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HomeMy WebLinkAbout03-1007SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- /Ogg~ CIVIL ACTION-LAW CIVIL TERM 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 are served, by entering a written appearance personally or by an 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- too ") CIVIL TERM CIVIL ACTION-LAW COMPLAINT NOW, comes Shippensburg/Southhampton Manor Limited Partnership ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within complaint and, in support thereof, sets forth the following: 1. Shippensburg/Southhampton Manor Limited Partnership ("Shippensburg Health") is a Maryland limited parmership duly authorized to conduct business in the Commonwealth of Pennsylvania. 2. Defendant, Mary A. Myers, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 3. Mary A. Myers was the attorney in fact for Ruth A. Myers, deceased. 4. Defendant, Sandy Foose, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 5. Sandy Foose was the attorney in fact for Ruth A. Myers, deceased. 6. Shippensburg Health operates a resident skilled nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania (the "facility"). 7. On or about December 1, 2001, Mary Myers sought to have Ruth A. Myers admitted to the Shippensburg Health skilled nursing facility. 8. On or about December 1,2001, Mary A Myers executed a Patient Data and Consent Form on behalf of Ruth A. Myers, along with additional admission documents. True and correct copies of the Patient Data and Consent Form and admission documents are attached hereto as Exhibit "A" and are incorporated. 9. Pursuant to the Patient Data and Consent Form and the admission documents, Ruth Myers knew and understood that Ruth A. Myers would be responsible to pay any costs of care which were not covered by policies of insurance or medical assistance. 10. On or about December 1,2001, Ruth A. Myers became a resident of the facility and she remained a resident of the facility until the time of her death on 11. In May, 2002, the Cumberland County Assistance Office determined that Ruth A. Myers was eligible for medical assistance with an effective date of December 1,2001. The Cumberland County Assistance Office calculated a private pay portion to be paid from Ruth A. Myers' monthly income to Shippensburg Health for the costs of her care not covered by medical assistance. 12. The private pay portion calculated by the Cumberland County Assistance Office was initially set at $878.62 per month. This amount was recalculated by the Cumberland County Assistance Office to be $950.02 beginning January 1, 2002. A copy of this determination is attached hereto as Exhibit "B" and is incorporated. The CAO found that Ruth A. Myers was receiving $840.00 in monthly social security and a retirement pension of $117.62 per month as of December, 2001 and $862.00 per month in social security and a retirement pension of $117.62 per month as of January, 2002. 13. Upon information and belief, Mary A. Myers and/or Sandy Foose was receiving the social security benefits and retirement benefits of Ruth A. Myers during the period of time that Ruth A. Myers was a resident of the facility. 14. Neither Ruth A. Myers, Mary A. Myers nor Sandy Foose has ever tendered to Shippensburg Health any sum of money payable on account of the monthly accruing private pay portion. 15. As of the time of her death, Ruth A. Myers owed Shippensburg Health the sum of $6,293.00 consisting principally of the non-payment of the private pay portion along with sundry other expenses. A true and correct copy of the statement reflecting the balance owed is attached hereto as Exhibit "C" and is incorporated. 16. Demand has been made upon Mary A. Myers and Sandy Foose to tender the amount due and owing to Shippensburg Health from the income of Ruth A. Myers. 17. Upon information and belief, Mary A. Myers and/or Sandy Foose have applied the sums received on account of Ruth A. Myers for their personal. COUNT I-BREACH OF CONTRACT SI-IIPPENSBURG ItEALTIt v. MARY A. MYERS AND SANDY FOOSE 18. Plaintiff incorporates by reference paragraphs one through seventeen as though set forth at length. 3 19. Mary A. Myers and/or Sandy Foose, as the attomey-in-fact for Ruth A. Myers, were obligated to use the assets and income of Ruth A. Myers to satisfy the debt due and owing to Shippensburg Health for services and care provided to Ruth A. Myers by Shippensburg Health. 20. to pay the amount due. 21. Mary A. Myers and/or Sandy Foose have breached the Patient Data and Consent Form and the admission documents by failing and refusing to pay for the services rendered from the assets and income of Ruth A. Myers. WHEREFORE, Plaintiff requests judgment in its favor and against Defendant for the sum of $6, 293.00 together with costs, interest and expenses. COUNT II-MONEY HAD AND RECEIVED SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 22. Plaintiff incorporates by reference paragraphs one through twenty-one as though set forth at length. 23. During the period of Ruth A. Myers' residency at the facility, Mary A. Myers and/or Sandy Foose have received the sum of at least $6,835.34 from the social security and retirement benefits of Ruth A. Myers. 24. The proper use of these funds would have been to pay the costs of care accruing for the care of Ruth A. Myers at Shippensburg Health in accordance with the private pay determination made by the Cumberland County Assistance Office. Mary A. Myers and/or Sandy Foose have, without justification, failed and refused 25. At the time of receipt of these funds, Mary A. Myers and/or Sandy Foose knew that they were obligated to pay these funds over to Shippensburg Health for the costs of Ruth A. Myers' care at the facility. 26. Mary A. Myers and/or Sandy Foose gave no consideration for the funds of Ruth A. Myers received by Mary A. Myers and/or Sandy Foose. 27. Demand has been made upon Mary A. Myers and/or Sandy Foose to tender the funds of Ruth A. Myers to Shippensburg Health and they have failed and refused to do so. WHEREFORE, Plaintiff requests that judgment in its favor and against Mary A. Myers and/or Sandy Foose requiring them to: a) return the subject matter in specie; b) pay over the value if Mary A. Myers and/or Sandy Foose have consumed the money in beneficial use; c) pay its value if Mary A. Myers and/or Sandy Foose have disposed of the funds received; and d) award costs, expenses and interest. COUNT III-CONVERSION SI-IIPPENSBURG }tEALTIt v. MARY A. MYERS AND SANDY FOOSE 28. Plaintiff incorporates by reference paragraphs one through twenty-seven as though set forth at length. 29. At the time Mary A. Myers and/or Sandy Foose received funds of Ruth A. Myers, they were aware that they had a legal obligation to dispose of those funds to or for the benefit of Ruth A. Myers under and pursuant to their authority as attorney-in-fact for Ruth A. Myers. 30. Knowing they had the aforesaid obligation, Mary A. Myers and/or Sandy Foose appropriated funds of Ruth A. Myers for their own benefit and use. 31. Mary A. Myers and/or Sandy Foose have refused to pay to Shippensburg Health the debt accruing from the non-payment of the private pay portion from the income of Ruth A. Myers. 32. Mary A. Myers and/or Sandy Foose have intentionally and substantially interfered with Shippensburg Health's right to receive the funds of Ruth A. Myers which were to be paid to Shippensburg Health as the private pay portion of the costs of Ruth A. Myers' care. WHEREFORE, Plaimiffrequests judgment in its favor and against Mary A. Myers and/or Sandy Foose for the sum of $6,293.00, costs, expenses, interest and punitive damages. Respectfully submitted, David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 da b.dir/shcc/myers/com plaint, pld 0~/~/2~ 11:18 7172~9~75~ OI)S LAW OF-FIGF- ~AOE 02 .VERIFICATION TI~ statcmeats in thc forel~om$ Complaint arc bas~-d upon information which has been assembled by ray ~l~orney in this litigation. Thc language of the statements is not my own. I have read ~ ~ts; and to the extent tha{ they are based upon ivforrnation which I have given to my count[, they a~ true and correct to the best of my knowledge, informalion and belief. I ~ that false statements hercin are made subjec! to the permlties of I ~ Pa.C.S, § 4904 relati~ to unswom falstflcatioas to authorities. SHIPPENSBURG HEALTH CARE CENTER ?ATIENT DATA AND CONSENT FORM Name: ' U_'th ID ,aS Soc. Sec.,:aa/-1g-/ Address: iDD~ ~,~,,//& ~ Cib': ~'~,lle State: ~ Date of Birth: lb Zip Code:. l~'-gql Male Marital Status: Single Primary Insurance: Policy Number: Secondary Insurance: Policy Number: MEDIC ARE#:, / 7q- o~D -,0 t_/.~ ~_/~ Married Separated INSURANCE Policyholder:.,, Group Number: Policyholder: Group Number: Divorced ~dow~d~ Relationship:_.. Rela['ionship:. MEDICAID#: RESPONSIBLE PARTY Referring Physician: Treating Diagnosis: Service Requested: Occupational Therapy Phone Number: Primary Care Physician:~ Primary Diagnosis: Physical Therapy Speech Therapy Patient's ancb'or family's permission to bill and consent to receive treatment, release information and make payment. Under Medicare Part B (a National Health Program through which certain medical and hospital ex?enses are paid from Federal Funds) you must meet the following conditions: 1. You must satisfy,,,'our deductible. 2. Medicare will pay 80% ofthe charge after the deductible has been satisfied up to a maximum annual cap. 3. The 20% unpaid balance an4'or amounts above the annual cap will be billed to you or the person responsible for paying your bills. ' 4. If you have a Tie-in Plan or other insurance that will pay the balance we will submit the bill to them. 5. This form must be signed by you or your family giving us permission to (1) bil! 80e0 to Medicare and (2) 20% (Co-pay). and amounts above the annual cap, and any deductible not a ..... ~ satisfied, to you or your insurance company. ' 6. For patients who are lVledicaid and Medicare Part B and decreed indigent, the Faciliw will accept assignment pursuant to state laws and regulations. I authorize treatment and payment of medical benefits to the Facilib' for services rendered as ordered by my physician. I further authorize the Facility to furnish medical or other information for an',' claims incurred for a period of one year under the Title XVIll'ofthe Social Security Act and its intermedia~'. 1 hereby accept all responsibility for treatment costs not covered or reimbursed b'y third part?, payers. EXHIBIT Date V,"itn~,~ (Signature) SHIPPENSBURG HEALTH CARE CENTER ADMISSION AND TRANSFER POLICY Shippensburg Health Care Center, in an effort to provide intensive nursing care during periods of increased need, maintains a skilled Medicare unit with about above average staffing. It shall be the goal of this unit to provide intensive nursing and rehabilitation services for those residents who require them. A resident may be transferred or admitted to this unit when his/her nursing needs require this level of care. This will be done after consultation with the resident, the residents physician, and the residents representative or guardian. The nursing home will seek to transfer a resident from this unit to another m~re suitable unit ',,,'hen his/her nursing needs fall below the Medicare criteria. Any transfer from the unit will be done in a consultation with the resident, the residents physician, and the resident's representative or guardian. LEAVES OF ABSENCE POLICY The following guidelines apply to leaves of absence for all residents. Leaves of absence should not be frequent or on a regular basis. A doctors order ,,,,'ill need to be obtained prior to anv. leave of overnight absence. The family member should contact either the Medicare Coordinator or the Charge Nurse at least one (I) da;,. t,.,~-..r'"'o"*"--~-.{"' ,,. hours) prior to leave, due to the need for a Doctors order. (See statement #2) Resident Signature Responsible Party / ~,l~tness Residents Narr/e Date SHIPPENSBURG HEALTH CARE CENTER CONSENT ACKNOWLEDGMENT FORM I hereby~/ do not consent to having my photography taken by Shippensburg Health Care Center staff, residents, family members or other outside organizations visiting our facility. I hereb)~ do not consent to having Shippensburg Health Care Staff or volunteers open my mail, in my presence, and read my mail to me. I hereby/do not consent that Shippensburg Health Care Center may release any and all parts of my medical records to hospitals, home health care agencies or any other medical services provider for the purpose of ensuring continuity of care. I have been informed of care plans/family counsel meetings. Resident Signature Date Responsible tParty/PO'A Signature ~tness Signatufed Date Date Resident Narrfe AUTHORIZATION TO RECEIVE SERVICES AND/OR SUPPLIES AND TO RELEASE INFORMATION REGARDING BENEFITS Name of Beneficiary: 1Medicare Number: / I hereby authorize Shippensburg Health Care Center to have the facility physician and whomever he may designate as his assistant or on-call physician to act as my physician. The~e duties may include, but are not limited to, prescribing medications, treatments, rehabilitation therapies, lab procedures, x-rays, medical procedures, and/or referrals to other physicians. I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits for related services and/or durable medical supplies. I request that payment of authorized Medicare benefits be made on my behalf to Shippensburg Health Care Center for any services and/or durable medical supplies furnished me by or in Shippensburg Health Care Center. I hereby authorize and gix'e permission to Shippensburg Health Care Center to release to my insurance carrier or its agents any medical information needed to determine benefits payable for related services and/or durable medical supplies furnished me by or in Shippensburg Health Care Center. I understand that I am responsible for any health insurance deductibles and coinsurance not paid mx' *ledicare, mx' insurance carrier, or an.,,' state Medical Assistance Program. Signatur~ of Beneficiar6- or Authorized Representative Dare SHIPPENSBURG HEALTH CARE CENTER Information Release and Payment Authorization Authorization to Release Information and Receive Direct Payment of Medicare Benefits: I certify that the information given by me in applying under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for payment of Medicare claims. I request that payment of authorized benefits be made in my behalf to: SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility I assign payment for the unpaid charges for physicians, for whom the facility is authorized to bill. health insurance deductibles and coinsurance. services furnished bF' specialists, or by I understand that I am responsible for any /Y- Date Resident/P&son acting/Sn behalf of the Beneficiary Authorization to Release Information and Recei('e Direct Payment of Medical Insurance Benefits: I hereby authorize and give permission to: SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility to release billing and medical information to include the diaznosis and reason for treatment. I, also, hereby authorize and give permission to the above named Nursinz Facility to release a transcript of mv medical records to my insurance carrier upon their request for the purpose of determining benefits payable under the contract. Date Resident/Pergon acting off`behalf of the Beneficiary I hereby authorize any and all benefits, to include professional services accruing under said policy to: SHIPPENSBURG HEALTH CARE CENTER Date Name of Nursing Facility Resi~de t/eegn c~4-:~ acting on/behalf of the Beneficiary SHIPPENSBURG HEALTH CARE CENTER BEAUTY/BARBER SHOP PRICE LIST .Beauty/Barber Shop Services Permanent $35.00 Haircuts and Blow Dry $10.50 Hair Sets $ 8.25 Cuts Only $ 8.25 Color $30.00 Resident I Room Number The above names resident or his/her representative has consented to the following marked services: Perms ~/Hair Cuts and Blow Dr.',' __ Hair Sets __ Cut Only Is the resident allergic to Ammonia? Is the resident combative/confused? Please bill: ~ Responsible Party Yes Yes How often: ~"/ No ~ Resident's Trust Account Name Address City/State/Zip Code Resident/Resp,bnsible ParC. Signature SHIppENSBURG HEALTH CARE CENTER CHANGE IN STATUS FORM LAUNDRY ANDTV CABLE RESIDENT:/~_)L'~ ..~.~l?~',~ ROOM:_~/~ LAUNDRY SERVICES: FACILITY LAUNDRY . YES . 'w/ NO. * Laundry services are completed on a daily basis at a rate orS1.50 per day. · · Laundry items washed by SHCC must be appropriately labeled and may be assessed a $25. O0 labeling fee. FAMILY DOING LAUNDRY ~/' YES NO DATE }~--J' ~l CABLE: CONNECT / YES NO , Cable services are available at a rate of S7. OOper month. · £amilies are asked to provide a television set that would appropriatelyfit above the Resident's closet. Remote controls are encouraged · Please ask for assistancefi.om the Maintenance Department upon television setq~. DISCONNECT YES ~NO OPTED FOR NO TV CABLE AT THIS TIME YES NO DATE MEDICARE SCREEN FOR SECONDARY PAYOR (Note: There may be situations where more than one insurer is primary to Medicare, e.g., automobi'le insurer and EGHP. Be sure to identify all possible insurers.) RESIDENT NAME: '~H~I'I] fl)~Or,,.~ ADMISSION DATE:./c~-/'Oj Part I: Was illness/injury due to a xvork-related accident/condition and covered by a Worker's Compensation (WC) plan or Federal Black Lung Program? Yes: Name and address of WC plan or Federal Black Lung Program part II:' 1. Patient's policy or identification number STOP: WC OR F/EDERAL BLACK LUNG PROGRAM IS PRIMARY PAYOR. No: t/ GO TO PART II. ' Was illness/injury due to non-work related accident? Yes: No: ~ GO TO PART III. What type of accident caused illness/injur),? Automobile Name and address of automobile insurer Insurance Claim Number: STOP: AUTO INSURER IS PRIMARY PAYOR. Other: Was another part3.' responsible for this accident? Yes: Name and address of any liabilit)' insurer Part III: Insurance Claim Number: STOP: LIABILITY IN'SURER IS PRIMARY PAYOR. No: GO TO PART III. Is the patient aged 65 or over? Yes: No: GO TO PART Is the patient undergoing kidne)' dialYsis for End Stage Renal Disease (ESRD)? Yes: No: ~ Is the patient employed and covered by an Employer's Group Health Plan (EGHP)? Yes: ' Name and address of EGHP Patients Identification Number: STOP: EGHP IS PRIMARY PAYOR. No: ~ Is the patient's spouse employed? Yes: S~P ~ No: i~ : MEDICARE IS PRIMARY PAYO..~. Is the patient covered under the group health plan of'the spouse's employer9 Yes: ' Name and address o£EGHP Pan IV: I. Patient's Identification Number: STOP: EGHP AS PRIMARY PAYOR. No: STOP: lvlEDICARE IS PRIMARY PAYOR. Is the patient entitled to benefits solely on the basis of End Stage Renal Disease.'? Yes: No: GO TO PART V. Is this patient covered by an Employer Group Health Plan? Yes: Name and address of EGHP Patient's Identification Number: Paa V: No: STOP: MEDICARE IS PRIMARY PAYOR. Has the patient been undergoing kidney dialysis for more than 12 months or been entitled to lVledicare for more than 12 months? Yes: STOP: MEDICARE IS PRIMARY PAYOR No: Is the patient within a 12-month period as defined in section 252.4 of the SNF Manual: Yes: STOP: EGHP IS PRIMARY PAYOR. No: STOP: MEDICARE IS PRIMARY PAYOR Is the patient a disable Medicare beneficiary under age 65? Yes: No:, STOP: MEDICARE IS PRIMARY PAYOR. Is the patient covered by an EGHP based on patient's own employment or employment of a spouse or a parent.'? Name and address of EGHP Patient's Identification Number: STOP: EGHP IS PRIMARY PAYOR. No: STOP: MEDICARE IS PRIMARY PAYOR. Signature Of Beneficia/'y/Authorized Representative Date SHIPPENSBURG HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, PA 17257 Date Name Address City, State, Zip RE: Name Dear On , We reviewed the medical information available at the time of, or prior to admission, and we believe that the services need(s) do not meet the requirement for coveraee 'under Medicare. ~ Medicare covers medically necessary skilled nursing care needed on a daily basis., only require(s) oral medications, assistance with daily activities and general supportive services. There is no evidence of medical complications or other medical reasons that require the skills of a professional nurse or therapist to safely and effectively carry out her plan of care. Therefore, we believe that care cannot be covered by Medicare. This decision has not been made by Medicare. It represents our judgment that the ser`.'ices you needed did not meet Medicare payment requirements. Normally, in this situation, a bill is not submitted to Medicare. A bill `.vill only be submitted to Medicare if you request that a bill be submitted. If you request that a bill be submitted, the Medicare intermediary will notify 3'ou of its determination. If you disa~oree with that determination, you ma.',, file an appeal. ' ' ~ Under a provision of the Medicare law, you do not have to pay. for non-covered sen'ices determined to be custodial care or not reasonable or necessary unless you had reason to knox`.' the sen'ices were non-covered. You are considered to know that these sen'ices were non-covered effective with the date of this notice. Please check one of the boxes on the third page of this letter to indicate `.vhether or not you ,.',-ant 3'our bill submitted to Medicare and sign the notice to verify receipt. Please return the signed second page to this facilit`.' as soon as possible, keeping a copy for your records. If I ma`., be of any assistance to you, please do not hesitate to contact me. Sincerely yours, Larry D. Cottle, LNHA Administrator ATTACHbIENT - Denial on Admission ( ) A. I d__9.o want my bill for services I continue to receive to be submitted to the intermediary for a Medicare decision. You will be notified when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request, you should contact: Aetna Medicare Claims Administration Mutual of Omaha P.O. Box 1602 Omaha, NB 68101 Please note: After October 1, 1989, a beneficiary will not be required to ~ay for .Services which could be covered by Medicare until a Medicare determination has Been made. ( ) B. I do not want my bill for services submitted to the intermediary for a Medicare decision. I understand that I do not have Medicare appeal rights if a bill is not submitted. VERIFICATION OF RECEIPT OF NOTICE ( ) C. This acknowledges that I received the notice of non-coverage of services under Medicare on Signature of beneficiary or person acting on behalf of the beneficiary ( ) D. This is to confirm that you were advised of the non-coverage of the services under Medicare by telephone on Name of beneficiary or representative contacted Patient representative Physician Patient medical/financial files Pharmacy -no 120-17 _m m..< r-r- ~< m~. I 0 O~ ~:"n I-' RECORD NE~-ffB ER GROSY'SS TOTAL GROSS UNF_~_RNED E S T ~W-%TED INTEREST TOTAL INCOME USED - PERSONAL C~RE ALLOW.%YCE - CO~-~2~-o~iTY SPOUSE/ HOME M-~ INTE N.~C E GROSS PATIENT PAY (53) - MEDICAL LY3ENSES (See below) NET PATIENT PAY (57) MEDICAL EXPENSES LISTED MOIYR MOIYR %'TTT I.~.. oo 1t .5-0 oo HO/¥R .JO oo 0 MO/YR LESS MEDICAL EXPENSES PAID MONTHLY NI~P...T~: Future changes in medical expenses should be reported to the Numing FaciliD-. DRUGS (E&) MEDICARE (55) BC/BS/OTHER MEDICAL INS (55) OTHER MEDICAL (56) MONTHLY TOTAL EXHIBIT "B" SIGNATURE ~LYDER: The resource !im!c is $~2400. See attache6 AiGen~um 121 N,qLNUT BOTTOM ROAD SHIPPENSBURG. PA 17257 -:'z17'? 530-S$C, 5 1'dA RY hlYERS .1.008 CEI'ITERVILLE RD NEWVILLE, PA 17241 R," ,':, I O E N T: HYER£:. F'.UTH DAI L'~ :ATE: C'O680 £";A T E r~ESC:Ri PTION ~ .... ¢- 7/Z 1/02 - PRE",/I,nUS 8;~! .~?'.4.- F O1/.,::6/03 8.a, SIC: C:~F',E PIED!CAIC:, -7 01/20/03 8,~SIC CARE t,~'='r'"'CC, ID 7 ANOU 1'47 BA LA NC: E c:..." 9,¢. C:'-'~ 6293. O0 -895. C(' 5598. O0 ,.,9~. r/ 6293. O0 PLEASE PAY UPON R_L. EIoT! i'l E.N E:A L~, >4't E 6-_-'93. O0 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff MARY MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003-1007 CIVIL TERM CIVIL ACTION-LAW PRAECIPE FOR LIS PENDENS TO THE PROTHONOTARY: Please index the above action as a.Lis Pendens against the following real property: ALL THAT CERTAIN lot of ground situate in Penn Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at a stake on the Western side of the Pine Grove Road at the comer of land now or formerly of Harry Bowermaster; thence 75 feet in a Southerly direction along said road, to a stake at the line of land of now or formerly of Gaylord Seavers; thence 160 feet in a Westerly direction along said Searvers land to a stake at the line of other land of the Grantors; thence 75 feet in a Northerly direction along the Grantors' land, to a stake at the line of land now or formerly of Harry Bowermaster; thence 170 feet along the said Bowermaster land, to the Place of BEGINNING. Recorded in Deed Book 219 Page 565. I hereby certify that this action affects the title to or other interest in the above-described real property. Respectfully submitted, O'BRIEN, BARIC & SCHERER David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 dab.dir/SLICC/myers/lispendens.pra SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003-1007 CIVIL TERM CIVIL ACTION-LAW CERTIFICATE OF SERVICE I hereby certify that on April ~ ,2003, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Praecipe For Lis Pendens, by first class U.S. mail, postage prepaid, to the parties listed below, as follows: Mary A. Myers 1008 Centerville Road Newville, Pennsylvania 17241 Sandra K. Foose 1008 Centerville Road Newville, Pennsylvania 17241 David A. Baric, Esquire _2. SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- CIVIL TERM CIVIL ACTION-LAW .NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are wamed that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- CIVIL TERM CIVIL ACTION-LAW COMPLAINT NOW, comes Shippensburg/Southhampton Manor Limited Partnership ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within complaint and, in support thereof, sets forth the following: 1. Shippensburg/Southhampton Manor. Limited Partnership ("Shippensburg Health") is a Maryland limited partnership duly authorized to conduct business in the Commonwealth of Pennsylvania. 2. Defendant, Mary A. Myers, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 3. Mary A. Myers was the attorney in fact for Ruth A. Myers, deceased. 4. Defendant, Sandy Foose, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 5. Sandy Foose was the attorney in fact for Ruth A. Myers, deceased. 6. Shippensburg Health operates a resident skilled nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania (the "facility"). 7. On or about December 1,2001, Mary Myers sought to have Ruth A. Myers admitted to the Shippensburg Health skilled nursing facility. 8. On or about December 1,2001, Mary A Myers executed a Patient Data and Consent Form on behalf of Ruth A. Myers, along with additional admission documents. True and correct copies of the Patient Data and Consent Form and admission documents are attached hereto as Exhibit "A" and are incorporated. 9. Pursuant to the Patient Data and Consent Form and the admission documents, Ruth Myers knew and understood that Ruth A. Myers would be responsible to pay any costs of care which were not covered by policies of insurance or medical assistance. 10. On or about December 1,2001, Ruth A. Myers became a resident of the facility and she remained a resident of the facility until the time of her death on 11. In May, 2002, the Cumberland County Assistance Office determined that Ruth A. Myers was eligible for medical assistance with an effective date of December 1, 2001. The Cumberland County Assistance Office calculated a private pay portion to be paid from Ruth A. Myers' monthly income to Shippensburg Health for the costs of her care not covered by medical assistance. 12. The private pay portion calculated by the Cumberland County Assistance Office was initially set at $878.62 per month. This amount was recalculated by the Cumberland County Assistance Office to be $950.02 beginning January 1, 2002. A copy of this determination is attached hereto as Exhibit "B" and is incorporated. The CAO found that Ruth A. Myers was receiving $840.00 in monthly social security and a retirement pension of $117.62 per month as of December, 2001 and $862.00 per month in social security and a retirement pension of $117.62 per month as of January, 2002. 13. Upon information and belief, Mary A. Myers and/or Sandy Foose was receiving the social security benefits and retirement benefits of Ruth A. Myers during the period of time that Ruth A. Myers was a resident of the facility. 14. Neither Ruth A. Myers, Mary A. Myers nor Sandy Foose has ever tendered to Shippensburg Health any sum of money payable on account of the monthly accruing private pay portion. 15. As of the time of her death, Ruth A. Myers owed Shippensburg Health the sum of $6,293.00 consisting principally of the non-payment of the private pay portion along with sundry other expenses. A true and correct copy of the statement reflecting the balance owed is attached hereto as Exhibit "C" and is incorporated. 16. Demand has been made upon Mary A. Myers and Sandy Foose to tender the amount due and owing to Shippensburg Health from the income of Ruth A. Myers. 17. Upon information and belief, Mary A. Myers and/or Sandy Foose have applied the sums received on account of Ruth A. Myers for their personal. COUNT I-BREACH OF CONTRACT SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 18. Plaintiff incorporates by reference paragraphs one through seventeen as though set forth at length. 3 19. Mary A. Myers and/or Sandy Foose, as the attorney-in-fact for Ruth A. Myers, were obligated to use the assets and income of Ruth A. Myers to satisfy the debt due and owing to Shippensburg Health for services and care provided to Ruth A. Myers by Shippensburg Health. 20. Mary A. Myers and/or Sandy Foose have, without justification, failed and refused to pay the amount due. 21. Mary A. Myers and/or Sandy Foose have breached the Patient Data and Consent Form and the admission documents by failing and refusing to pay for the services rendered from the assets and income of Ruth A. Myers. WHEREFORE, Plaintiff requests judgment in its favor and against Defendant for the sum of $6, 293.00 together with costs, interest and expenses. COUNT II-MONEY HAD AND RECEIVED SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 22. Plaintiff incorporates by reference paragraphs one through twenty-one as though set forth at length. 23. During the period of Ruth A. Myers' residency at the facility, Mary A. Myers and/or Sandy Foose have received the sum of at least $6,835.34 from the social security and retirement benefits of Ruth A. Myers. 24. The proper use of these funds would have been to pay the costs of care accruing for the care of Ruth A. Myers at Shippensburg Health in accordance with the private pay determination made by the Cumberland County Assistance Office. 4 25. At the time of receipt of these funds, Mary A. Myers and/or Sandy Foose knew that they were obligated to pay these funds over to Shippensburg Health for the costs of Ruth A. Myers' care at the facility. 26. Mary A. Myers and/or Sandy Foose gave no consideration for the funds of Ruth A. Myers received by Mary A. Myers and/or Sandy Foose. 27. Demand has been made upon Mary A. Myers and/or Sandy Foose to tender the funds of Ruth A. Myers to Shippensburg Health and they have failed and refused to do so. WHEREFORE, Plaintiff requests that judgment in its favor and against Mary A. Myers and/or Sandy Foose requiring them to: a) return the subject matter in specie; b) pay over the value if Mary A. Myers and/or Sandy Foose have consumed the money in beneficial use; c) pay its value if Mary A. Myers and/or Sandy Foose have disposed of the funds received; and d) award costs, expenses and interest. COUNT III-CONVERSION SI-IIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 28. Plaintiff incorporates by reference paragraphs one through twenty-seven as though set forth at length. 29. At the time Mary A. Myers and/or Sandy Foose received funds of Ruth A. Myers, they were aware that they had a legal obligation to dispose of those funds to or for the benefit of Ruth A. Myers under and pursuant to their authority as attorney-in-fact for Ruth A. Myers. 30. Knowing they had the aforesaid obligation, Mary A. Myers and/or Sandy Foose appropriated funds of Ruth A. Myers for their own benefit and use. 31. Mary A. Myers and/or Sandy Foose have refused to pay to Shippensburg Health the debt accruing from the non-payment of the private pay portion from the income of Ruth A. Myers. 32. Mary A. Myers and/or Sandy Foose have intentionally and substantially interfered with Shippensburg Health's right to receive the funds of Ruth A. Myers which were to be paid to Shippensburg Health as the private pay portion of the costs of Ruth A. Myers' care. WHEREFORE, Plaintiff requests judgment in its favor and against Mary A. Myers and/or Sandy Foose for the sum of $6,293.00, costs, expenses, interest and punitive damages. Respectfully submitted, David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 da b.dir/shcc/myers/complaint.pld MAR. 05 ' O~ (WED) !~'09 83.."~5/2~;E~3 11; 18 7172495755 PAO~. OBS LA~,,J OFFDD_~ PAGE 82 DATE:. _V~RIFICATIo/~ Thz statcm~t$ in ~c ~somg ComplMnt ~ ba~d u~n info~ation Which has ~mbl~ by ~y a~mey ia ~i$ litigation. ~e ]~e of the statements is not my ow~. have ~ ~e ~t$; ~ ~ ~e ~tent that ~ey ~ based u~ information which I giver tO my ~l, ~ey ~ ~ ~d ~ to t~ best of my knowledge, info~ation and ~[ief. I ~~ ~t f~ smg~ ~cin ~e made subject to the ~ties of l g Pa.C.$. SHIPPENSBURG HEALTH CARE CENTER PATIENT DATA AND CONSENT FORM ~ Date of Bi,h: /~-.~/./~d~ Ma~ied Separated Divorced ~do~ INSURANCE Zip Code:,,/].,4. q/ Male Marital Status: Single Primary Insurance: Policy Number: Secondary Insurance: Policy Number: M EDICARE#:J 7q Policyholder:_ Group Number: Policyholder:. Group Number: Relationship:_ Relationship: MEDICAID#: RESPONSIBLE PARTY Address: /OI3g ?p,qJ~_~.,/, I/~ Referring Physician: Treating Diagnosis: Service Requested: Occupational Therapy Relationship: C~/5,,~:z5 ?'/c'~,q~.~ Phone Number: ~?/-, Primary Care Physician' .Z~,':. Primary Diagnosis: Physical Therapy Speech Therapy Patient's an&'or family's permission to bill and consent to receive treatment, release information and make payment. Under Medicare Part B (a National Health Pro,2ram through which certain medical and hospit2[ expenses are paid from Federal Funds) you must meet the follow~'ng conditions: 1. You must satisfy,,,'our deductible. 2. Medicare will pa,,.' 80°,.6 of the charge after the deductible has been satisfied up to a maximum annual cap. 3. The 20% unpaid balance and.'or amounts above the annual cap will be billed to you or the person responsible for paying )'our bills. ' 4. If you have a Tie-in Plan or other insurance that will pa,,,' the balance we will submit the bill to them. 5. This form must be signed by you or your family giving us permission to (I) bi'.:. S00o to Medicare and (2) 20% (Co-pay). and amounts above the annual cap, and an,,, deductible not a ..... ? ,ansfied, to you or your insurance company. ' 6. For patients who are Medicaid and [Medicare Part B and decreed indi_oent, the 7a:ilit-.' will accept assignment pursuant to stare laws and regulations. - ' I authorize treatment and payment of medical benefits to the Facility for sen'ices rendered as ordered by ms, physician. I further authorize the Facility to furnish medical or other information for an.,,' ',' - c~_~,'7,, incurred f~r a period of one >'ear under the Title XVIll'ofthe Social Security Act and its intermediary. I ire:eh.,, accept all responsibility for treatment costs not covered or reimbursed b'y third part3., payers. of Pat/ent or Authoj4zed Representative ~,x,Stness (Name) / EXHIBIT Date Vv'itn~ (Si_zna~t. re) SHIPPENSBURG HEALTH CARE CENTER ADMISSION AND TRANSFER POLICY Shippensburg Health Care Center, in an effort to provide intensive nursing care during periods of increased need, maintains a skilled Medicare unit with about above average staffing. It shall be the goal of this unit to provide intensive nursing and rehabilitation sen'ices for those residents who require them. A resident may be transferred or admitted to this unit when his/her nursing needs require this level of care. This will be done after consultation with the resident, the resident's physician, and the resident's representative or guardian. The nursing home will seek to transfer a resident from this unit to another more suitable unit when his/her nursing needs fall below the Medicare criteria. Any transfer from the unit will be done in a consultation with the resident, the resident's physician, and the resident's representative or guardian. LEAVES OF ABSENCE POLICY The following guidelines apply to leaves of absence for all residents. Leaves of absence should not be frequent or on a regular basis. A doctor's order will need to be obtained prior'to an,',' leave of overni_oht absence. The family member should contact either the Medicare Coordinator or the Charge Nurse at least one (I) ,-,-: ~ ....... . .....hours) prior to leave, due to the need for a Doctor's order. (See statement #2) Resident Signature Responsil~le Part), / tl~itness Residenfs Nam4 Date SHIPPENSBURG HEALTH CARE CENTER CONSENT ACKNOWLEDGMENT FORM I hereby~/ do not consent to having my photography taken by Shippensburg Health Care Center staff, residents, family members or other outside organizations visiting our facility. I hereb)~ do not consent to having Shippensburg Health Care Staff or volunteers open my mail, in my presence, and read my mail to me. I hereby/do not consent that Shippensburg Health Care Center may release any and all parts of my medical records to hospitals, home health care agencies or any other medical services provider for the purpose of ensuring continuity of care. I have been informed of care plans/family counsel meetings. Resident Signature Responsible tparty/PCyA Signature X~tness Si natu _J Date /Y--l-w~ Date Date Resident Narr(e AUTHORIZATION TO RECEIVE SERVICES AND/OR SUPPLIES AND TO RELEASE INFORMATION REGARDING BENEFITS Name of Beneficiary:_ Medicare Number:_ I hereby authorize Shippensburg Health Care Center to have the facility physician and whomever he may designate as his assistant or on-call physician to act as my physician. The}e duties may include, but are not limited to, prescribing medications, treatments, rehabilitation therapies, lab procedures, x-rays, medical procedures, and/or referrals to other physicians. I certify the information given by me in applying for payment under Title XVIH of the Social Security Act is correct. I authorize an)' holder of medical or other information about me to release to the Health Care Financing Administration and its agents an.,,' information needed to determine benefits for related services and/or durable medical supplies. I request that payment of authorized Medicare benefits be made on my behalf to Shippensburg Health Care Center for an.,,, services and/or durable medical supplies furnished me by or in Shippensburg Health Care Center. I hereby attthorize and give permission to Shippensburg Health Care Center to release to my insurance carrier or its agents an,,' medical information needed to determine benefits payable for related services and/or durable medical supplies furnished me bv or in Shiepensburo. Health Care Center. ' · ~ I understand that I am responsible for an,,' health insurance deductibles and coinsurance not paid mv '.X. ledicare, mv insurance carrier, or an',' state Medical Assistance Program. Signatur~ of Beneficiar.L' or Authorized Representative SHIPPENSBURG HEALTH CARE CENTER Information Release and Payment Authorization Authorization to Release Information and Receive__D.Direct Payment of Medicare Ben~ I certify that the information given by' me in applying under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any' information needed for payment of Medicare claims. I request that payment of authorized benefits be made in my behalf to: SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility I assign payment for the unpaid charges for sen'ices furnished by specialists, or by physicians, for whom the facility is authorized to bill. I understand that I am responsible for any health insurance deductibles and coinsurance. / Y- i-ol Date sident/Pdrson actin,,6n behalf of the Beneficiary Authorization to Release Information and Recei4,'e Direct Payment of Medical Insurance Benefits: I hereby authorize and give permission to' SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility to release billing and medical information to include the diao. nosis and reason for treatment. I. also, hereby authorize and give permission to the above named Nursinz Facility to release a transcript of mv medical records to my insurance carrier upon their request for the purpose of determining benefits payable under the contract. Date Resident/Pergon actin= off behalf of the B ezeficiarv I hereby' authorize any and all benefits, to include professional sen'ices accruing under said policy to: SHIPPENSBURG HEALTH CARE CENTER Name ' ' ' ot Nursing Facility Date Resident/Pers/on acting offbehalfofthe Beneficiary SHIPPENSBURG HEALTH CARE CENTER BEAUTY/BARBER SHOP PRICE LIST Beauty/Barber Shop Services Permanent $35.00 Haircuts and Blow Dry $10.50 Hair Sets $ 8.25 Cuts Only $ 8.25 Color $30.00 Resident Room Number The above names resident or his&er representative has consented to the followino marked services: = ~ Perms ~'Hair Cuts and Blow Dry ~ Hair Sets Cut Only Is the resident allergic to Ammonia? Is the resident combative/confused? Please bill: _ t,/// Responsible Part)- _ Yes Yes How often: V'/ No __ Resident's Trust Account Name /'a'a S' Address City/State/Zip Code ResidenffResgbnsible ParC. Signature SHIppENSBURG HEALTH CARE CENTER CHANGE IN STATUS FORM LAUNDRY ANDTV CABLE RESIDENT:./~)1 _'~ LAUNDRY SERVICES: FACILITY LAUNDRY · YES ',,,/ NO £aundry services are completed on a daily basis at a rate of S1.5OpeJ. day. Lattndty items washed by SHCC must be appropriately labeled and may be assessed a S25. O0 labeling fee. FAMILY DOING LAUNDRY v//YES -_, N0 DATE 12-)- Lq TV CABLE: CoN'rNECT / YES ~ NO · Cable services are available at a rate ors 7. O0 per month. · Families are asked to provide a television set that would appropriateh,fit above the Resiclent's closet. Remote controls are encouraged · Please ask for assistancefi.om the Maintenance Department upon television set-up. DISCO~ECT . YES . NO OPTED FOR NO TV CABLE AT THIS TIME DATE YES . NO MEDICARE SCREEN FOR SECONDARY PAYOR (Note: There may be situations v,'here more than one insurer is primary to Medicare, e.g., automobile insurer and EGHP. Be sure to identify all possible insurers.) Part I: Was illness/injury due to a work-related accident/condition and covered by a Worker's Compensation (WC) plan or Federal Black Lung Program? Yes: Name and address of WC plan or Federal Black Lung Program Patient's policy or identification number Part II:' 1. STOP: WC OR F/EDERAL BLACK LUNG PROGRAM IS PRIMARY PAYOR. No: v' GO TO PART II. Was illness/injury due to non-v,'ork related accident? Yes: No: ~" GO TO PART IlL What type of accident caused illness/injuo,? Automobile Name and address of'automobile insurer Insurance Claim Number: STOP: AUTO INSURER IS PRIMARY PAYOR. Other: Was another part).' responsible for this accident? Yes: Name and address of any liability insurer Insurance Claim Number: Part III: STOP: LIABILITY IN'SURER IS PRIMARY PAYOR. No: GO TO PART III. Is the patient aged 65 or over? Yes: v,'"' No: GO TO PART IV. Is the patient undergoing kidney dialysis for End Staze Renal Disease (ESRD)? Yes: ~ No: ~ Is the patient employed and covered by an Employer's Group Health Plan (EGHP)? Yes: ' Name and address of EGHP Patients Identification Number: STOP: EGHP IS PRIMARY PAYOR. No: w'""' Is the patient's spouse employed? Yes: S~P '"' No: L,/' : MEDICARE IS PRIMARY PAYOr.. Is the patient covered under the group health plan of the spouse's employer.'? Yes: Name and address of EGHP Patient's Identification Number: Part IV: 1. STOP: EGHP AS PRhMARY PAYOR. No: STOP: NIEDICARE IS PRIMARY PAYOR. Is the patient entitled to benefits solely on the basis of End Stage Renal Disease9 Yes: , ' No: GO TO PART V. Is this patient covered by an Employer Group Health Plan? Yes:.. Name and address of EGHP Patient's Identification Number: Part V: No: STOP: MEDICARE IS PRIMARY PAYOR. Has the patient been undergoing kidney di-alysis for more than 12 months or been entitled to Medicare for more than 12 months? Yes: STOP: MEDICARE IS PRIMARY PAYOR No: Is the patient within a 12-month period as defined in section 252.4 of the SNF Manual: Yes: STOP: EGHP IS PRhMARY PAYOR. No:. STOP: MEDICARE IS PRIMARY PAYOR Is the patient a disable Medicare beneficiary under age 657 Yes: No: STOP: MEDICARE IS PRIMARY PAYOR. Is the patient covered by an EGHP based on patient's own emplovment or employment of a spouse or a parent.'? ' Name and address of EGHP Patient's Identification Number: STOP: EGHP IS PRIMARY PAYOR. No: STOP: MEDICARE IS PRIMARY PAYOR. Signature Of Beneficiab,.'/Authorized Representative SHIPPENSB'URG HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, PA 17257 Date Name Address City, State, Zip RE: Name Dear On , We reviewed the medical information available at the time of, or prior to admission, and we belie`.'e that the services need(s) do not meet the requirement for coveraoe 'under Medicare. = Medicare covers medically necessary skilled nursing care needed on a daily basis, only require(s) oral medications, assistance with daily activities and general supportive sen'ices. There is no evidence of medical complications or other medical reasons that require the skills of a professional nurse or therapist to safely and effectively carry out her plan of care. Therefore, we believe that care cannot be covered by Medicare. This decision has not been made by Medicare. It represents our judgment that the services you needed did not meet Medicare payment requirements. Normally, in this situation, a bill is not submitted to Medicare. A bill ,,,,'ill only be submitted to Medicare if you request that a bill be submitted. If you request that a bill be submitted, the Medicare intermediary will notify you of its determination. If you disao, ree with that determination, you ma.',, file an appeal. ' ' ~ Under a provision of the Medicare law, you do not have to pay for non-covered services determined to be custodial care or not reasonable or necessan' unless you had reason to know the sen'ices were non-covered. You are considered to know that these sen'ices were non-co`.'ered effective with the date of this notice. Please check one of the boxes on the third page of this letter to indicate v;hether or not you `.,,'ant 3'our bill submitted to Nledicare and sign the notice to verit\- receipt. Please return the signed second page to this facility as soon as possible, keeping a copy for .','our records. If I mav be of any assistance to you, please do not hesitate to contact me. Sincerely yours, Larry D. Cottle, LNHA Administrator ATTACHMENT - Denial on Admission ( ) A. I d._~o want my bill for sen'ices I continue to receive to be submitted to the intermediary for a Medicare decision. You will be notified when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request, you should contact: Aetna Medicare Claims Administration Mutual of Omaha P.O. Box 1602 Omaha, NB 68101 Please note: After October 1, 1989, a beneficiary will not be required to ~ay for Services which could be covered by Medicare until a Medicare determination has Been made. ( ) B. I do not want my bill for services submitted to the intermediary for a Medicare decision. I understand that I do not have Medicare appeal rights if a bill is not submitted. ( )C. on VERIFICATION OF RECEIPT OF NOTICE This acknowledges that I received the notice of non-coverage of sen'ices under Medicare Signature of beneficiary or person acting on behalf of the beneficiary ( ) D. This is to confirm that you were advised of the non-coverage of the services under Medicare by telephone on Name of beneficiary or representative contacted Patient representative Physician Patient medical?financial files Pharmacy ~0 ~7 Z 0~ ~0 7 C o ~Z ~>o m RECORD Nb?lB ER GROS~-'SS TOTAL GROSS IIN~R~NED ESTL~-TED INTEREST TOTAL INCOME USED ~0/YR , qo.°o /.00 ~O/¥R .... · :/) '~- ~- c~q u~ .~0 oo 0 MO/YR - PERSONAL Cg_~E ALLOW3~N'CE - CO~-Wi~-u~i'--Y SPOUSE/ HOME M-~ INTEN.~N C E GROSS PATIENT PAY (53) - MEDICAL ~C=ENSES (See below) NET PATIENT PAY f57) .5-0 oo LESS MEDICAL EXPENSES PAID MONTHLY MEDICAL EXPENSES LISTED /,>-(ol .! I o~ ~O/YR MO/¥~ N2.Q.T~.: Future changes in medical expenses should be reported to the Numing Faciliv,.-. DRUGS (Sg) MEDICARE (55) BC/BS/OTEER MEDICAL iNS (55) OT'.~ER MEDICAL (56) MONTHLY ?0?AL EXHIBIT "B" ~ SIGNATUP. E ~Ih~lR: The resource !imic is $~2400. See attached Addendum '"'~i~'S.F~.~.C~PENSBURG HEALT~ C:~RE C:TR' 121 WALNUT BOTTOM ROAD - SHZPPEHSBURG. PA 17257 ":' 1 / ---' 0 .,,' C, 3 I"iA ,~ Y M y E.q:S lOOS CEHTERVILLE RD NEW"/ILLE. PA 17241 ,'7 7£. --,:-',-' ! 5 R,_,:. I [) Ei'IT: hlYER.~. F::JTH [,ATE DESPRi PT ]: O,'i OAYS 07/31/02' PREVIOUS e;qLAi'.IC.'E 01120/03 BASIC CARE HZE'ICAIO -7 01/20/05 BASIC CARE MEDiCAIC~ 7 A MOU ..'.~': S A L A FIC: E PLCAS, E PAY UPOi'.; RECEIPT! 6?93. O0 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- /~.7 CIVIL ACTION-LAW CIVIL TERM 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 are served, by entering a written appearance personally or by an 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003- CIVIL TERM CIVIL ACTION-LAW COMPLAINT NOW, comes Shippensburg/Southhampton Manor Limited Partnership ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within complaint and, in support thereof, sets forth the following: 1. Shippensburg/Southhampton Manor. Limited Partnership ("Shippensburg Health") is a Maryland limited partnership duly authorized to conduct business in the Commonwealth of Pennsylvania. 2. Defendant, Mary A. Myers, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 3. Mary A. Myers was the attorney in fact for Ruth A. Myers, deceased. 4. Defendant, Sandy Foose, is an adult individual with an address of 1008 Centerville Road, Newville, Cumberland County, Pennsylvania. 5. Sandy Foose was the attomey in fact for Ruth A. Myers, deceased. 6. Shippensburg Health operates a resident skilled nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania (the "facility"). 7. On or about December 1,2001, Mary Myers sought to have Ruth A. Myers admitted to the Shippensburg Health skilled nursing facility. 8. On or about December 1,2001, Mary A Myers executed a Patient Data and Consent Form on behalf of Ruth A. Myers, along with additional admission documents. True and correct copies of the Patient Data and Consent Form and admission documents are attached hereto as Exhibit "A" and are incorporated. 9. Pursuant to the Patient Data and Consent Form and the admission documents, Ruth Myers knew and understood that Ruth A. Myers would be responsible to pay any costs of care which were not covered by policies of insurance or medical assistance. 10. On or about December 1,2001, Ruth A. Myers became a resident of the facility and she remained a resident of the facility until the time of her death on 11. In May, 2002, the Cumberland County Assistance Office determined that Ruth A. Myers was eligible for medical assistance with an effective date of December 1, 2001. The Cumberland County Assistance Office calculated a private pay portion to be paid fi.om Ruth A. Myers' monthly income to Shippensburg Health for the costs of her care not covered by medical assistance. 12. The private pay portion calculated by the Cumberland County Assistance Office was initially set at $878.62 per month. This amount was recalculated by the Cumberland County Assistance Office to be $950.02 beginning January 1, 2002. A copy of this determination is attached hereto as Exhibit "B" and is incorporated. The CAO found that Ruth A. Myers was receiving $840.00 in monthly social security and a retirement pension of $117.62 per month as 2 of December, 2001 and $862.00 per month in social security and a retirement pension of $117.62 per month as of January, 2002. 13. Upon information and belief, Mary A. Myers and/or Sandy Foose was receiving the social security benefits and retirement benefits of Ruth A. Myers during the period of time that Ruth A. Myers was a resident of the facility. 14. Neither Ruth A. Myers, Mary A. Myers nor Sandy Foose has ever tendered to Shippensburg Health any sum of money payable on account of the monthly accruing private pay portion. 15. As of the time of her death, Ruth A. Myers owed Shippensburg Health the sum of $6,293.00 consisting principally of the non-payment of the private pay portion along with sundry other expenses. A true and correct copy of the statement reflecting the balance owed is attached hereto as Exhibit "C" and is incorporated. 16. Demand has been made upon Mary A. Myers and Sandy Foose to tender the amount due and owing to Shippensburg Health from the income of Ruth A. Myers. 17. Upon information and belief, Mary A. Myers and/or Sandy Foose have applied the sums received on account of Ruth A. Myers for their personal. COUNT I-BREACH OF CONTRACT SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 18. Plaintiff incorporates by reference paragraphs one through seventeen as though set forth at length. 19. Mary A. Myers and/or Sandy Foose, as the attorney-in-fact for Ruth A. Myers, were obligated to use the assets and income of Ruth A. Myers to satisfy the debt due and owing to Shippensburg Health for services and care provided to Ruth A. Myers by Shippensburg Health. 20. Mary A. Myers and/or Sandy Foose have, without justification, failed and refused to pay the amount due. 21. Mary A. Myers and/or Sandy Foose have breached the Patient Data and Consent Form and the admission documents by failing and refusing to pay for the services rendered from the assets and income of Ruth A. Myers. WHEREFORE, Plaintiff requests judgment in its favor and against Defendant for the sum of $6, 293.00 together with costs, interest and expenses. COUNT II-MONEY HAD AND RECEIVED SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 22. Plaintiff incorporates by reference paragraphs one through twenty-one as though set forth at length. 23. During the period of Ruth A. Myers' residency at the facility, Mary A. Myers and/or Sandy Foose have received the sum of at least $6,835.34 from the social security and retirement benefits of Ruth A. Myers. 24. The proper use of these funds would have been to pay the costs of care accruing for the care of Ruth A. Myers at Shippensburg Health in accordance with the private pay determination made by the Cumberland County Assistance Office. 4 25. At the time of receipt of these funds, Mary A. Myers and/or Sandy Foose knew that they were obligated to pay these funds over to Shippensburg Health for the costs of Ruth A. Myers' care at the facility. 26. Mary A. Myers and/or Sandy Foose gave no consideration for the funds of Ruth A. Myers received by Mary A. Myers and/or Sandy Foose. 27. Demand has been made upon Mary A. Myers and/or Sandy Foose to tender the funds of Ruth A. Myers to Shippensburg Health and they have failed and refused to do so. WHEREFORE, Plaintiff requests that judgment in its favor and against Mary A. Myers and/or Sandy Foose requiring them to: a) return the subject matter in specie; b) pay over the value if Mary A. Myers and/or Sandy Foose have consumed the money in beneficial use; c) pay its value if Mary A. Myers and/or Sandy Foose have disposed of the funds received; and d) award costs, expenses and interest. COUNT III-CONVERSION SHIPPENSBURG HEALTH v. MARY A. MYERS AND SANDY FOOSE 28. Plaintiff incorporates by reference paragraphs one through twenty-seven as though set forth at length. 29. At the time Mary A. Myers and/or Sandy Foose received funds of Ruth A. Myers, they were aware that they had a legal obligation to dispose of those funds to or for the benefit of Ruth A. Myers under and pursuant to their authority as attorney-in-fact for Ruth A. Myers. 5 30. Knowing they had the aforesaid obligation, Mary A. Myers and/or Sandy Foose appropriated funds of Ruth A. Myers for their own benefit and use. 31. Mary A. Myers and/or Sandy Foose have refused to pay to Shippensburg Health the debt accruing from the non-payment of the private pay portion from the income of Ruth A. Myers. 32. Mary A. Myers and/or Sandy Foose have intentionally and substantially interfered with Shippensburg Health's right to receive the funds of Ruth A. Myers which were to be paid to Shippensburg Health as the private pay portion of the costs of Ruth A. Myers' care. WHEREFORE, Plaintiff requests judgment in its favor and against Mary A. Myers and/or Sandy Foose for the sum of $6,293.00, costs, expenses, interest and punitive damages. Respectfully submitted, David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 dab.dir/shcc/myers/complaint.pld ~3,/85/261~ 11:18 7172495755 OBS LA~# OFFICE PAGE 02 ~%r~RIFICATION The statemeltts in the foregoing Comp[~nt ~ b~ upon info~afio, which has aa~m~J~ by my a~mey ia ~is Jitigation. ~c J~e of the s~tements is not my ow~. have ~ ~e ~~; ~ ~ ~e ~tent ~at ~ey ~ b~ed u~ i~formation which I giv~ ~ my ~1, ~ey ~ ~ ~ ~ to t~ best of my kncwiedge, infor~atJon and ~lief. l ~~ ~t f~ ~e~ ~ein ~e made subject to the ~tties of ~ ~ Pa.C.S. SHIPPENSBURG HEALTH CARE CENTER PATIENT DATA AND CONSENT FORM / Zip Code: /,7...J.q/ Male Marital Status: Single Primary Insurance: Policy Number: Secondary Insurance: Policy Number: NIEDICARE#:J 7q Soc. Sec a...~r) - .... -.. I /oc°& 7LIS' Date: /~--/-,0/ City: A,/Lwg, V/e_ State: /"OAL ~ Date of Birth:. lb Married Separated Divorced ~dowed~ INSURANCE Policyholder: Group Number: Policyholder: Group Number: Relationship:_ Relationship: MEDICAID#: RESPONSIBLE PARTY Name:jg)~.f)//')/37b/.5 / '~'.0n,~, ..~. Referring Physician: "- Treating Diagnosis: Service Requested: Occupational Therapy of Patl/ent or Autho/{zed Repre~'entative o,/0 Jt',,e ~,xri'tness (Name) / Re I at i ° n s h i P: c~,j~, J,~:;5 ,~P27,q Phone Number: ~',Td, PrimaQ.' Care Physician: ,/.~,c. Primary Diagnosis: Physical Therapy Speech Ther,Dv Patient's ancb'or family's permission to bill and consent to receive treatment, release information and make payment. Under .Medicare Part B (a National Health Proeram through v.'hich certain medical and hospital expenses are paid from Federal Funds) you must meet the follow'lng conditions: 1. You must satisfy.,,-our deductible. 2. Medicare ',viii pa,,.' 80% of the charge after the deductible has been satisfied up to a maximum annual cap. 3. The 20% unpaid balance and'or amounts above the annual cap will be billed to you or the person responsible for paying >'our bills. ' 4. If you have a Tie-in Plan or other insurance that wilt pa,,,' the balance v.'e ',viii submit tke bill to them. 5. This form must be signed by you or your family giving us permission to (1) bi': 800 o to Medicare and (2) 20g0 (Co-pay). and. amounts above the annual cap. and an.,,' deductible not a ..... '. satisfied, to you or your insurance company. :'~"'~.' 6. For patients who are Medicaid and Medicare Part B and decreed indigent, the Fari!it,.' will accept assignment pursuant to stare laws and regulations. I authorize treatment and payment of medical benefits to the Facility for services rendered as ordered by mv physician. I further authorize the Facility to furnish medical or other information for an,.' c~, ms in:.u:-red f~)r a period of one )'ear under the Title XVHl'ofthe Social Securirv Act and its intermediaD-. I ' -'---:, - responsibility for treatment costs not col ered or reimbursed I:~' third part3., payers, n ....3 accept all EXHIBIT Date Witn~ (Signature) SHIPPENSBURG HEALTH CARE CENTER ADMISSION AND TRANSFER POLICY Shippensburg Health Care Center, in an effort to provide intensive nursing care during periods of increased need, maintains a skilled Medicare unit with about above average staffing. It shall be the goal of this unit to provide intensive nursing and rehabilitation sen'ices for those residents who require them. A resident may be transferred or admitted to this unit when his/her nursing needs require this level of care. This will be done after consultation with the resident, the resident's physician, and the resident's representative or guardian. The nursing home will seek to transfer a resident from this unit to another m~>re suitable unit when his/her nursing needs fall below the Medicare criteria. Any transfer from the unit will be done in a consultation with the resident, the resident's physician, and the resident's representative or guardian. ' LEAVES OF ABSENCE POLICY The follo~ving guidelines apply to leaves of absence for all residents. Leaves of absence should not be frequent or on a regular basis. A doctors order will need to be obtained prior'to an.,,' leave of overni_oht absence. The family member should contact either the Medicare Coordinator or the Charge Nurse at least one (I) day rm.~,,,~,, c,-, ,,. hours) prior to leave, due to the need for a Doctors order. (See statement #2) Resident Signature Date SHIPPENSBURG HEALTH CARE CENTER CONSENT ACKNOWLEDGMENT FORM I hereby~/ do not consent to having my photography taken by Shippensburg Health Care Center staff, residents, family members or other outside organizations visiting our facility. I hereb)~ do not consent to having Shippensburg Health Care Staff or volunteers open my mail, in my presence, and read my mail to me. I hereby/do not consent that Shippensburg Health Care Center may release any and all parts of my medical records to hospitals, home health care agencies or any other medical services provider for the purpose of ensuring continuity of care. I have been informed of care plans/family counsel meetings. Resident Signature Responsible ~Party/PCYA Signature ~tness Signat~_] Date Date Date Resident Narnte AUTHORIZATION TO RECEIVE SERVICES AND/OR SUPPLIES AND TO RELEASE INFORIMATION REGARDING BENEFITS Name of Beneficiary: Medicare Number:. I hereby authorize Shippensburg Health Care Center to have the facility physician and whomever he may designate as his assistant or on-call physician to act as my physician. The}e duties may include, but are not limited to, prescribing medications, treatments, rehabilitation therapies, lab procedures, x-rays, medical procedures, and/or referrals to other physicians. I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits for related services and/or durable medical supplies. I request that payment of authorized Medicare benefits be made on my behalf to Shippensburg Health Care Center for an.,,, services and/or durable medical supplies furnished me by or in Shippensburg Health Care Center. I hereby authorize and give permission to Shippensburg Health Care Center to release to my insurance carrier or its agents any medical information needed to determine benefits payable for related services and/or durable medical supplies furnished me bv or in Shiapensburz Health Care Center. · ~ I understand that I am responsible for an.,,' health insurance deductibles and coinsurance not paid my *Iedicare. my insurance carrier, or any state Medical Assistance Program. Signatur~ of Beneficiar.~-or Authorized Representative SHIPPENSBURG HEALTH CARE CENTER Information Release and Payment Authorization Authorization to Release Information and Receive Direct Payment of Medicare B~ ~enefits: I certify that the information given by me in applying under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for payment of Medicare claims. I request that payment of authorized benefits be made in my behalf to: SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility I assign payment for the unpaid charges for services furnished by specialists, or by physicians, for whom the facility is authorized to bill. I understand that I am responsible for any health insurance deductibles and coinsurance. /3- Date Residbnt/Pdrson acting,~n behalf of the Beneficiary Authorization to Release Information and Receii,'e Direct Payment of Medical Insurance Benefits: . I hereby authorize and give permission to: - SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility to release billing and medical intbrmation to include the diaznosis and reason for treatment. I. also, hereby authorize and give permission to the above named Nursing Facility to release a transcript of my medical records to my insurance carrier upon their request for the purpose of determining benefits payable under the contract. -/-o / Date Resident/Pergon actin= off behalf of the Beneficiary I hereby authorize any and all benefits, to include professional ser~'ices accruinz under said policy to: ' ~ Date SHIPPENSBURG HEALTH CARE CENTER Name of Nursing Facility Resident/Per~n acting offbehalf of the Beneficiary SHIPPENSBURG HEALTH CARE CENTER BEAUTY/BARBER SHOP PRICE LIST Beauty/Barber Shop Services Resident Permanent $35.00 Haircuts and Blow Dry $10.50 Hair Sets $ 8.25 Cuts Only $ 8.25 Color $30.00 / Room Number The above names resident or his/her representative has consented to the followino marked services: ~ Perms ~Hair Cuts and Blow Dry _ _ Hair Sets __ Cut Only Is the resident allergic to Ammonia? Is the resident combative/confused? Please bill: _, v//_ Responsible Party Yes Yes How often: t/// No __ Resident's Trust Account Name _/'~'a ~ ~e,~/'~-~.//~ ~ ~5 Address . /v~""", l City/State/Zip Code ResidentdR. esp/~nsible Parc. Signature SHIppENSBURG HEALTH CARE CENTER CHANGE IN STATUS FORM LAUNDRY AND TV CABLE RESIDENT: '~,,_'~h .~..~?_r~ ROOM:_c~E~/~/ LAUNDRY SERVICES: FACILITY LAUNDRY YES ~ NO . · Laundry services are completed on a daily basis at a rate orS1.50 per day. · Lalmdry items washed by SHCC must be appropriately labeled and may be assessed a S25. O0 labeling fee. FAMILY DOING LAUNDRY DATE i2-)- Lq ~'/YES .NO TX' CABLE: CONNECT / YES ~ N0 · Cable services are available at a rate of S 7. O0 per month. · Families are asked to provide a television set that would appropriatelyfit above the Resident's closet. Remote controls are encouraged · Please ask for assistancefi.om the Maintenance Department upon television set-up. DISCONNECT ~ YES ~ NO OPTED FOR NO TV CABLE AT THIS TIME DATE. 1~-1-/31 YES ~N0 MEDICARE SCREEN FOR SECONDARY PAYOR (Note: There may be situations ',,,'here more than one insurer is primary to Medicare, e.g., automobile insurer and EGHP. Be sure to identify all possible insurers.) Part I: I. Was illness/injury due to a work-related accident/condition and covered by a Worker's Compensation (WC) plan or Federal Black Lung Program? Yes: Name and address of WC plan or Federal Black Lung Program Patient's policy or identification number Part II:' I. STOP: WC OR F,,EDERAL BLACK LUNG PROGRAM IS PRIMARY PAYOR. No: t,/ GO TO PART II. ' Was illness/injury due to non-v,'ork related accident? Yes:.. No:.. w'" GO TO PART III. What type of accident caused illness/injuD.? Automobile Name and address of automobile insurer Insurance Claim Number: STOP: AUTO INSURER IS PRIMARY PAYOR. Other: Was another parr3., responsible for this accident? Yes: Name and address of an)' liability insurer Insurance Claim Number: Part III: I. STOP: LIABILITY INSURER IS PRhMARY PAYOR. No: GO TO PART III. Is the patient aged 65 or over? Yes: No: GO TO PART IV. Is the patient undergoing kidney dialysis for End Staze Renal Disease (ESRD)? Yes: ~ No: ~ Is the patient employed and covered bv an Emplover's Group Health Plan (EGH_P)? Yes: ' ' Name and address of EGHP Patients Identification Number: STOP: EGHP IS PRhMARY PAYOR. No: Is the patient's spouse emplo.ved? Yes: S~P No: ~ : MEDICARE IS PRIMARY PAYOr. Is the patient covered under the group health plan ofthe spouse's employer.? Yes: Name and address of EGHP Patient's Identification Number: Part IV: 1. STOP: EGHP AS PRIMARY PAYOR. No: STOP: MEDICARE IS PRIMARY PAYOR. Is the patient entitled to benefits solely on the basis of End Stage Renal Disease? Yes: . No: GO TO PART V. Is this patient covered by an Employer Group Health Plan? Yes: Name and address of EGHp Patient's Identification Number: Part V: No: STOP: MEDICARE IS PPdMARY PAYOR. Has the patient been undergoing kidney di. al.vsis for more than 12 months or been entitled to Medicare for more than 12 months? Yes: STOP: MEDICARE IS PRINIAR\' PAYOR No: Is the patient within a 12-month period as defined in section 252.4 of the SNF Manual: Yes: STOP: EGHP IS PRINIARY PA'fOR. No: STOP: MEDICARE IS PRIMARY PAYOR Is the patient a disable Nledicare beneficiary tinder age 65? Yes: No: STOP: NIEDICARE IS PRIMARY PAYOR. Is the patient covered by an EGHP based on patient's own employment or employment of a spouse or a parent? ' Name and address of EGHP Patient's Identification Number: STOP: EGHP IS PRIMARY PAYOR. No: STOP: MEDICARE IS PRIMARY PAYOR. signature c~f Beneficia('3.'/Authorized Representative Dare SHIPPENSBURG HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, PA 17257 Date Name Address City, State, Zip RE: Name Dear On , We reviewed the medical information available at the time of, or prior to admission, and we believe that the services need(s) do not meet the requirement for coveraoe · under Medicare. = Medicare covers medically necessary skilled nursing care needed on a daily basis. ~ only require(s) oral medications, assistance with daily actMties and general supportive sen'ices. There is no evidence of medical complications or other medical reasons that require the skills of a professional nurse or therapist to safely and effectively can-3., out her plan of care. Therefore, v,'e believe that care cannot be covered by Medicare. This decision has not been made by Medicare. It represents our judgment that the ser``'ices you needed did not meet Medicare payment requirements. Normally, in this situation, a bill is not submitted to Medicare. A bill ,,,,'ill only be submitted to Medicare if you request that a bill be submitted. If you request that a bill be submitted, the Medicare intermediary 'will notifv you of its determination. If you disa_.v, ree with that determination, you may file an appeal. ' ' ~ Under a provision of the Medicare law, you do not have to pay for non-covered sen'ices determined to be custodial care or not reasonable or necessan' unless you had reason to know the sen'ices were non-covered. You are considered to know that these sen'ices were non-co,,'ered effective with the date of this notice. Please check one of the boxes on the third page of this letter to indicate whether or not you want .,,'our bill submitted to Medicare and sign the notice to verify receipt. Please return the signed second page to this facility as soon as possible, keeping a cop.,,' for 3'our records. If I ma,.' be of any assistance to you, please do not hesitate to contact me. Sincerely yours, Lan',,' D. Cottle, LNHA Administrator ATTACHMENT - Denial on Admission ( ) A. I d_9_o want my bill for services I continue to receive to be submitted to the intermediary for a Medicare decision. You will be notified when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request, you should contact: Aetna Medicare Claims Administration Mutual of Omaha P.O. Box 1602 Omaha, NB 68101 Please note: After October I, 1989, a beneficiary will not be required to ~ay for Services which could be covered by Medicare until a Medicare determination has Been made. ( ) B. I do not want my bill for services submitted to the intermediary for a Medicare decision. I understand that I do not have Medicare appeal rights if a bill is not submitted. ( )C. on VERIFICATION OF RECEIPT OF NOTICE This acknowledges that I received the notice of non-coverage of services under/Vledicare Signature of beneficiary or person acting on behalf of the beneficiary ( ) D. This is to confirm that you were advised of the non-coverage of the sen'ices under Medicare by telephone on Name of beneficiary or representative contacted CC: Patient representative Physician Patient medical/financial files Pharmacy Z> ~0 C~ OZ Z C -r 0 O~ ~> -ri- O0 ~Z ~>o r- NAME RECORD Nb,~f~ER GROSS SS TOTAL GROSS UN~L~NED ESTD~J. TED INTEREST TOTAL INCOME USED M0/YR °° /.00 MOIYR '::.'.:Il ~- ~> · JO oo 0 MO/YR - PERSONAL C~_RE ALLOWA=h'CE - CO~-W~f-u~'i~-Y SPOUSE/ HOME Y-~ INT E N.~NC E GROSS PATIENT PAY (53) - MEDICAL F-Y2ENSES (Se=_ below) NET PATIENT PAY (57) '.:O oo LESS MEDICAL EXPENSES PAID MONTHLY MEDICAL EXPENSES LISTED />(si / / ~0/~,"-t MO/YR NI.~)...T~.: Future changes in medical expenses should be reported to the Nursing Facility. DRUGS (54) MEDICARE (55) BC/BS/OTHER MEDICAL INS (55) OTHER MEDiCAL (56) MONTHLY TOTAL EXHIBIT "B" S IGNATUIIE ~Ih'DER: The resource !imic is $~2400. See attached A6den6um DATE · 4:~..$HIPPEHSB!.JRG H£~LTH CARE .~2'1' 14ALNUT BOTTOM RORD SHIPP,_Hz,'SURG. PA 17257 C:TP, 0 L / 20 ./0.:-: I"iA RY I"1 '~ t-_. ,'-.. :~ LC, OS C:EHTERVI LLE H£WVI/.LE. PA 17241 R~,--IL.:.I'tT: MYERE. qUTH OA!L'- :'TE- RESIOENT ~""=-EP C',AT E C" ESPRZ PT IOH C',A 1'S 07/31/02 ' PREVIOUS BALAi'-~CE 01/20/0.=-. BASIC CARE MEC, ICAIO -7 0]./20/05 BASIC CARE M.--DZCAID ~ AMOLI ;-;': SA LA HC: E ,5293. C.'-: 6293. O0 - '895 . C,C' 5393,00 oc~ r;,-. ~,°9.~ O0 PLEASE PAv UPO?; R':',";"IPT! FIE.I,~¢ E:ALA.'hl ~ 6293. C'C' . ... :: <. ..... SHERIFF'S RETURN - NOT FOUND CASE NO: 2003-01007 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS MYERS MARY A ET AL duly sworn according to law, inquiry for the within named DEFENDANT FOOSE SANDY unable to locate Her COMPLAINT & NOTICE ,Sheriff or Deputy Sheriff, who being says, that he made a diligent search and in his bailiwick. but was He therefore returns the the within named DEFENDANT , FOOSE SANDY , NOT FOUND , as to 1008 CENTERVILLE ROAD NEWVILLE, PA 17241 PER NEIGHBOR, SANDY FOOSE NO LONGER LIVES AT THIS ADDRESS. THERE IS NO FORWARDING ADDRESS ON FILE AT POST OFFICE. Sheriff's Costs: Docketing Service Not Found Surcharge 6 00 00 5 00 10 00 00 21 00 ~ R. Thomas Kline Sheriff of Cumberland County OBRIEN BARIC SCHERER 04/07/2003 Sworn and subscribed to before me this ~ q~ day of ~ A.D. P~o~ honot a ry ' SHERIFF'S RETURN - NOT FOUND CASE NO: 2003-01007 p COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MAiXIOR VS MYERS MARY A ET AL R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT MYERS MARY A unable to locate Her COMPLAINT & NOTICE in his bailiwick. but was He therefore returns the the within named DEFENDANT , MYERS MARY A 1008 CENTERVILLE ROAD NEWVILLE, PA 17241 UNABLE TO LOCATE AT GIVEN ADDRESS, ALTHOUGH NUMEROUS ATTEMPTS WERE MADE. , NOT FOUND , as to Sheriff,s Costs: Docketing 18.00 Service 24.84 Not Found 5.00 Surcharge 10.00 .00 57.84 So answer~ .? j, R. Thomas ~ne- ~ Sheriff of Cumberland County Sworn and subscribed to before me this ~ day of ~ ~ o~3~ A.D. Pro~h6not ary OBIEN BARIC SCHERER 04/07/2003 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff Vo MARY MYERS and SANDY FOOSE, Defendants 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003-1007 CIVIL TERM CIVIL ACTION-LAW PRAECIPE TO REINSTATE. TO THE PROTHONOTARY: Please reinstate the Complaint filed in the above-captioned matter on March 6, 2003. Respectfully submitted, David A. Baric, Esquire Off/) I.D. # 44853 Date [ ~ '~ 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff SHIPPENSBURG/SOUTHAMPTON MANOR, L.P., Plaintiff MARY A. MYERS and SANDY FOOSE, Defendants · IN THE COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY, PENNSYLVANIA · NO. 2003-1007 CIVIL TERM · CIVIL ACTION - LAW ANSWER AND NOW, comes the Defendant, Sandra K. Foose, by' her attorney William A. Addams, of Hanft & Knight, P.C., and makes the following Answer to the Complaint: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted except the Defendant no longer resides at the Centerville Road address. 5. Admitted. 6. Admitted. 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. 11. After reasonable investigation, the Defendant is without knowledge sufficient to form a belief as to the truth of the averment. The same is therefore denied. 12. The answer to Paragraph 11 is incorporated herein by reference· 13. retirement benefits of Ruth A. Myers. finances. 14. 15. 16. 17. 18. 19. by reference. 20. 21. It is denied that Defendant Sandra K. Foose was receiving the Social Security and Defendant Mary A. Myers was in charge of her mother's The answer to Paragraph 11 is incorporated herein by reference. The answer to Paragraph 11 is incorporated herein by reference. Admitted. The answer to Paragraph 13 is incorporated here by reference. COUNT I - BREACH OF CONTRACT The answers to Paragraphs 1-17 are incorporated herein by reference. The conclusion of law is denied and the answer to Paragraph 13 is incorporated herein The answer to Paragraph 19 is incorporated herein by reference. The answer to Paragraph 19 is incorporated herein by reference. WHEREFORE, Defendant Sandra K. Foose requests that Count I be dismissed. COUNT II - MONEY HAD AND RECEIVED 22. 23. 24. 25. 26. The answers to Paragraphs 1-21 are incorporated lherein by reference. The answer to Paragraph 13 is incorporated herein by reference. The answer to Paragraph 11 is incorporated herein by reference. The answer to Paragraph 19 is incorporated herein by reference. The answer to Paragraph 19 is incorporated herein, by reference. 27. Admitted. WHEREFORE, Defendant Sandra K. Foose requests Count II be dismissed. .COUNT III = CONVERSION_ 28. The answers to Paragraphs 1-27 are incorporated herein by reference. 29. The answer to Paragraph 13 is incorporated hereiin by reference. 30. The answer to Paragraph 13 is incorporated herein by reference. 31. The answer to Paragraph 13 is incorporated herein by reference. 32. The answer to Paragraph 13 is incorporated herein by reference. WHEREFORE, Defendant Sandra K. Foose requests Count III be dismissed. HANFT & KNIGHT, P.C. Attorney I.D. No. 015265 19 Brookwood Avenue, Suite 106 Carlisle, PA 17013 (717) 249-5373 Attorney for Defendant Sandra K. Foose VERIFICATION Sandra K. Foose hereby verifies that the facts set forth in the foregoing Answer to Complaint are tree and correct to the best of her knowledge, information and belief, and understands that false statements herein are made subject to the: penalties of 18 Pa. C.S. §4904 relating to unswom falsifications to authorities. DATE: CERTIFICATE OF SERVICE AND NOW, this 28th day of May, 2003, I, Mary M. Price, an employee of Hanft & Knight, P.C., hereby certify that I have served a copy of the Answer of Defendant Sandra K. Foose by mailing the same by United States mail, postage prepaid, to: David A. Baric, Esquire O'BRIEN, BARIC & SCHERER 17 West High Street Carlisle, PA 17013 Mary A. Myers 1008 Centerville Road Newville, PA 17241 SHERIFF'S RETURN - CASE NO: 2003-01007 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTONMANOR VS MYERS MARY A ET AL REGULAR DAWN KELL , Cumberland County, Pennsylvania, says, the within COMPLAINT & NOTICE MYERS MARY A DEFENDANT , at 1121:00 HOURS, at 1008 CENTERVILLE ROAD NEWVILLE, PA 17241 MARY A MYERS a true and attested copy of COMPLAINT & NOTICE Sheriff or Deputy Sheriff of who being duly sworn according to law, was served upon the on the 18th day of June , 2003 by handing to together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 6.90 Affidavit .00 Surcharge 10.00 .00 34.90 Sworn and Subscribed to before me this ~0 ~ day of C~_. ~ A.D. ,vrothonotary ~ So Answers: R. Thomas Kli~e 06/19/2003 OBRIEN BARIC SCHERER By: Deputy Sheri SHERIFF'S RETURN - CASE NO: 2003-01007 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS MYERS MARY A ET AL REGULAR HAROLD WEARY , Cumberland County, Pennsylvania, says, the within COMPLAINT & NOTICE FOOSE SANDY DEFENDANT , at 1355:00 HOURS, at 22 GLEBE AVENUE NEWVILLE, PA 17241 AMY WEYANT, DAUGHTER a true and attested copy of COMPLAINT & NOTICE Sheriff or Deputy Sheriff of who being duly sworn according to law, was served upon on the 23rd day of May by handing to the , 2003 together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 6.90 Affidavit .00 Surcharge 10.00 .00 22.90 Sworn and Subscribed to before me this 3D ~ day of ~ ~3 A.D. ~ ;Prothonotary ' So Answers: R. Thomas Kline 06/19/2003 OBRIEN BARIC SCHERER By: ~De~p ty~S~r u iff SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff MARY A. MYERS and SANDY FOOSE, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2003-1007 CIVIL TERM : CIVIL ACTION-LAW PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY OF SAID COURT: Please enter the appearance of Robert J. Mulderig, on behalf of the Defendant Mary A. Myers in the above-captioned case. Respectfully Submitted, TURO LAW OFFICES Data ' Robert J/,l(4~ldefig, Esquire Turo Law Offices 28 South Pitt Street Carlisle,, PA 17013 (717) 245-9688 ID #48619 SHIPPENSBURG/ SOUTHAMPTON MANOR, L.P. Plaintiff MARY A. MYERS and SANDY FOOSE, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2003-1007 CIVIL TERM C1VIL ACTION - LAW ANSWER AND NOW, comes the defendant, Mary A. Myers, by her attorney Robert J. Mulderig, of Turo Law Offices, and makes the following answer to the Complaint: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted except Defendant Sandy Foose no longer resides at the Centerville Road address. 5. Admitted. 6. Admitted. 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. 11. After reasonable investigation, the Defendant is without knowledge sufficient to form a belief as to the troth of the averment. The same is therefore denied. 12. The defendant admits that Ruth A. Myers was receiving Social Security and a pension. After reasonable investigation, the Defendant is without knowledge sufficient to form a belief as to the truth of the averment regarding the private pay portion determined by the Cumberland CoUnty Assistance Office. The same is therefore denied. 13. Admitted. 14. Admitted. 15. Admitted. 16. Admitted. 17. Admitted. 18. Denied. Mary A. Myers applied the sums received on account of RUth A. Myers to debts which had priority over the debts to Shippensburg Ilealth and did not use said moneys for personal expenses or purchases. COUNT I - BREACH OF CONTRACT 18. The answers to paragraphs 1-17 are incorporated herein by reference. 19. The conclusion of law is denied. 20. The answer to paragraph 19 is incorporated here by reference. 2 21. The answer to paragraph 19 is incorporated here by reference. WHEREFORE, Defendant Mary A. Myers requests that Count I be dismissed. COUNT II - MONEY HAD AND RECEIVED 22. The answers to Paragraphs 1-21 are incorporated herein by reference. 23. Admitted. 24. The conclusion of law is denied. 25. The conclusion of law is denied: 26. Admitted, 27. Admitted. WHEREFORE, Defendant Mary A. Myers requests Count II be dismissed. COUNT III - CONVERSION 28. The answers to Paragraphs 1-27 are incorporated herein by reference. 29. The conclusion of law is denied. 30. The conclusion of law is denied. 31. Admitted. 32. Denied. WHEREFORE, Defendant Mary A. Myers requests Count III be dismissed. TURO LAW OFFICES rl~)bert ~. M~lderig ~ Attorney I.D. No. 48619 28 South Pitt Street Carlisle, PA 17013 (717) 249-9688 Attorney for Defendant Mary A. Myers 4 VERIFICATION I verify that the statements made in the foregoing Answer to Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unswom falsification to authorities. ~-r/5 rd 3 Ma~ A.~yers Date CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the Answer te Complaint upon David A. Baric, Esquire, by depositing same in the United States Mail, first class, postage pre-paid on the 18th day of August, 2003, from Carlisle Pennsylvania, addressed as follows: David A. Baric O'Brien, Baric & Scherer 17 West South Street Carlisle, PA 17013 TURO LAW OFFICES 28 South Pitt Street Carlisle, PA 17013 (717) 245-9688 Attorney for Mary A. Myers CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the Answer tc Complaint upon William A. Adams, Esquire, by depositing same in the United States Mail, first class, postage pre-paid on the 18th day of AUgust, 2003, from Carlisle, Pennsylvania, addressed as follows: William A. Adams Hanft & Knight, P.C. 19 Brookwood Avenue, Suite 106 Carlisle, PA 17013 TURO LAW OFFICES 28 South Pitt Street Carlisle, PA 17013 (717) 245-9688 Attorney for Mary A. Myers