors or governmental coverages on admission and throughout the stay including copies of
insurance cards, identification or verification of eligibility and coverage information.
The Resident and/or Lega! Representative agree to provide the Center with notice
within five (5) days of the Resident's disenrollment, enrollment, change in health Care coverage,
failure to pay premium(s) or renewal of insurance coverage and any cancellations in cove~age as
the Center relies on the information supplied regarding such coverage. The Resident and/or Legal
Representative acknOWledge that if they fail to provide such information, they may be responsible
for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs
associated with the failure to provide such notice in accordance with the terms and conditions of
this Agreement.
1.09 Apolication for Benefits, It shall be the responsibility of the Resident and/or Legal
Representative to apply for coverage and to establish eligibility under any governmental, third
party payor, managed care or private insurance program. The Center shall be under no
obligation to bill any third party payor other than the Legal Representative and, when applicable, a
governmental program third party payor or managed care organization with which the Center is
under contract.
1. 10 Primary Responsibility for Pament. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall remain primarily liable
for any and all charges for which the Center may agree to bill a third party. The Resident and/or
Legal Representative acknowledge that the insurance company, I-tVIO, PPO. PSG, PHO or
managed care provider may not pay for non-covered services, supplies, equipment, medications,
and other care and services which may be delivered by the Center or its subcontractors. This
3
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917TT8178 01 68[6 6[6 6T6
3~~) ~ON~W ~~ 617:TT c00c 90 Nnr
Agreement serves as a written notice that the Center has notified the Resident and/or Legal
Representative that services provided at the Center may not be covered by a governmental payor,
third party payor or managed care organization, The Resident and/or Legal Representative agrees
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
1.11 Personal Phvsician. The Resident has the right to choose a personal physician,
provided that the physician selected is properly licensed and agrees to abide by applicable law and
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name of his/her personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notifY the Center of
the new physician's name. If the physician chosen by the Resident fails to provide needed
coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have
the right to call another physician to attend the Resident and the fees charged by such physician
shall be borne by the Resident.
~
1,12 Pharmacy, The Resident and/or Legal Representative acknowledge the right to
choose a pharmacy of choice, provided the phannacy selected is properly licensed, packages and
supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies
and procedures and the pharmacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distribution system,
n. RIGHTS AND RESPONSmn..ITY OF THE LEGAL REPRESENTATIVE
2.01 Legitl Authoritv. The Legal Representative hereby represents that he/she has legal
access to the Resident's income or resources and that the documents supporting such authority, if
any, have been delivered to the Center.
2.02 Agreement to Make Pavments on Behalf of Resident. The Legal Representative
agrees to pay promptly from the Resident's income or resources all fees and charges for which the
Resident is liable under this Agreement. The Legal Representative shall not incur personal
liability on behalf of the Resident except for a breach of the duty to provide payment from the
Resident's income or resources for the fees and charges provided for in this Agreement.
2.03 Requested Items. The Legal Representative shall be personally liable for any
services or products specifically requested by the Legal Representative to be supplied to the
Resident, unless such services or products are covered by a governmental program.
2,04 Exhaustion of Resident's Funds. If the Resident's financial resourCes change such
that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must
notifY the Center in writing when the application for Medicaid is made. If the Legal
Representative faits to notifY the Center in writing or fails to file for Medicaid in a timely and
proper manner, the Legal Representative shall be personally liable for all charges and fees not
co....ered by Medicaid which otherwise would have been covered had application been made in a
timely and proper manner,
~
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9pttSpS 01 5S~L L~L LtL
3~~J ~ON~W ~~ Lp:tt 2002 90 Nnf
2.05 Cooperation for financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such information about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally responsible
for any charges denied the Center due to any lack of cooperation,
2.06 Acceptance Upon Discharge, Upon termination of this Agreement as provided in
the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of
the Resident from the Center. If after notice the Resident is not removed as requested, then the
Center is authorized and empowered to remOve the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Representative, if
the Resident's condition permits, who shall unconditionally be obligated to accept the Resident
and to pay promptly all charges.
2.07 Additional Resoonsibilities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement and
Attachments. . '-
m. RIGHTS AND RESPONSffill-ITIES OF THE CENTER
3.01 Room and Standard Services. As part of the Room and Board Rate, the Center
shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and
bedding, general nursing care, personal assessment, social services, and such other personal
services. as may be required pursuant to the plan of care prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general well-being of the
Resident.
3.02 Other Services. The Center shall act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at
the beginning of this Agreement. The Deposit shall be applied to the charges for the first month
of the Resident's stay at the Center.
3,04 Refunds. Any refund owed to the Resident for advance payments shall be paid by
the Center within thirty (30) days after discharge or transfer or within the time frame required by
State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days
of the Center's receipt of the final Medicaid payment for care of the Resident.
IV. GENERAL PROVISIONS
4.01 Consent to Release of Infonnation. The Resident and/or Legal Representative
hereby consents to the release of hislher medical records to the following persons: Center
personnel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organization responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
s
11/90' d
9v118v8 01 68[L L[L L1L
3~~J ~ON~W ~~ 8v:11 c00c 90 Nnr
. \ , I
, .
reviews or payment audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care
and services (hereinafter "Treatment") as are necessary to maintain the weIJ-being of the Resident,
including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily
activities; and general nursing care, the administration of medications and treatments, and the
performance of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to
any rights provided to the Resident by federal and/or state law.
As applicable, the undersigned Legal Representative hereby represents that he/she
has the legal authority to make health care decisions on behalf of the Resident, that documents
supporting such authority have been delivered to the Center, and that such Legal Representative
hereby consents On behalf of the Resident to the Treatment described above,
4.03 Consent to Photoeraph. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for USe in identifying the Resident, for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to identify the Resident.
4,04 Notice of Services. Policies and Additional Information. The Resident and/or
Legal Representative acknowledge that the items listed below have been explained and have
received copies of the items or policies and procedures, if applicable. The Resident and/or Legal
Representative acknowledge they have had the opportunity to ask questions and questions have
been answered satisfactorily.
a. Authorization for Release or Review of Medical Information. See
Attachment C.
b. Authorization for Payment of Benefits. See Attachment D.
c. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Detennination Notice, See Attachment F.
e. Medicare Secondary Payor Questionnaire. See Attachment G.
f At the request of the Resident and/or Legal Representative, the Center
shall maintain the Resident's personal funds in compliance with the laws
and regulations relating to the Center's management of such funds, A
description and/or policies and procedures of protection of resident funds
and the Personal Trust Fund Agreement, Resident Personal Funds
r,
H/.!.0'd
9vll8v8 01 68[.!. .!.[.!. .!.l.!.
3~~J ~ON~W ~~ 8v:ll c00c 90 Nnr
l:U80'd
. . - ,
. .
Authorization and any other related documents, See Attachment H-l and
H-2.
g. The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
h. Social Service Agencies and Advocacy Groups addresses and phone
numbers, See Attachment I (Center Supplement).
I. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
J. The location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state survey and certification
agency, the state licensure office, the state ombudsman program, the
protection and advocacy network and the Medicaid fraud control unit. See
Attachment I (Center Supplement).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phone number On how to file a complaint
with the state survey and certitication agency concerning resident abuse,
neglect, mistreatment and misappropriation of property, See Attaclunent I
(Center Supplement),
m. The Resident Handbook. See Attachment 1.
n. ResidentiPatient Rights. See Attachment K.
0, Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
p. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Care's
Limited Treatment Practices and "No Cardiopulmonary Resuscitation
Orders" and a copy of the State summary of its laws governing the
Resident's right to direct hislher medical treatment. See Attachment M-l
and M.2.
q, Privacy Act Notification. See Attachment~.
r. Inventory sheet and/or policy of personal items. See Attachment O.
7
9vl:l:8v8 01 68[L L[L Ll:L
3~~J ~ON~W ~~ 6v:l:l: c00c 90 Nnr
I . . ,
I . . I
s. ASM Form. See attachment p,
L Bedhold Agreement. See Attachment Q.
u, See Attachment R,
v. See Attachment S.
w. See Attachment T.
x. See Attachment U.
y. See Attachment V.
z. ~ See Attachment W.
4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to
me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal
Representative hereby authorizes the Center' and any holder of medical or other information to
release such information to the Health Care Financing Administration and its agents and to third
party payors any information needed to determine these benefits or benefits for related services.
4.06 Termination. Dischar~e and Transfer. This Agreement may be terminated as set
forth below and as set forth in the Resident Handbook under the Section Heading "Discharge".
The Resident and/or Legal Representative may terminate this Agreement before the Resident's
discharge from the Center by providing the Center written notice of the Resident's desire to leave
at least ~ (7) days in advance of the Resident's departure. If the Resident leaves before the
end of that time, the Resident must still pay for each day of the required notice unless the Center
fills the bed before the end of the notice period. Except in the event of an emergency or death, the
Resident shall be responsible for all charges for the Room and Board Rate and for all services
performed up to the end of the day that the Admission ends. Discharge from the specialized units
such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice.
If discharge or transfer becomes necessary because the Resident and/or Legal Representative or
someone else abused the Resident's funds, the Center will request that local, state and federal
authorities, as appropriate investigate, which may result in prosecution,
4.07 Indemnification. The Resident shall defend, indemnifY and hold the Center
harmless from any and all claims, demands, suit and actions made against the Center by any
person resulting from any damage or injury caused by the Resident to any person or the property
s
H/50 . d
9v118v8 01 58~~ ~~~ ~1~
3~~~ ~ON~W ~~ 5v:11 c00c 90 Nnr
I I . I
t . , I
of any person or entity (including the Center), except in the case of negligence of the Center's
employees and agents.
4.08 Chanlles in the Law, Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal law will not invalidate the remaining
provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the
Center will continue to fulfill their respective obligations under this Agreement consistent with the
law.
TIlE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY
HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND
THAT THEY HAVE HAD A1'i OPPORTUNITY TO ASK QUESTIONS AND TBA T ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION.
Signature ofResiqent:
Date:
Signature ofLega! Representative, if signing on behalf of Resident:
,-P~--. 9- ~ ~o'/j
Date: .3-620_ 01
Signature of Legal Representative, signing on hislher own behalf:
......
Date:
C"""R<p".....t~~
Date: .,..1' ~ -0/
9
H/0T . d
9pTT8p8 01 68~6 6~6 6T6
3~~J ~ON~W ~~ 6p:TT c00c 90 Nnr
. .. , .
. . ,. ,
EXHIBIT "0"
li., 0 H SERVICES 583
1700 MARKET STREET
CAMP HILL, PA 17011
(717).737.8551
PATRICIA REED
FOR JUNE ESWORTHY
22 CORNELL DR
CAMP Hill, PA 17011
IESWUI'<IHY, JUNE
03t:l0/2001
,u~
CABLE
03/21-30/01 THERPHY
04/30/01 PAYMENT
04/01/01 CABLE
05/04/01 PAYMENT
05/01/01 CABLE
03/31/01 MEDICAL SUPPLIES
03/31/01 NUTRITIONALS
03/31/01 ROOM CHRGS 03/01
04/30/01 MEDICAL SUPPLIES
04/30/01 INCONTINENT FEE
04/30/01 NUTRITIONALS
04/30/01 KlNAIR BED
04/30/01 THERPHY
04/30/01 ROOM CHRGS 04/01
05/31/01 THERPHY
05/31/01 MEDICAL SUPPLIES
05/31/01 INCONTINENT FEE
05/31/01 NUTRITIONALS
05/31/01 KINAIR BED
05/31/01 ROOM CHRGS 05/01
. .
IPRIVATE
Il
L.0/c0"d
9vrrsvs 01 6S[L. L.[L. L.rL.
3~~J ~ON~W ~~ vs:[r c00c S0 nON
~.OO
$617.16
$5.00
$5,00
$255,00
$39.00
$2,256.00
$694.20
$90.00
$120,90
$1,980.00
$325.00
$5,640,00
$175.00
$206.40
$30,00
$39.00
$660.00
$1,880.00
($624,00)
($624,00)
$13,114,561
I .. , I
EXHIBIT "E"
- ,
DEPARTMENT OF PUill.lC.lNaFARE
CUMB~RLANO COUN'TV A~ISTAI'lCE OFFICE
33 WESTMINSTER DR
PO BOX 599
CARUSLE PA 17013-0599
1-8OO-269-{)l73 (717) 240-2700
NU II(;c I U APPLICANT
oYC'JR Rt'cEt,T APPI.ICATION HAS aEEN REVIE\vED AND YOUR ELIGIBILITY
HAs 6EEIl DETERl,llNED FOR THE 6EI\EFITS SHOWN SElOW
BENEFIT
o ASSISTANCE
CHECK
Etl~ ~ PENDINe
.AiW'f me- fJr.;,l ~ wnlel'1lTR1)' be ZI ~l amount you will receive $
D TWIce. Mootll 0 onoe a Montll 0 In m. Mail
o A' ,he Elonk
o You l\ave a pstiMt ~ liQbility of $
for ~he poril;ld' begionm!;3
You will reoetVEl.$
monttlfrom
and ending
lor ttJe n'lOOtI\(S) of th",n you will teoeoiv@ lood stamp; in the ...moun~ of $
(Q D1n\tleMfl!l 0 Atth&Bill:nk
D En.""". Date
you al'B I!lxpeeted to pay $
oil month toward your cafC.
NAME
Name
Name
$
$
($
TOTAL GROSS MONTHLY INCOME $
GROSS MONTHLY DEPENDENT CAllE COSTS $
GROSS MEDICAL COSTS $
: Telephone WalerlSewa'il"
ElectriC GarbagefTresh
G"" Utiuty InslallaliOl'l
Oil other
GROSS ImUT'Y COSTSlUTILrTY STANDARD" $
1'lENTIMORTGAGE $
TAXES ($
INSURANCE COST ON I1OM~ $
TOTAL SHELteR COST $
: ,. "" :" ',," ,'" " . " "..::'" ' ,~"'." '''':'' :","" ", " >, :':" "" " ,,' ':", ,'"" """ ., " "" .,,',.,' ,"...; , " . ' ':,.
:.~,OOut;iihoIc!-!,r"aY'SwitchlJetW8Brhtlie. aCflJai>ilii/iJY:oos/snand ./hs
'stB.nd.~''!tJl/!y a/lOINElIlCe. at .,/hs Jiffll.l. .df..reapplication .and. .one
:adr.5tional~ffJ~ dUIirlg eacb,twe/vBo(fJOll1h pel'itxf,o,'-<-'.
$
$
$
Name
$
$
$
TOTA~ GROSS MONTHLY INCOME
NET MONTHLY INCOMElNET SEMI.ANNUA~ INCOME
INCOME UMIT
$
$
$
GJ A;~~U\~ER ~
r
~~~~
~CvU-
OJo ~ ~
l..
DIST
~~rk~~
6 is/Oj Ii'Oo~qOJi3
Date Teleptlone Number
lEQAt H!lJ>,I$'AVAll:AIlt.E AT. , '.',._ '. .:' . ....:. ,.... .
i
.
LEGAL SERVICES. INC.
8 IRVINE ROW
CARUSlE PA 17013-0019
717-243-9400 717-76&-ll475
.J
'.~~;i?fou;JljJ~~JJ~de;;;-;;;';bi:tif.;;';~;'~~~j;';;;;!_~~r-
""111=~IT""n"'Y
9vl18v8 01 68[6 6[6 616
11/10. d
3~~J ~ON~W ~~ 9v:11 G00G 90 Nnr
** L0'3~d -1H101 ** 7 ~: r
-.. s. ~ vcrr.R ~ mc~i ~'V~" {"VL7LIN rf LLPA~7L
CUMBERLAND t~0UN1Y A
ANCE OFFlCE
~
33 WESTMlN3 R DR.
P.O
BOX
BENEFIT tE a,,,,e, F .
CARL!$LE. PA 17013-0589
^ ASSISTANCE Altar the fist caeok w~ may 0e a speeiat arrant you will roewe 5
CraECK [~ Twice a Moral, ~ Onae a Month ^ In Ina Nyl ^ Pi the t)arMc
®
TAN '~ ^ Y0i ~`'° • Pasant pay lvh~Yty of 5
ASSIS
CE ~ the pe~od begimirg an0 endn0 ^ Etltxliw txita
FOOD You wlu recelva S ~,.,,~ !er the marx;lt(s) of than ynu wA receNe 1000 scamps in me anaune d S
STAMPS a mon0+ from m ^ In lM Mad ^ Az the t>atrik
NURSING FIOMff CARD I.wal of care aWronxaO ya+we a~acteo to Pay S a rrtonlh bwara your care.
S IC s ^
TNEFOL'~OYVWCIEP~N S:i~i NGl1lG EQ .. .. .,. ,...~• '-:
.
L~• ' ~~ giEd( SiAM93
0 AS~Sr. SER ~ E N ~E q~ r~D ~~~
JDNE E ORTBY
SSN 1 8-GO-71 1
5 PA CODE 178.1(.) 81..1 b 1.1
R.aaow t`,oae
All income and recources of applicants must be verifi-ed. On April 11, 2001 and June 5, 2001,
I sent requests for current bank account information, life insurance policies & income verifzca
To date I Have not received this verificatioa. As eligibility for Nursing Home assistiance cane
be made without this information and the final notice sent requested it by June 19, 2001. th~.s
~'=:~:.:~~~ "" =iViiamer.~dCPei"mni- '~.ASS187AN~fitNMieCK••--•~'• :-l~uedeernli
Name G MONTIiLY y
D INCAME E D
$ $
.~ ~
Name tNGUt_ARNffDD1NN YE @ LMVEARNEDIlH LY
$ $
$ $ ..
~ $
TOTAL (iR033 MtaNTHIY INCOME ~ $ TOTAL GROSS M $
GROS8 MONTHLY DtsePENt]~ENT CARP COSTS $ GROS$ MOM'NLY DEPENDENT DARE COSTS $
GROSS MEDICAL COSTS ~
Telephone water/$ewage [] MEDICAL ASSISTANCE Ntxtlbet at Peraans~
Electric GarCagen7ash Name ROSS tdoTfiMt.
Ca35 Utility Installation ARNED Ih1~
S
Oa Other $
' GROSS UTiL1TY COST$M71JiY STANDARD' $ $
RENT/MORTGAGE $ Name ~
~
MONTtiLY
TAXES
$ ~
D
E
$
INSURANCE CDBT ON HOME $ $
TOTAF. SHtiLTt:R COST
• :. ....
.
:: 5 $
,
; .:
.:s
;_!',?/~p~~,p~::~: gw,~yy.; . ~.:El, ~7~,;.~• :~ .fir
:
`
TOTAL GAb$$ deONTHLY INCOME
$
_
' 'std/.IGI~d•..tl~fy
: ~al/odvsrlpp• a1 .able' •t~ne of •' /8appliCa~OIT' '2Jid 01y@ :..
....
~
bA?~:EhJiillg
BBCh
w19r1AbFN7pllfh¢G
fOd
' NET MONTFILV INCOMEMET t3t:1111•ANNUAL INCOME
;
?.
,
•?
,.
l
.
• '::' •:
INCOME LIMIT
co RecoaDrrt~~l
87519 cAr CTRPIG blsT Lynne Gordon 1-800-269-0173
21 PJ _ _ ~ /s lnt
1
271
0
2
_
i
w
,.
~
wflt~ar: sinnaaae ~ d..w..,......~.
r
June Esworthy
Manorcare
1700 xitd.rket St
Camp Hill, PA 1701.1
-~
L J
CLIENT COPY
L0iL0'd 9btiI8b8 Ol 68£L L£L LIL
LEGAL SERVICES, INC.
8 IRVINE R8W
CARLISLE. PA 17013.3019
717-243-9d00 ~ 777-766.5475
3ati~ ~IONFiW dd Zb : Z t z00z 90 Nflt
i~
t
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.'-----
SHERIFF'S RETURN - REGULAR
CASE NO: 2003-00212 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
REED PATRICIA ET AL
BRIAN BARRICK
, Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
REED PATRICIA
the
DEFENDANT
, at 1950:00 HOURS, on the 29th day of January ,2003
at 22 CORNELL DRIVE
CAMP HILL, PA 17011
by handing to
PATRICIA REED
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
18,00
10.35
.00
10,00
,00
38.35
So Answers:
"""/'?,j!:;':'" . " ~~
?-;:,"" (~,A~.., .,.".......... . ~. .~.;.-; _"'"
'7 ' ,.;...~-:....;~~' ."oc-.. >~ -'-. ,." ~--
.
R, Thomas Kline
me this
3(s.1-
day of
01/30/2003
WOLFS::,& ASSOCI~ ~
Deputy Sheriff
Sworn and Subscribed to before
Pro
00rtzr
A,D,
SHERIFF'S RETURN - REGULAR
CASE NO: 2003-00212 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
REED PATRICIA ET AL
BRIAN BARRICK
, Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
REED PATRICIA AS LEGAL REP OF JUNE R ESWORTHY DECEASED the
DEFENDANT
at 1950:00 HOURS, on the 29th day of January , 2003
at 22 CORNELL DRIVE
CAMP HILL, PA 17011
by handing to
PATRICIA REED
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof,
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
6.00
,00
,00
10,00
.00
16.00
~f,?{:::,,;<<::. ,/~~
~.....~... ...-.......~..,.-
R. Thomas Kline!
me this 31s1
day of
01/30/2003
WOLFS::,& ASSOCI~ ~
Deputy Sheriff
Sworn and Subscribed to before
HCR MANOR CARE,
Plaintiff
:IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
V.
:No. 03-212 Civil Term
PATRICIA REED, Individually,
and as Legal Representative
of June R. Esworthy,
Deceased,
:JURY TRIAL DEMANDED
Defendant
ANSWER
AND NOW comes the defendant, Patricia Reed, individually,
and as legal representative of her mother, June R. Esworthy,
deceased, by and through her attorneys, Stone LaFaver &
Shekletski, and sets forth the following answer to plaintiff's
complaint.
1. Admitted.
2. Admitted.
3. Admitted.
4 . Admitted.
5. Admitted.
6. Denied. Paragraph
#19 specifically states in full "To
authorize my admission to a medical, nursing, residential or
similar facility and to enter into agreements for my care."
-1-
7. Denied. Defendant did not consider placing her mother,
the deceased into the Manor Care facility until the deceased, who
suffered from bone cancer, fell and broke her leg and which did
not occur until March 15, 2001. Defendant believes and therefore
avers that the date on the application is incorrect and does not
accurately reflect the truth. Moreover, page two of the
application states that the deceased was in the Holy Spirit
Hospital on March 11, 2001, not the plaintiff's facility.
Finally, the defendant signed and dated the application on March
20, 2001, not February 20, 2001. Proof thereof is demanded at
time of trial.
8. Admitted and Denied. It is admitted that the defendant
slgn the attached Exhibit "8" prior to the admission of her
deceased mother into the plaintiff's nursing home. It is further
averred that defendant asked very specific questions with regard
to her personal financial responsibility of her mother's care. In
fact, the only reason that Manor Care was chosen over other
facilities is that the plaintiff said that they could care for
and agreed to care for the tracheotomy tube that the deceased
had.
It is also averred that the Deceased never received the
quality of care that she bargained for and promised by plaintiff.
Defendant's deceased mother suffered a most painful death just
seven (7) weeks after her admission, due to the physical and
-2 -
emotional abuse that she endured at the hands of the less than
qualified care givers employed by plaintiff's facility.
9. Denied. Deceased Esworthy was admitted to and was a
resident at the plaintiff's facility from March 20, 2001, to her
death on May II, 2001. By way of further answer, it is denied
that the decedent received any quality care at the plaintiff's
facility. Defendant lasted a mere seven weeks at the plaintiff's
facility perhaps from the unqualified and improper treatment to
which she was hourly subjected both physically and emotionally by
the horrific and terrifying brutal behavior exhibited by the
alleged care givers.
10. Admitted and Denied.
It is admitted that defendant
signed an Admission Agreement, however defendant signed as Power
of Attorney. It is denied that defendant signed as Agent or
Legal Representative.
11. Denied. By way of further answer, it denied that
Exhibit "CU, Section 1, Paragraph 1.05 states that the defendant
will assume any financial responsibility other than those costs
not covered by Medicaid. It is denied that Paragraph 1.06 is
applicable, since the deceased did not participate in a Third
Party payor, HMO or PPO. It is denied that the defendant did not
comply with Paragraph 1.07. Defendant specifically began the
process of application for Medicaid upon the discontinuance of
-3-
Deceased's Health Insurance when she reduced her employment to
part-time hours. This Medicaid application began on or before
January, 2000.
12. Admitted and Denied. The defendant admits to beginning
the process of the application for Medicaid insurance for her
mother, the deceased herein on or about January, 2000. By way of
further answer, the defendant was told conflicting information
regarding the how to liquify the decedent's assets. Moreover,
the decedent passed away before the application was approved and
was advised by Manor Care Facility, the plaintiff, that they
would complete the application process for defendant and that she
should not worry about this.
13. Denied.
It is specifically denied that the application
was denied. The application as attached to the plaintiff's
il
II
II
II
il
II
il
II
I '
:1
II
II
II
II
Ii
II
'I
!I
II
II
II
!,
II
II
Ii
il
complaint and marked as Exhibit "E" reflects that the
applications were "discontinued"; and the defendant needed to
supplement the information, which was provided.
14. Denied.
It is specifically denied that defendant owed
a duty to plaintiff.
Proof thereof is demanded at time of trial.
15. Denied.
It is denied that defendant agreed to be
personally liable for any the debts that arose as a result of the
decedent's time at the plaintiff's facility. Exhibit "C",
Section II, Paragraph 2.05 states that there must be a lack of
-4-
cooperation, ln order to trigger this clause.
Further, even if
there were a lack of cooperation, defendant is in no way
personally liable for the care of lack thereof that the decedent
received or did not receive during her brief, but intolerable
stay at plaintiff's facility.
trial.
16. Denied. It is denied that defendant breached any duty.
There is no duty under the law to be personally financially
responsible for signing as a Power of Attorney to admit someone
to a nursing care facility. Proof thereof is demanded at time of
Proof there is demanded at time of
trial.
17.
Denied.
It is denied that the defendant had any
connection to the debt that was incurred while her mother was
wasting away and being abused at plaintiff's facility. Further,
defendant paid all incidental costs throughout the seven weeks
that her mother, the Decedent, endured while she stayed at the
plaintiff's facility. It is averred that the plaintiff is
seeking payment twice for items already paid for. Moreover,
defendant gave the plaintiff the Decedent'~ social security check
to the plaintiff directly as indicated on the invoice marked as
plaintiff's exhibit "D".
18. Denied. It is denied that the plaintiff made numerous
and repeated requests for payment. Plaintiff sent ONE (1)
-5-
invoice for services rendered to defendant on or about May, 2002,
over one year after the death of her mother.
19. Denied. It is denied that the defendant is personally
financially responsible for the decedent's debts by virtue of a
Power of Attorney that gave her the ability to sign and admit her
to health care facility. Moreover, plaintiff was aware of the
financial situation of the Decedent upon admission. Further, it
is averred that the defendant asked very specific questions of
the facility before she signed as Power of Attorney on behalf of
the resident, the Decedent, as reflected by plaintiff's Exhibit
"e".
20. Admitted. By way of further answer, this was sent to
defendant on or about May, 2002
21. Denied. By way of further answer, defendant sent a
letter to the plaintiff upon receiving the invoice one year after
the death of her mother, and explained that due to the horrendous
treatment of her mother at their facility she would not be paying
any of the bill, not only was she not personally responsible, but
that there was no estate. This letter is attached hereto and
marked as defendant's Exhibit "AU.
22. After reasonable investigation, defendant is without
knowledge to either admit or deny the averments of paragraph 22
and proof thereof, if relevant, is demanded at time of trial.
-6-
23. Denied. It is denied that the defendant is personally
responsible for the decedent's debts. Defendant merely held the
Durable Power of Attorney, she did not agree to any of terms as
set forth in Paragraph 1.01 et. seq., specifically 1.03.
24. Neither admitted nor denied.
Defendant is not aware,
nor would she be able to answer whether the plaintiff retained
any particular attorney for any particular reason. It is
admitted that Wolfson and Associates, P.C. signed this complaint.
25. Denied. It is denied that the plaintiff by virtue of
two phone calls, one invoice, and one letter could have possibly
incurred over $4,000.00 in attorney fees. Proof thereof, if
relevant, is demanded at time of trial. It is an unreasonable
amount of money to demand one-third that lS due and owing on the
Decedent's account, if proven.
26. After reasonable investigation, defendant is without
knowledge to either admit or deny the aver~ents of paragraph 22
and proof thereof, if relevant, is demanded at time of trial.
27. Admitted.
NEW MATTER
Breach of Dutv to Care
29. Paragraphs 1 through 28 of plaintiff's complaint are
incorporated herein by reference thereto.
-7-
30. The defendant herein was appointed as the Power of
Attorney upon the diagnosis of bone cancer of her mother, the
Decedent herein.
31. The law controlling the powers that can be exercised by
a Power of Attorney are clear and controlling.
32. The law is clear that the Power of Attorney while she
may have the power to sign legal documents in the stead of the
person, does not then bind herself personally to said documents.
33. The Decedent was treated so badly by the alleged care
givers at the plaintiff's facility that she was terrified to
complain to anyone other than her daughter for fear of
retaliation by the workers.
34. The plaintiff contracted to care for the Decedent and
make her stay more comfortable, and instead, the Decedent was
terrorized and treated like a child, or wo~se an animal.
Plaintiff's employees never changed her, never moved her, never
bathed her, never cleaned out her tracheotomy tube, which is why
she was there. The employees turned there backs on the Decedent
and watched her television on the night she died. The defendant
happened to stop by on the night before her mother passed away,
she was in a near coma state, and had turned off the television.
Her mother, in the late stages of bone cancer, could not move,
yet when her daughter returned the next day upon learning of her
-8-
mother's passlng the curtain was drawn and the television was
blaring, The roommate was hysterical that the workers had been in
the room all night with the television blasting, chattering away,
and partying, all the while ignoring her pleas to leave the room
and most importantly, never tended to the suffering of the
Decedent.
35. Plaintiff's daily care givers routinely yelled at the
decedent admonishing her if she told anyone of the lack of
quality of care, there would be ramifications.
36. Plaintiff's facility made the last seven weeks of the
defendant's mother life a living hell.
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37. The Decedent died without any es~ate due to the fact
that the bone cancer treatments prior to her admission to the
plaintiff's facility cost $3500 per treatment, per month. Thus
any and all funds that might have been available, were exhausted
prior to the debt being incurred during the decedent's stay at
the plaintiff's facility.
-9-
WHEREFORE, it is respectfully submitted that this Court
dismiss the plaintiff's complaint with prejudice, and award
judgment, attorney fees and costs to the defendant.
Respectfu17 submitted,
STONE ~~ HEKLETSKI
~
Esquire
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VERIFICATION
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II Patricia Reed states that she is the Defendant named in the
ii
II foregoing instrument and that she is acquainted with the facts
I
! set forth in the foregoing instrument; that the same are true and
correct to the best of her knowledge, information and belief; and
that this statement 1S made subject to the penalties of 18 Pa.
C.S.A. 54904 relating to unsworn falsification to authorities.
(,
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Patricia R'eed
Date: :). /3
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CERTIFICATE OF SERVICE
I, Elizabeth B. Stone, Attorney at Law, of the law firm of Stone
LaFaver & Shekletski, attorneys for Defendant, Patricia Reed,
individually and as Legal Representative of June R. Esworthy,
Deceased, hereby certify that on this date I served a true and correct
copy of the within instrument on Plaintiff's counsel of record by
first class mail, postage prepaid, addressed as follows:
Amy F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
DATE:_t=~U"'~~ -u:" L<l~
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 03-212 Civil Term
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually, and as Legal
Representative of June R. Esworthy, Deceased
Defendant
PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER
AND NOW, TO WIT, this 11 th day of March, 2003, comes the Plaintiff, HCR
Manor Care, by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of
Wolfson & Associates, P.c., and files the following Reply to New Matter and in support
thereof avers as follows:
The allegations and averments contained within paragraphs one (1 ) through twenty-
eight (28) of the Plaintiff's Complaint are incorporated herein by reference as if set forth in
full.
29. Paragraph twenty-nine (29) of Defendant's Answer and New Matter is an
incorporation paragraph to which no response is required. To the extent that a response is
necessary, same is denied and the allegations contained in Plaintiff's Complaint are
incorporated herein by reference as if set forth in full.
30. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a belief as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial.
31 . Denied. The allegations contained in paragraph thirty-one (31 )of
Defendant's Answer and New Matter are conclusions of law to which no response is
required. To the extent that a response is necessary, same is denied and strict proof is
demanded at trial.
32. Denied. The allegations contained in paragraph thirty-two (32) of
Defendant's Answer and New Matter are conclusions of law to which no response is
required. To the extent that a response is necessary, same is denied and strict proof is
demanded at trial. By way of further answer, Defendant did agree to assume and accept
personal responsibility for the debt to be incurred by Decedent in the event that she
breached her duties under the Admission Agreement.
33. Denied. It is specifically denied that the Deceased received inadequate or
negligent treatment while a resident of Plaintiff's facility. To the contrary, the Decedent
received quality attention, consideration, and healthcare while under the care and
supervision of the Plaintiff. It is also specifically denied that Decedent was provided any
services which were below the standard of care expected for residential health care services
and treatment in the community or below the standard of care which the Defendant
contracted for. By way of further response, any and all allegations or insinuations by the
Defendant of any wrongdoing on the part of the Plaintiff are hereby specifically denied and
strict proof is demanded at Trial.
2
34. Denied. It is specifically denied that the Deceased received inadequate,
negligent Denied. It is specifically denied that the Deceased received inadequate or
negligent treatment while a resident of Plaintiff's facility. To the contrary, the Decedent
received quality attention, consideration, and healthcare while under the care and
supervision of the Plaintiff. It is also specifically denied that Decedent was provided any
services which were below the standard of care expected for residential health care services
and treatment in the community or below the standard of care which the Defendant
contracted for. By way of further response, any and all allegations or insinuations by the
Defendant of any wrongdoing on the part of the Plaintiff are hereby specifically denied and
strict proof is demanded at Trial.
35. Denied. It is specifically denied that the Deceased received inadequate or
negligent treatment while a resident of Plaintiff's facility. To the contrary, the Decedent
received quality attention, consideration, and healthcare while under the care and
supervision of the Plaintiff. It is also specifically denied that Decedent was provided any
services which were below the standard of care expected for residential health care services
and treatment in the community or below the standard of care which the Defendant
contracted for. By way of further response, any and all allegations or insinuations by the
Defendant of any wrongdoing on the part of the Plaintiff are hereby specifically denied and
strict proof is demanded at Trial.
3
36. Denied. It is specifically denied that the Deceased received inadequate or
negligent treatment while a resident of Plaintiff's facility. To the contrary, the Decedent
received quality attention, consideration, and healthcare while under the care and
supervision of the Plaintiff. It is also specifically denied that Decedent was provided any
services which were below the standard of care expected for residential health care services
and treatment in the community or below the standard of care which the Defendant
contracted for. By way of further response, any and all allegations or insinuations by the
Defendant of any wrongdoing on the part of the Plaintiff are hereby specifically denied and
strict proof is demanded at Trial.
37. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a belief as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial.
4
WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss
Defendant's New Matter and enter judgment in favor of Plaintiff and against Defendant,
along with the allowable costs of this action, and such further relief as the Court deems
appropriate.
Respectfully submitted,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 03-212 Civil Term
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually, and as Legal
Representative of June R. Esworthy, Deceased
Defendant
CERTIFICATE OF SERVICE
AND NOW, this 11 th day of March, 2003, I, Amy F. Wolfson, Esquire, do
hereby certify that I have served a copy of the foregoing Plaintiff's Reply to
Defendant's New Matter upon the parties and/or counsel of record by regular mail,
postage prepaid, and addressed as follows:
Elizabeth B. Stone, Esquire
STONE, LAFAVER & SHEKLETSKI
41 4 Bridge Street
New Cumberland, PA 17070
(Counsel for Defendant)
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A F. Won, Esquire
WOLFS & ASSOCI
267 East Market Street
York, PA 17403
(717) 846-1252
I.D. No. 87062
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA
HCR MANOR CARE, NO. 2003-212
Plaintiff
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually, and as Legal
Representative of June R. Esworthy, Deceased
Defendant
RULE 1312-1.
The Petition for Appointment of Arbitrators shall be substantially in the following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Amv F. Wolfson. Esquire , counsel for the Plaintiff in the above action (or actions), respectfully
represents that:
1. The above-captioned action (or actions) is (are) at issue.
2. The claim of the plaintiff in the action is $13,774.66, plus attorney's fees in the amount of
$4,132.40.
3. The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counselor are otherwise disqualified to sit as arbitrators:
Elizabeth B. Stone. Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case
,hall be submitted.
ORDER OF COURT
AND NOW,
, ~-:-in co~r~tion of the
Esq., :e.J',ub ~
Esq., are appointed arbitrators in the above captioned action (or
Esq., and
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HCR MANOR CARE,
Plaintiff
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYL VANIA
: CIVIL ACTION - LAW
v.
PATRICIA REED, Individually,
and as Legal Representative of
June R. Esworthy, Deceased,
Defendant
: NO, 2003-212 CIVIL TERM
ORDER
-rV
AND NOW, this ~h day of ~
, 2003, the Order
appointing Michael A. Scherer, Esquire, as an arbitrator in the above-captioned matter is
hereby vacated and Michael J, Whare, Esquire, is appointed as arbitrator in his stead.
By the Court,
Wayne F. Shade, Esquire
Chairman
53 West Pomfret Street
Carlisle, Pennsylvania 17013
Michael J. Whare, Esquire
Arbitrator
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Carlisle, Pennsylvania 17013
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Cory J. Snook, Esquire
Arbitrator
Gates, Halbruner & Hatch
10 13 Mumma road, Suite 100
Lemoyne, Pennsylvania 17043
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Amy F. Wolfson, Esquire
Wolfson & Associates, P,C.
267 East Market Street
York, Pennsylvania 17403
Attorneys for Plaintiff
Elizabeth B. Stone, Esquire
Stone, LaFaver & Shekletski
414 Bridge Street
New Cumberland, Pennsylvania 17070
Attorneys for Defendant
V.
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-212 CIVIL TERM
HCR MANOR CARE,
Plaintiff
PATRICIA REED, Individually
and as Legal Representative
of June Esworthy, Deceased
Defendant
IN RE: APPOINTMENT OF ARBITRATORS
ORDER OF COURT
AND NOW, July 24, 2003, the appointment of Cory Snook, Esquire, as
an arbitrator in the above-captioned case is vacated, and Tricia D, Naylor,
Esquire is appointed in his stead. Wayne Shade, Esquire, shall remain as
Chairman, and Michael Scherer, Esquire, shall remain on the panel.
By the Court,
INayne Shade, Esquire
Chairman
~chael Scherer, Esquire
. ry Snook, Esquire
.A Jicia D, Naylor, Esquire
-Elizabeth Stone, Esquire
.Amy Wolfson, Esquire
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Court Administrator
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: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2003-212 CIVIL TERM
HCR MANOR CARE,
Plaintiff
PATRICIA REED, Individually
and as Legal Representative
of June Esworthy, Deceased
Defendant
IN RE: APPOINTMENT OF ARBITRATORS
ORDER OF COURT
AND NOW, July 30, 2003, the appointment of Michael Scherer,
Esquire, as an arbitrator in the above-captioned case is vacated, and Jane
Adams, Esquire is appointed in his stead, Wayne Shade, Esquire, shall
remain as Chairman, and Tricia D. Naylor, Esquire, shall remain on the panel.
By the Court,
Ge
oI.tvayne Shade, Esquire
Chairman
Michael Scherer, Esquire
.<lane Adams, Esquire
,/f"ricia D. Naylor, Esquire
vElizabeth Stone, Esquire
,/Amy Wolfson, Esquire
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P'(RIG
07-30-03
Court Administrator
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Plaintiff
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYL VANIA
: CIVIL ACTION - LAW
v.
: NO. 2003-212 CIVIL TERM
PATRICIA REED, Individually,
and as Legal Representative of
June R. Esworthy, Deceased,
Defendant
OATH
We do solemnly swear (or affirm) that we will support, obey and defend the Constitution
of the United States and the Constitution of this Commonwealth and that we will discharge the
duties of our office with fidelity.
w~~a~
.MLMp?~
ne f\dams Esquire
AWARD
We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed),
make the following award:
(Note: If damages for delay are awarded. they shall be separately stated)
For the Plainriff in the amount of $13,774.66 plus costs and lnterest from
August 11, 2063, at the legal rate, Attorney fees are denied OIl the ba~is
that the provisions of 111.~03 limit llability for attorney fees ro the Resident.
_' Arbitrator, dissents. (Insert name if applicable.)
Date of Hearing: August II, 2003 ?f/tz?I<,( ~
ayne f. Shade, Chairman
Date of Award: ~( dJCCiJ q A..... n €-.,-..
A ams, Es(juire
NonCE OF ENTRY OF AWARD
NOW, the I fJ^. day of t:Jt,U'1t.(~ ,2003, at.b3...-:E:!:L R.M., the
above award was entered upon the docket and notice thereof given by mail to the parties or their
attorneys.
$290.00
p~
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Deputy
Arbitrator's compensation to be
paid upon appeal:
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Cumberland
In the Court of Common Pleas of I County, Pa,
HCR MANOR CARE,
Plaintiff
v.
2003-212 CIVIL TERM
No.... ............. ............ ..lta..............
PATRICIA REED,
Representative
Deceased,
individually and as Legal
of June R. Esworthy,
Defendant
Appeal from Board of Arbltntors
NOTICE OF
APPEAL FROM AWARD OF ARBITRATORS
TO THE PROTHONOTARY:
Notice is given that . P.~f.~1).~.~1).t. .1:'A~~~.~~i\ . R!':~D... . ~~~~:vi~.~",~.~~. .a~d. . a~. . ~7.g",1,. R.e~!-".~~7~~a.~iy.': . ?f. June
R. Esworthy, Deceased,
. . . . . . . . . , .. . . . . . . . . . . . .. . . . . .. .. . . . ... . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . Hereby appeals to the Court of Common Pleas of
C~mberland August 11 2003
/ County from the award of the arbitrators entered in the above case on. . . . . . . . . . . . .'. . . . . . . . . . . . . . . . D. . . . . . . . . . . . . ..
G A jury trial is demanded. (If box is not checked, jury trial is waived.)
I hereby certify that (check appropriate box):
7
N olices sent to
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the compensation of the arbitrators has been paid, or
application has been made to proceed in forma pauperis.
PRAECIPE
Stone
Arbitration fees ($
) received 0
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on
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Deputy Prothonotary
WHITE' ORIGINAL - YELLOW' APPELLANT - PINK' APPELLEE
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
NO: 03 212
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually and as the
Legal Representative of June Esworthy, Deceased
Defendant
PRAECIPE TO LIST FOR PRE. TRIAL CONFERENCE
To the Prothonotary:
Kindly list the above referenced matter for Pre-Trial Conference.
Respectfully. bmitted,
Amy;2i::YI~Z?N
lD No. 870
Philip C. rholic, Esquire
ID No. 86341
WOLPOFF & ABRAMSON, LLP
Attorneys in the Practice of Debt Collection
267 East Market Street
York, PA 17403
(717) 846-1252
CA
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PRAECIPE FOR LISTING CASE FOR TRIAL
(Must be typewritten and submitted in duplicate)
TO THE POOTHO/lOTARY OF CUMBERLAND COUNI'Y
Please list the following case:
(Check one)
for JURY trial at the next tenn of civil court.
( x
for trial without a jury.
-----------------------------------------
CAPTION OF CASE
(entire caption must be stated in full)
(check one)
HCR MANOR CARE,
(x
Civil Action - Law
Appeal from Arbitration
(other)
( Plaintiff)
vs.
PATRICIA REED, Individually and as
the Legal Representative of June
Esworthy, Deceased
The trial list will be called on April 19,20 5
and
Trials commence on
(Defendant)
Pretrials will be held on
(Briefs are due 5 days before pretrials.)
vs.
(The party listing this case for trial shall
provide forthw:Lth a copy of the praecipe to
all counsel, pursuant to local Rule 214.1.)
No. O~-1-12 Civil
Indicate the attorney who will try case for the party who files this praecipe:
Amv F. Dovle. Esquire
Indicate trial counsel for other parties if known: Elizabeth Stone, Esquire
Date:
Signed: ~i?A~
Print Nacre: ~lQ
Attorney for: ~~'~
This case is ready for trial.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
NO: 03 212
vs,
CIVIL ACTION - LAW
PATRICIA REED, Individually and as the
Legal Representative of June Esworthy, Deceased
Defendant
PRAECIPE TO LIST FOR PRE-TRIAL CONFERENCE
To the Prothonotary:
Kindly list the above referenced matter for Pre-Trial Conference.
~~~
Amy F. ~y squir .
ID No. 870
Philip C. rhollc, Esquire
10 No, 86341
WOLPOFF & ABRAMSON, LLP
Attorneys in the Practice of Debt Collection
267 East Market Street
York, PA 17403
(717) 846-1252
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HCR MANOR CARE,
PLAINTIFF
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
PATRICIA REED, INDIVIDUAllY AND:
AS lEGAL REPRESENTATIVE OF
JUNE R. ESWORTHY, DECEASED,
DEFENDANT 03-212 CIVil TERM
ORDER OF COURT
r
AND NOW, this _l ) day of March, 2005, IT IS ORDERED that a
bench trial shall be conducted at 9:30 a.m., Wednesday, April 13, 2005, in Courtroom
Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania.
By. the Court, ",1
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Edgar B. Bayley, J.
.Amy F. Doyle, Esquire
267 East Market Street
York, PA 17403
/
~abeth Stone, Esquire
414 Bridge Street
New Cumberland, PA 17070
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Court Administrator
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
NO: 03-212
vs.
CIVIL ACTION - LAW
PATRICIA REED, Individually and as the
Legal Representative of
JUNE R. ESWORTHY, DECEASED
Defendant
PRAECIPE TO SETTLE, SATISFY AND DISCONTINUE
To the Prothonotary:
Kindl y mark the above captioned matter as settled, satisfied and discontinued.
Resp~. tf lly Submitted,
Jil/ltA ,/0'
y F. D ,squi
ID No. 87 62
Philip C. Warholic, Esquire
ID No. 86341
WOLPOFF & ABRAMSON, LLP
Attorneys in the Practice of Debt Collection
267 East Market Street
York,PAI7403
(717) 846-1252
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