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HomeMy WebLinkAbout01-03280 ~-. "~"~illb' .. . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA HCR MANOR CARE, Plaintiff NO. d I - J)j>6 OlU~L<-r~ vs. CIVIL ACTION - LAW RUTH M. GILBERT, GAIL E. HAYWOOD and JOHN E. GILBERT Jointly and Severally, Defendants 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 EST A DEMANDA A UN ABODOAGO IMMEDIA T AMENTE. SI NO T1ENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VA Y A EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE ENCUENTRA ESCRIT A ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASSIT ANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 -lI!: ,'1,'_ , ". , ,,->-,~-,,~,t!-,: .... IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCRMANORCARE, NO. 19/. 3.2.~ ~ I~ Plaintiff vs. CIVIL ACTION. LAW RUTH M. GILBERT, GAIL E. HAYWOOD and JOHN E. GILBERT Jointly and Severally, Defendants COMPLAINT AND NOW, this ~ day of ,~ ,2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel 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 (hereinafter referred to as "Plaintiff'), is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17315. 2. Defendant, Ruth M. Gilbert, hereinafter referred to as "Defendant Ruth"), is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013 2. Defendant, Gail E. Haywood, (hereinafter referred to as "Defendant Gail"), is an adult individual with a last known address of 916 Cora Street, Joliet, Illinois 60435. 2 ..~ - '-. ->~+i>- '"'-, 3. That Defendant Gail represented to be Legal Representative and/or Responsible Party for Ruth M. Gilbert. Defendant Gail is the daughter of Ruth M. Gilbert. 4. Defendant, John E. Gilbert, (hereinafter referred to as "Defendant John"), is an adult individual with a last known address of 517 High Street, Elizabethtown, Lancaster County, Pennsylvania 17022. 5. That the invoices for Defendant Ruth were forwarded to the home of Defendant John for payment of same. 6. That on or about January 29, 2000, through the present, Ruth M. Gilbert was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and collectively marked as Exhibit "A". 7. That on or about January 29, 2000, Defendant Gail, as Ruth M. Gilbert's Power of Attorney, executed an Admission Agreement which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and collectively marked as Exhibit "8". 8. That Plaintiff submitted to Defendants a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously identified as Exhibit" A" and incorporated herein by reference. 3 . ._._",1: ~.,' ....., 9. That Defendant s did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 10. As of May 2, 2001, the balance due, owing and unpaid on Ruth M. Gilbert's account as a result of said charges is the sum of Fifty-Four Thousand Two Hundred Thirty-Six and 42/1 00 Dollars ($54,236.42). See Exhibit "A" previously identified and incorporated herein. 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Ruth's account balance, all to the damage and detriment ofthe Plaintiff. 12. Plaintiff has made numerous requests to Defendant Gail, as Legal Representative and/or Responsible Party, for Ruth M. Gilbert, demanding that the sums due and owing to Plaintiff be paid, and Defendant Gail, as Legal Representative and/or Responsible Party for Ruth M. Gilbert, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Ruth.. 13. Plaintiff has made numerous requests to Defendant John, as a Responsible Party and as the person to whom all of Defendant Ruth's bills were sent, demanding that the sums due and owing to Plaintiff be paid, and Defendant John, as a Responsible Party of Defendant Ruth, has ignored his obligation to pay necessary and appropriate bills and obligations for his mother, Defendant Ruth. 14. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (1 8 %) per year on past due balances. See Exhibit JIB" previously 4 ..~ ."""'..,..;i'~~,,~ .... , identified and incorporated herein. 15. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance is the sum of Twelve Thousand Two Hundred Fifty- One and 50/100 Dollars ($12,251.50). 16. Plaintiff has retained the services of the law firm of Wolfson & Associates, P.c., in the collection of the amounts due from Defendants. 17. Pursuant to Section I, Paragraph 1.03, ofthe Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney's fees and all court costs if the aCCOunt is referred to an attorney for collection. See Exhibit "B" previously identifiedalld incorporated herein. 18. 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 Dt!fendants. 19. That the amount' of attorney's fees which represents thirty percent (30%) of the principal amountclue and owing is the sum of Sixteen Thousand Two Hundred Seventy-One and 29/100 Dollars ($16,271.29). 20. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. ;-, . 5 - , , . ' "-~,~ ~- ., ',i1~","""'<oiii,,',c ' L , 2 1 . The amount in controversy exceeds the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gail E. Haywood and John E. Gilbert for Ruth M. Gilbert, jointly and severally, in the amount of Fifty-Four Thousand Two Hundred Thirty-Six and 42/100 Dollars ($54,236.42), contractual interest in the amount of Twelve Thousand Two Hundred Fifty-One and 50/1 00 Dollars ($12,251.50), reasonable attorney's fees in the amount of Sixteen Thousand Two Hundred Seventy-One and 29/100 Dollars ($16,271.29), the costs of this action and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff 6 Statement 'Jl..ManorCare JOHN GIL8ERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA i I [ GILBERT, RUTH M 20013 05/07/00 02/28/01 I , ----------------------------------------------------------------------\ I I .00 i , i I I i ! TE OF 9VlCE , , MANORCARE CARLISLE 372 940 WALNUT 80TTOM ROAD CARLISLE, PA 17013 (717)-249-0085 PAGE 3 PRIVATE Roor~ 100 -A 17022 Please Return This Portion With Your Payment SERVICE RENDERED CREDITS CHARGES sTI'n 131/00 /30/00 /30/00 131/00 '31/00 131/00 '30/00 '30/00 '30/00 130/00 '31/00 '31/01 ADJ ADJ ADJ AOJ ADJ ADJ ADJ ADJ AOJ ADJ ADJ ADJ FWD FROM PRECEDING REC R &< B/30 REC NON LEGEND REC R & B 30 REC LEGEND REC NON LEGEND REC R & B 31 REC LEGEND REC NON LEGEND REC WOUND TREATMENT REC R /; 8 30 REC R & B 31 CABLE RENTAL 32,964.48 4,123.00 10.78 3,990.00 550.24 139.74 4,123.00 159.68 9.50 48.00 3,990.00 4,123.00 5.00 PAYMENT DUE BY THE 10TH OF THE MONTH 54,236.42 AMOUNT DUE " , i I I l I I I I I I I J l , \ CR-ManorCare i I I I I I I I ! I , I I ',. I GILBERT, RUTH M 20013 05/07/00 02/28/01 I ----------------------------------------------------------------------1 :~~!g~ I CODE ! SERVICE RENDERED I CHARGES I CREDITS II I I I r MANOR CARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 JOHN GILBERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA /01/01 /01/01 11100 /01/01 11100 /01/01 11100 /01/01 11100 /01/01 11100 /28/01 11600 /13/01 29001 /05/01 30001 /28/01 51501 /07/01 11100 /15/01 11100 /01-02/28/01 /01,-:,03/31/01 17022 BALANCE FORoJARD BEAUTY S~U~ WASH 1/18 BEAUTY SHOP WASH 1/25 BEAUTY AND BARBER BEAUTY W & S 1/4 BEAUTY W & S 1/11 CABLE RENTAL PHARMACY LEGEND PHARMACY NON LEGEND WOUND TREATMENT BEAUTY AND BARBER BEAUTY AND BARBER ROOM CHARGE ADV ROOr1 CHARGE SUB TOTALS ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY Statement PRIVATE ROOM 100 -A Please Return This Portion With Your Payment 1 ) 1 ) 1 ) 1 ) 1 ) 1 ) 1 ) 1 ) 56 ) 1 ) 1 ) 8,004.50 9.00 9.00 9.00 9.00 9.00 5.00 293.17 10.00 448.00 9.00 9.00 4,123.00 4,123.00 17,069.67 .00 CARRIED FWD AMOUNT DUE I I I [ I I I I I I I ! I I I I I _~!~~~~~~!~!~_~___________________~~~~~___~~[~~(0~___________~3i~~~~~___1 [ I I .00 I I I , I I I I I I I I I ! Statement CR.ManorCare --'~ , , , MANORCARE CARLISLE 372 ,940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 PAGE PRIVATE JOHN GILBERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA ROOM 100 -A , 17022 Please Return This Portion With Your Payment 2 ,~TE OF ERVICE SERViCE RENDERED CREDITS /31/00 ./31/00 ./31/00 /31/00 /31/00 '/31/00 ,/31/00 /30/00 ,/30/00 1/30/00 /31/00 '/31/00 /31/00 ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ FWD REC REC REC REC REC REC REC REC REC REC REC REC REC CHARGES FROM PRECEDING LEG E riD' NON LEGEND WOUND TREATMENT R & B 6 R & B 25 NON LEGEND R & B 25 DAYS NON LEGEND R & B 22 R & B 8 NON LEGEND R & 8 31 NON LEGEND STMT 17,069.67 124.94 7.95 464.00 798.00 3.325.00 3.39 3,300.00 2.65 2,904.00 1.016.00 .90 3,937.00 10.98 SUB TOTALS 32,964.48 CARRIED FWD AMOUNT DUE -...-"'-"="- .00 'I I , ~ . ~ .... ~.~'~~\, , , ' J" ( , HCR Manor Care ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care the Resident and the L~gal Representative, for the purpose of providing for the rights and resp;nsibiIities of the parties wtth respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center"), c,",," tlJ{'01ffL(!'~ t {!~. () '1' I Resident: . '--" /C~ . Legal Representative: ( /-rJC::7 Admission Date: C7 '-<I<:': 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 RESPONSrnll..ITIES OF THE RESIDENT 1.01 Room and Board Rate, For the basic services provided for in Section 3,01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment 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 (10th) 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 Ancillary 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 persqnal 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. Ancillary 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 (10th) day of the month, ". -""'~. -."'- . . ~~, , , , , , . 1.03 Late Payments, Accounts not paid in full within thirty (30) days of billing shall be subJe~t 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 Independent 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 Programs, 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: ~edicare, ~edicaid 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 additional 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 sul:!h legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), 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 " .~, i, ,,j.''1,-~;',,i , " , . will bil! 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 Pay Resident. The Resident and/or 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 determined 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 determination 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 federal laws, 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 Legal Representative agree to provide the Center with notice within five (5) davs 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 coverage 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 Application 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 inS'llrance 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 Payment. 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, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medication~, and other care and services which may be delivered by the Center or its subcontractors. ThIS 3 . . '"~ ';'" ".; t~~'< , . . . . Agreement serves as a written notice that the Center has notified the Resident and/or Legal R7presentative 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. I,ll Personal Physician, 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 pharmacy 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. II. RIGHTS AND RESPONSmILITY OF THE LEGAL REPRESENTATIVE 2,01 LelJ:al Authority, 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 Payments 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 Lega~ 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 fails 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 covered by Medicaid which otherwise would have been covered had application been made III a timely and proper manner. 4 " - "-, '<""";r- ~~~'''!i.'-_",_ ( ., , . 2,05 Coooeration 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 Residen~ fwm 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 RESPONSIDILITIES 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 dischllrge 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 Information, The Resident and/or Legal Representative hereby consents to the release of his/her 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 5 1<' - . fI' , .-~...- ' < - ~. ~" L -.it. lIf?_i ", . ~ . reviews or payment audits performed by such; the personnel of any hospital or other health care ~acility or pr~vider to whom or whic~ the Resident may be transferred; the Center's liability Insurance carner; and any person authonzed 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 well-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 Photograph, 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 Admini~tration Appointment. See Attachment E, d, SNF Medicare Determination 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 6 .,- ". - ~. ., '~..~,- '.4l~i:J~iMIll~' '" . ," , . Authorization and any other related documents. See Attachment H-I 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 certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property, See Attachment I (Center Supplement), m, The Resident Handbook. See Attachment 1. n. ResidentlPatient Rights. See Attachment K. 0, MedicareIMedicaid 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 HeR 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 hisfher medical treatment. See Attachment M-l and M-2. q, Privacy Act Notification, See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 r" '. " ,.. .~ ~-,-,., -,. " s, ASM Form, See attachment p, 1. Consent to Photograph 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. Discharge 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 seven (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 Atlmission 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 8 "';."''';;''';''' , . .' .. , ; . , ~" ~Jii;' . '", . . , of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents, 4.08 Changes 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, THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: X Wif/cdbfN~ Signature of Legal Representative, signing on his/her own behalf: Date: /~:)9-()O I Date: Center Representative: 0 fl~ {z) on1 tL; ()~ IMJ1 Date: I - 9- <5. tJ D .1 9 ~;JjM@~~~~;'llfi;l;;-1'!i~..mit)ji0t;i!"-Ji'i:,~~~"yq,li21;~~i1,illi',-i,::i';;;h.~"~"{d,'_,:,,'g"'9.~hiU'l<,o\'1X;,;'e~i~~'''''''' ". - 11kil>llJkll/ilil;;im~_~ ."~".,..".l._ -n ~ .. ...) . ~- y/, ~ - );:J 0 ~ 'i ~J ~ ..... (i' ._,. ~ & I -d F f- -6s. ~ ~o o "'l D () v1 R1' 1 . :',:j -< ,,~ ~ l!IImW,j . ," -,,/(;) .~ I " CJ =) .::::-\ ~; ::< 01 . ..~~~:;i , ... SHERIFF'S RETURN - REGULAR CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS GILBERT RUTH M 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 GILBERT RUTH M the DEFENDANT , at 1003:00 HOURS, on the 4th day of June , 2001 at 940 WALNUT BOTTOM RD CARLISLE, PA 17013 by handing to RUTH M GILBERT 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: 18.00 3.10 .00 10.00 .00 31. 10 r~~ R. Thomas Kline Sworn and Subscribed to before 06/14/2001 WOLFSON & ASSOCIATES ~ By: ~ f/!r #ato Deputy Sheriff me this .) 7 'e. day of Q- ~~ Q~thon~ ,A~ A.D. ~- ."'~ ."b~~'--" ........- fiJ .-....~.>>*.ill~i\' '. SHERIFF'S RETURN - U.S. CERTIFIED MAIL CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND HCR MANOR CARE VS. GILBERT RUTH M ET AL R. Thomas Kline , Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law served the within named DEFENDANT ,HAYWOOD GAIL E by United States Certified Mail postage prepaid, on the 31st day of May ,2001 at 0000:00 HOURS, at 916 CORA ST JOLIET, IL 60435 , a true and attested copy of the attached COMPLAINT & NOTICE Together with The returned receipt card was signed by GAIL E HAYWARD 06/07/2001 on Additional Comments: Docketing Certified Mail Affidavit Surcharge 6.00 5.68 .00 10.00 .00 21. 68 So _~w~-;s: d ~~ / R. Thomas Kline Sheriff of Cumberland County Sheriff's Costs: Paid by WOLFSON & ASSOCIATES on 06/14/2001 . Sw?rn an~ subscri~ed to before th~s :l.'i day of Sf'~' .,)"V/ A.D. Q~'L 0 7'h,.,/(.- A ~~ P 0 honotary I me '. . 0-' -'''''''''''>>:: .. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS GILBERT RUTH M ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: GILBERT JOHN E but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of LANCASTER County, Pennsylvania, to serve the within COMPLAINT & NOTICE 14th , 2001 , this office was in receipt of the On June attached return from LANCASTER Sheriff's Costs: Pocketing Out of County Surcharge Pep Lancaster Co 6.00 9.00 10.00 42.92 .00 67.92 06/14/2001 WOLFSON & ASSOCIATES ~~~ R. Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this .< ~ IE' day of ~ .lw( A.D. ,91- P~t~t; ~ft --..-:--'----=-+--------'------ -~--_._---- -~.---_._----~~----~ ~---- Complete items 1, 2, and 3. Also complete - item 4-:;f Restricted Delivery is desired. . Print your name and address on the reverse so that we can return the card to you_ . Attach this card to the back of the mailpiece, or on the front if space permits. 1> Article Addressed to: Gail E. Hayward 916 Cora St. Joliet, IL 60435 2. Article Number (Copy from service Jabel) 7099 3220 0009 1574 4422 PS Form 3811, July 1 eee $. Service Type XXKcertified Mail o Registered o Insured Mail 4. Restricted Delivery? (Extra Fee) DYes ()I~ 3;nc c,,;i 102595-C(l-M-0952 Domestic ~turn Receipt -,f; SHERIFF'S OFFICE 50 NORTH DUKE STREET, P,Q. BOX 83480, LANCASTER, PENNSYLVANIA 17808-3480 . (717) 299-8200 ~:, PLEASE TYPE DO NOT DElACH ANY COPIES. 2_ COURT NUMBER 2001-3280 civil 4, TYPE OF WRIT OR COMPLAINT: & Canplaint SHERIFF SERVICE PROCESS RECEIPT, and AFFIDAVIT OF RETURN L PLAINTIFF/SI Her Manor Care 3. DEFENDANT/Sf Ruth M. Gilbert etal S;E {,.cc~~~:~:~I:E~~:~~:::::::,~~::~:_;:::::E:,P Code) AT ,,,}l'[7HJ.911 St,EIJ.Zabetht?"ih '~Pll.17022 j 7. INDICATE UNUSUAL SERVICE: "DEPUTIZE 0 OTHER ""~:;:::~1 ;:lnrl Now, :>/.31 20U1. I, SHERIFF OF~_....:..Bl'ER COUNTY. PA., do he eb eputlze the~' of Lan~Rst@.r County to execute this W ' etu re d~, to law, This deputation being made at the request and risk of the piaintiff." 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: CUmberland ,- " c- '- G' , u_ i.~_ CUMBERLAND CO NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N,D. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching allY property under withio writ may ieave same without a watchman, in custody of whomever is found in possession, after notifying person of levy orattachment, without liability on the part of such deputy or the sheriff to any plaintiff herein for any loss, destruction or removal of any such property before sheriff's sale thereot 9. SIGNATURE of ATTORNEY or other ORIGINATOR 10. TELEPHONE NUMBER 111. DATE DANIEL F WOLFSON ESQ (717) 846-1252 5/31/01 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW; (ThIS area must be completed if notice is to be mailed) CUMBERLAND CO SHERIFF LAW OFFICE OF WOLFSON & ASSOC SPACE BELOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS LINE 13.lacknowledgereceiPtofthewrit} NAME of Authorized LeSO Deputy or Clerk 14. Date Received 15. Expiration/Hearing date oreompl.;"!..;"d;e.'.d."ov" ANNETTE WALTON 717-295-3609 6/4/01 6/28/01 16. I hereby CERTIFY and REtURN lhat ~ave personally served, 0 have legal evidence of service as shown in "Remarks", 0 have executed as shown in "Remarks", the writ or complaintdesc~n the individual, company. corporation, etc" atthe address shown above or on the individual, company, cor- poration, etc.. at the address inserted below by handing a TRUE and ATTESTED COPY thereof. 20. Address of where served (complete only if different than shown above) (Street orRFD,Apartment No" City, Bora, Twp. State and ZIP Code) 17.01 hereby certify and relurn a NOT FOUND because I am unable to locate the individual, company. corporation, etc,. named above. (See remarks below) 18. Name and title of individual served (if not shown above) (Relationship to Defendant) 19. ONoService See Remarks Below (No. SO) 21. Date of Service 22. Time <.t \'%~ \ -" '\L" \..) ~ eJ-7) ....... PM .......... ED$T 23, ATTEMPTS Dep. Int. R \15317 100.00 30. REMARKS: 30.50 COST DUE OR REFUND ;; -c::B Cg~-373 (.(! orl'o I S.T.A.: 37, '-" ~ SHERIFF OF.J,Mll;A.STER,CDUNTY AC i I N~ ~H1t:rUt'r 1. WHITE - Issuing Authority 2. PINK" Attorney 3. CANARY" Sheriifs Office 4. BLUE % Sheriifs Offjce P,\~. II ~", < Ci-\\-', '=11 ,~" I: :~ ~ ,-- , r <-:r--.. ~:.--#'. ", ,'" ~, .! I -----'~-~.._'-~,="~,,"'.,""'"'=''"',~..~,.,'"=, _."!-_-1' . "'" , - ;-----.~~ ~--o-"""""""" SHE R I F,Fc'S---O F Fie E 50 NORTH DUKE STREEl:~ P,O,'BOX 8;"'" NC~EA,-PENNSYLVANIA 17!ld8,3480 . (717) 299-8200'" PLEASE TYPE DO NOT DETACH ANY GO~IE$. r ~ "--" .. ,t~ 't. . , t SHERIFF SERVICE PROCESS RECEIPT, and AFFIDAVIT OF RET . ..-. ..-. - ~~ - 1, PLAINTIFF/St Hcr Man= Care , ,. 2. COURT NUMBER 20Ql-3280 civil" 4 TYPE OF WBlT.oR COMPlA1NT :'r:~~~,""!"~ & Canplaint m"n"" "'n~~",*" 3 DEFENDANTtSt Ruth M. GIU,ertetaL \.... ,- .... -."-"' .- .~. ..~ ..-. - SERVE' { 5 NAME OF INDIVIDUAl. COMPANV,-cDRPORATJON ETC.. 0 BE SERVED _ ...... John E. Gilbert ___nn _ n / _n - n - r ..". 6 ADDRESS (Street or RFQ:APartment-No, criY:.soro, Twp, State and ifp COde)~ AT -::l1'Hiah St. s'lizabethtown:-PA 17022 ..' '7.INDICA1"EUNUSUAL SERVICE~ ~ Dl:PtlTlZiiJ o~r'HE#--- :-=--' P":" ;"~~~~~~n";.~~~ ,,- Now, ':)1_1J. '. 20U..!..:..-\, I, SHE81FF OP"E/!.1<l~fE:R_ OQl.INTy, PA., do hereby deputize the Sheriff of . . Lan~?~tP-r n:._ _ _._ ___.; .J:-.- -;"?- .CC)l,Jn~Y, to execu~e: this.Wri.t ~qd mflke.return.therepf accprc;ting to'law, _Illis dep,utation being made at the request and risk of the plaintiff, - ..... ......_SHERIfF.~~~COUNTY b. SPECIAl~ tNSTRUCTIO~S OR 'OntER INFORMATIONO THAT ~WILL ASSIST IN'-Ex~eiiIT'iN.G SERVICE: .. _ _ _ -c lber .land ,~_l~, .~--~. '- 1'- . '\ , c~~ ;;: H '" ('l -~ >3 Gl H r;; !H >3 " CUMBtRJ:,AND CO _ .. ... ... .. . ,/",'-_n_--l_c'!{:;D"-.,_ NOTE ONLY-APPLICABLE ON WRIT OF EXECUTION: N.8. WAIVER OF WATCHMAN - Any deputy shenff levying upon or attachil:'l9~a.,y property -uc:\der within writ ~ leave same without a watchman, In custody of whomever is found In possession, afternotifyinQperson 01 levy or attachment. wlthoutllability on the part o-'-~_uctl deputy or the sheriff to any plaintiff here,in for ar:'!X l~ss, .de.struc:tio,n C?~..re.m!=lval_~l_~ny. s_l;l.<?.h P!~l?~_rty .9~fClr~_ sh.eriff:::;; 8,a_le_ tll~reof.' , ,~ _ ~9. SIGNATURE of A,TTORNEY Of other ORIGINATOR 10. TELEPHONE NUMBER 11. DATE DANI~ F WOLFSON ESQ ,."., ., _ (717) ~6:;)252 5/31/01 "!..2. SEND NOTIC~ OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed). ~~" . CUMBERI.AND CO SHERIFF J:,AW OFFICE OF WOLFSON & ASSOC , ,f" nSP~Ce:BELOW "OR USE OF SHERIFF ONLY DO NQTWRI OW THIS LINE 13.1 a'ckno-wledge receipt of the wrill NAME of Authortzed LCSO Deputy or Clerk 14. Date Received 15. Expiration/Hearing date orcomPlaintas~rdicatedabove. f ANNETT~ W}!LTq!f 717-.f~5:".~.~O~ ''- 6/4/01 6/28/01 16. -, here-by CEfhIFY. and RETURN that~ h;~e pers~nl'!Hy served, 0 have' IJg-al eV!denJe of service as shown in '~Aemarksn, O.~ve ~~ecuted as shown in . . ..:Rema(ksn, the wntor complalntdes~on the In_dlVJdual. compa~y, corporation. etc., at the address shown above or on the indiVIdual, company, cor~ poration-;-etc., at the address inserted below by handing a TRUE and ATTESTED COPY thereof. p' -.. - ~,,~_. ~-,-.....,.,.--_. -~ 17. OJ her@y cer1lfy~and return a NOT FOUND bec'.l.~s~ L~I11.unabre to.105~~te: ~_f!.e.J,"!djvi?u,ar~ cOf]1P.any, corpC?~.ation, atc-"..~named above., (See remarks ~e.lowt", 18. Name and title of individual served (if not shown_ above) (Aela1ionship to Defendant) 19 .y r" o No ServIce See Aemarlcs Below (No. 30) 21. Date .of Service <..t \~tO\ 22. Time '3 ~J d-5 ~ -~ EaST ;30. Address_of where served (complete only if different than shown abovel (Str_eetor8FD.Apartment No_, City,Bpro, Twp. State aria'Zip Code) ._ 23. ATTEMPTS Mile. ~ Oop.lnt. 24. Advance Co_sts R " .. :31/ 100.00 30, flEMAflKS, . _....,~"";"',.l.;....._ S.T.A... >-,/ _ :It'''' ''''~'7;",~. F,," .>>>''''"'"-~....., ....... ~-~~ . "..~. " ,,--. -:: '';:';'-'' ~ COST DUE OR REFUND ;)- ~ Cg~3/3 , ".,'... &:<(/,OJ < 30~ 50 . ,:.\" "-~ "- " . ... ........ 31. AFrtRM~b ~anq subscribed to beforeume This ;; '~.=-( . , 3.4.dayb .r: .~ -1 . A . n~ SO ANSWER. =:s. 3.2. SliInature Oep. Sheflff 4. Bll.lE--; Sl1enff's QfflC_B -. . ''''\.fIU U 3{ ,0''6 {6 i 'cs 36'\Dale \ \ >,~1'~ -..D' _.....,i' , 37, ; PrOlhonota y/D.e.p.uly sSio./l EX~IRES., -",:.. f '<-; SHER .OJl;,Loll .,. ~. ,...;.. - 1. WHITE" Issuing- Authority:.. 2. PINK' . Attorney 3. CAf:1J:it~. Sh'erifrs otii~ """"' <t.:~~.~~ . ..,.- ~ ,;;,j- .-, , "" ~-~i.' -,-, ~-" ,~,"-'~ ~- - -~'.~!/, HCR MANOR CARE, Plaintiff vs. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 01-3280 CIVIL TERM . . RUTH M. GILBERT, GAIL E. HAYWOOD and JOHN E. GILBERT Jointly and severally Defendants CIVIL ACTION - LAW . . PRELIMINARY OBJECTIONS TO COMPLAINT AND NOW, comes Defendant John E. Gilbert in the above captioned action, by and through his attorney Herschel Lock, Eequire, pursuant to Pa. R. Civ. P. 1028, and files the within p~eliminary Objection to Plaintiff's Complaint, rep~esenting as follows: I. PRELIMINARY OBJECTION IN THE NATURE OF A DEMURRER FOR FAILURE TO SET FORTH A CAUSE OF ACTION AGAINST DEFENDANT JOHN E. GILBERT 1. Plaintiff, a health care provider, has pled that since January 29, 2000, through the date of the filing of its Complaint it provided Defendant Ruth M. Gilbert, a resident at one of its facilities, with residential health care service and treatment (Paragraph 6 of Plaintiff's Complaint attached hereto and marked ae Exhibit "A"). 2. Paragraph 4 of Plaintiff's Complaint names John E. Gilbert as a Defendant in this action and Paragraph 5 thereof states "...that the invoices for his mother Defendant Ruth were forwarded to the home of Defendant John for payment of same." , '.- - ,~"" '" . .~. ~- -. ; '- - - " -"'<"""""0, 3. As an Exhibit to its Complaint, Plaintiff attached the Admission Agreement between itself and Defendant Ruth Marie Gilbert (See Complaint's Exhibit B attached hereto). 4. Paragraphs 1.07 and 1.10 of said Admission Agreement, these entitled "Private Pay Resident" and "Primary Responsibility for payment" respectively, deal with the issue of payment to Plaintiff for services it provided Defendant Ruth M. Gilbert, indicating that Defendant Ruth M. Gilbert is primarily responsible for the payment for those services which are not covered by other party insurance. 5. Paragraph 2.02 of said Admission Agreement, this entitled "Agreement to Make Payments on Behalf of Resident", states that a legal representative of resident Defendant Ruth M. Gilbert, this being Defendant Gail E. Haywood, "...agrees to promptly pay from resident's income and 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 and resources ..." The Admission Agreement has on its last page the signatures of both Defendant Ruth Marie Gilbert and her legal representative Gail E. Haywood. 6. At no place on the Admission Agreement or any other document provided by Plaintiff in its Complaint is there shown the signature of Defendant John E. Gilbert. 7. Plaintiff's Complaint fails to plead any duty on the part of Defendant John E. Gilbert for payment for services " " " ~ - , '" '. . " ~. ~ L~""t,w",o Plaintiff provided to Defendant Ruth M. Gilbert and, instead, seemingly bases Plaintiff's assertions that he is responsible therefor solely because it mailed her bills to him. WHEREFORE, it is requested that this Court grant the Demurrer and dismiss the Complaint against Defendant John E. Gilbert for failure to allege a cause of action against him upon which relief may be granted. DATED: b/2P/01 , ' ResP~~fullY submitted, ~Jd( HERSCHEL LOCK, ESQUIRE 3107 N. Front Street Harrisburg, PA 17110 (717) 238-6661 Counsel for Defendant Supreme Court ID No. 22691 ^ '"_~;b'~=n.. "'.'-,' [-0;:, --'k. ' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. vs. CIVIL ACTION - LAW RUTH M. GILBERT, GAIL E. HAYWOOD and JOHN E. GILBERT Jointly and Severally, Defendants COMPLAINT AND NOW, this~ day of j1,1o U ,2001, comes the Plaintiff, .' ) HCR Manor Care, by and through its attorney, 'Daniel 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 (hereinafter referred to as "Plaintiff'), is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17315. 2. Defendant, Ruth M. Gilbert, hereinafter referred to as "Defendant Ruth"), is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013 2. Defendant, Gail E. Haywood, (hereinafter referred to as "Defendant Gail"), is an adult individual with a last known address of 916 Cora Street, Joliet, Illinois 60435. 2 Exhibit A I --',~c" ~"~ '~, ! ' II t, I I , I , ill . ~~ - ~ "' -I-<. 'iw'-l- ~" ~,', .-,:. . ,._c', ,,_ c - < ' ; " , I , I ! - --~ -- -----_._~_..~.~,,----> That Defendant Gail represented to be Legal Representative and/or Responsible Party for Ruth M. Gilbert. Defendant Gail is the daughter of Ruth M. -, -,:;,!)tC" 3. Gilbert. 4. Defendant, John E. Gilbert} (hereinafter referred to as "Defendant John")} is an adult individual with a last known address of 517 High Street} Elizabethtown, Lancaster County, Pennsylvania 17022. 5. That the invoices for Defendant Ruth were forwarded to the home of Defendant John for payment of same. 6. That on or about January 29, 2000, through the present, Ruth M. Gilbert was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto} incorporated herein and collectively marked as Exhibit "A". 7. That on or about January 29, 2000, Defendant Gail} as Ruth M. Gilbert's Power of Attorney} executed an Admission Agreement which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and collectively marked as Exhibit "8". 8. That Plaintiff submitted to Defendants a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously identified as Exhibit "A" and incorporated herein by reference. 3 Ii. " _.!.. '.~' - ,u--~-,-, '-~-~ilfgj- 9. That Defendant s did not object to the above mentioned Statement ~; -.----- Account submitted by Plaintiff to Defendants. 10. As of May 2, 2001, the balance due, owing and unpaid on Ruth M. Gilbert's account as a result of said charges is the sum of Fifty-Four Thousand Two Hundred Thirty-Six and 42/100 Dollars ($54,236.42). See Exhibit "A" previously identified and incorporated herein. 11. Despite Plaintiff's reasonable and repeated demands for payment, 'r': Defendants have fai/ed, refused and continue to refuse to pay all sums due and owing on Defendant Ruth's account balance, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant Gail, as Legal Representative and/or Responsible Party, for Ruth M. Gilbert, demanding that the sums due and owing to Plaintiff be paid, and Defendant Gail, as Legal Representative and/or , , Responsible Party for Ruth M. Gilbert, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Ruth.. 13. Plaintiff has made numerous requests to Defendant John, as a Responsible Party and as the person to whom all of Defendant Ruth's bills were sent, demanding that the sums due and owing to Plaintiff be paid, and Defendant John, as a Responsible Party of Defendant Ruth, has ignored his obligation to pay necessary and appropriate bills and obligations for his mother, Defendant Ruth. 14. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "R" previously 4 ._~" ~~---"".~-.,;';',.-",,-.",~.".O~~c... L- C _ "~_~'. '. ~_,'~ id entmed andlncorporaied. herein. 1 5. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance is the sum ofTwelve Thousand Two Hundred Fifty- One and 50/100 Dollars ($12,251.50). 16. Plaintiff has retained the services of the law firm of Wolfson & Associates, P.c., in the collection of the amounts due from Defendants. t 7. Pursuant to Section 1, Paragraph t .03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney's fees and all court costs if the account is referred to an attorney for collection. See Exhibit "B" previously identified and incorporated herein. t 8. 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 Defendants. 19. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Sixteen Thousand Two Hundred Seventy-One and 29/100 Dollars ($16,271.29). 20. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 5 >, .~ II r I I il I " I i ;j \~ . ~ ."" __, Co, _' _n'''' ,~, .~ "" __, .~, _ , _'c~."." "'~'~~'~=-i'.<~;"~""".:.\1-:",'M,,,~J-':$,,-:C'<'$"'> ~",'" '_,,', .,.rlc ,.?'." ,_"_,,," , 2 1 . The amount in controversy exceeds the jurisdictional amount requiring --~ I compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gail E. Haywood and John E. Gilbert for Ruth M. Gilbert, jOintly and severally, in the amount of Fifty-Four Thousand Two Hundred Thirty-Six and 42/100 Dollars ($54,236.42), contractual interest in the amount of Twelve Thousand Two Hundred Fifty-One and 50/1 00 Dollars ($12,251.50), reasonable attorney's fees in the amount of Sixteen Thousand Two Hundred Seventy-One and 29/100 Dollars ($ 16,271.29), the costs ofthis action and such other relief as the Court deems proper and just. Respectfully Submitted, ff'/, Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff I ! i ! i , I, I , I ! 6 PAGE I c ..J.,., I 3 I I i I I I I , "J.4"..,,41,..,';L lL~l.._~"",-~"~_,,,,_.:J~ j".., .4/.","" " 1 el' I, ~. MANORCARe CAR~X~~C 372 940 WALNUT BOTTOM ROAD CARLISLE, PA ~7C~3 (717)-249-0085 LJlIo! PRIVATE JOHN GILBERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA ROOM 100 -A 17022 Please Return Tnis Portion With Your Payment ! I I GILBERT, RUTH r~20013 05/07/00 02/28/01 i ----------------------------------------------------------------------1 dE OF SERVICE RENDERED CHARGES CREDITS '''/ICE FWD FRO ~1 PRECEDING STMT 32,964.48 .00 31/00 ADJ REC R & B ]30 4,123.00 30/00 ADJ REC NON LEGErW 10.78 30/00 ADJ REC R & B 30 3,990.00 31/00 ADJ REC LEGEND 550.24 31/00 ADJ REC NON LEGEND 139.74 31/00 ADJ REC R & B 31 4,123.00 30/00 ADJ REC LEG EtW 159.68 30/00 ADJ REC NON LEGEND 9.50 30/00 ADJ REC WOUND TREATMEtn 48.00 30/00 ADJ REC R & B 30 3,990.00 31/00 ADJ REC R & B 31 4,123.00 31/01 ADJ CABLE RENTAL 5.00 PAYMENT DUE BY THE 10TH OF THE MONTH 54.1,236.42 AMOUNT DUE "'~ i ! I I I i, I , , i I I ! ,. .. - ., .'., " . . . ... ' . '.. . ",,- ,i{::'illt,Di'~:'i~1;~'.::::i~&f~'~r1~~:irtt'~1~"{;";~"~':;::~::"j~;~~'m'~';'O:"~':;':i'i!~Jit'-'i'~\'''~'r~';,"""'~:'~"gii~h1:"~t~';!;l" "'-';m!~ ""r~~'~'i~,~i.'>Ii"I~_\'" .,,;.<>:, ,'. ''-. ")!~..,....,....)ir<,:. __.,'.:f~..., .,.,- ...",NOHCAR.e: C....JltI..:l:SI..-t:: :2172 -~: - 940 WALNUT eOTTO~ ROAD CARLISLE. PA ~7013 (7~7)-249-0085 JOHtl GILBERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA /01/01 /01/01 11100 /01/01 11100 /01/01 11100 /01/01 11100 /01/01 11100 /28/01 11600 /13/01 29001 /05/01 30001 /28/01 51501 /07/01 11100 /15/01 11100 101-02/28/01 /01.--,03/31/01 17022 BALANCE FOR"JARO BEAUTY S~DP WASH 1/18 BEAUTY SHOP WASH 1/25 BEAUTY ANO BARBER BEAUTY W & S 1/4 BEAUTY W & S 1/11 CAB l ERE rn A l PHARMACY LEGEr~D PHARMACY NON LEGEND WOUND TREATMENT BEAUTY AND BARBER BEAUTY AND BARBER ROOM CHARGE ADV ROOt1 CHARGE ( OTY ( OTY ( OTY ( OTY ( OTY ( QTY ( OTY ( OTY ( OTY ( OTY ( DTY SUB TOTAlS "',","'-" Please Return This Portion With Your Payment 1 1 1 ::. ) ) ) ) ) ) ) 1 1 1 55 1 1 8,004.50 9.00 9.00 9.00 9.00 9.00 5.00 293.17 10.00 448.00 9.\H\ 9.00 4,123.00 4,123.00 17,069.67 AMOUNT DUE e'..... ~ ~ , .. ... ~ '". . , ,', ~ i i I I ,. GILBERT, RUTH t1 20013 05/07/00 02/28/01 I ----------------------------------------------------------------------1 ~~Ig~ CODE SERVICE RENDERED I CHARGES I CREDITS I I i I r I I I I I I I I I I , .00 ! I CARRIED F,"D i I I I I , ! [ I 1 ! PRIVATE ROOt1 100 -A ~ "-'.MtrN:'il(\'~lh--d;':" "~'.." '. ,"".'" ' , , , "'j"" ~~, ,~..., :-- ,._, '.........."-"...;:"11 ti;'i)(F~';""""':""';:'1r"~';';:i;"""~"';;"':'''-'.k-''u..''', ^'.~_Jl..."~",-,;.o,, '_""';~"W-i."'..,"". .,:. ."-,,..., ,;.",..-, MANO~CARE CAR~%SLE ~72 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 PAGE 2 -. -,.,.,..", "" ';.. -, .,", ~ ^" ~". ~~ ~'" ", . ''''~'''''''''~'';';'..<;:;;::&:...:.,;..:.:,;;.,..:.- f . I I I I I I I I I I I I I I I .~!~~~~~~3~!~_~___________________~~~~~___~~L~~(~~____------~3i~~~~~___1 I I .00 I I , I I , I I I I , I I I i ! PRIVATE JOHN GILBERT FOR RUTH GILBERT 517 HIGH STREET ELIZABETHTOWN, PA .\TE O~ :::RVICE /31/00 ,/31/00 /31/00 /31/00 /31/00 /31/00 /31/00 /30/00 /30/00 /30/00 /31/00 /31/00 /31/00 ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ ADJ FWD REG REC REG REG REC REC REG REG REG REG REG REG REG ROOM 100 -A 17022 PJe~$e Return This Portion With Your Payment SERVICE RENDERED CHARGES CREDITS FROM PREGEDHW LEGErfD' NON LEGENO ~,JOUND TREAH1ENT R [, B 6 R & B 25 NON LEGEtW R & B 25 DAYS NON LEGEND R & B 22 R [, B 8 NON LEGEND R [, B 31 NON LEGEND STMT 17,069.57 124.94 7.95 <;64.00 798.00 3,325.00 3.39 3,300.00 2.65 2,904.00 1,016.00 .90 3,937.00 10.98 SUB TOTALS 32,964.48 .00 CARRIED FWD AMOUNT DUE ~ ' >- , -'II l.\;'~I:Y'~~~~"~J"'-~:~~ii~',e.0M~'~~'{~~{";;~S~~l'~~e'~;$.;"~u.,;"o~-'-~f~;'),W':"~'~'~~~'~Jk;'''4<~f(~r~;;};:'~;:/<Q'.i1}:",-i,j:;i~c",:!~;.,'-.;;lS-;':h";)ikS'<i 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: in{u,/UrL(:C~ 0./ {!&~Jz. () v1-'-o- I, Resident: ,,,' JC~ \ Legal Representative: ( J-d<) ~ Admission Date: 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 RESPONSffiILITIES OF THE RESIDENT 1.01 Room and Board Rate, For the basic services provided for in Section 3,01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment 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 (lOIh) 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, Ancillary 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 (IOIh) day of the month, "'. ,_I '-~\ -"""-/,,,-, 0.' :, "k1~1 >, >'",e, """'""'",'i",,,, ".' ',.",,', ;C,",,'. '.' .."", " ,'.. ,..,"" . ',,, .,'.' ,. 1 03 '~;" '''' ': -"',,"'-' ':,.,-, : . L.2te Pa......ment:s. A.ccounts Clot p",-.c:I In I"-'11 __":.hin t.h.1r""1:y (30) c:l~yS ~r bU/r:~ .i.<, subJe~t to a seD/Ice charge equal to the highest legal rate of interest permitted by Stat~l-:;h~' s~~ fo~h ,m Attachment A on the. past due balance each month until such time as the balance due is paId m 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 ~ . ~I < ':i . I. o~ In?ependent Provi?ers, The Resident shall be directly responsible to independent prOVIders, mcludmg but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program, I: I. 'R- I. 05 Governmental Programs, 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: hedicare, hedicaid 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 additional 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 suclh legal action as necessary, including requesting a court to order such payment. ~~ , 1 I;' I i f: 1.06 Third Partv Pavors and Managed Care Orllanizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), 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 k' i f' , 2 l~,'" ;~~ -,,:,- ---1Y~ -'"~-__;;.,, "'" __ ~_, ___c_" "~ .~,:,;~~:..;,,>-..:. ' vvill-bill the Resident':S; third party payor as a service but th'; R. "d . c'> .'- .C",-'_" ,C,_ not paid ~r covered by that third party payor inc1~ding char;:~ ~~~ r;;d'~;;;i~'-;' r~;a~~~;bi~ penod ofhme, ~~~" 1.07 P:ivate Pav ~esident. The Resident and/or Legal Representative acknowledge that they are respon.slble f~r pa~mg the Ce?ter for items and services provided during the stay at the Center and dunng whIch tIme the ReSident has not been determined 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 determination 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 federal laws, , 1-: 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 Legal Representative agree to provide the Center with notice within five (5) davs 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 coverage 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. I 1.09 Application 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 in5urance 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. 1.1 0 Primary Responsibility for Pavment. 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 Leoal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or ma~aged care provider may not pay for non-covered services, supplies,. equipment, medication~, and other care and services which may be delivered by the Center or Its subcontractors. ThiS 3 J,., , ,~ -,.: - ;''::'' . ."~,,,_.., WI '~;.~~~~~ii:r\~(4~~+;.fji~i'1~i;~;i.\{j;k,;;:~>1It~~-:'~':i~~;'i..,~~:i.:...'.:;",;~c"i;~'~;;C.~"^i~':;;,,,,,'/'~' .". " "' "~ .", _.. , ~.__.~ Agreement ser'o'es as a v.rrjtten notice that the Center- has notified the Resident and/or Legal Reptesentative that services provided at the Center may not be covered by a governmental payor, third party pa~or 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 Physician, 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 shaIl 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 Pharmacv, The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy 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, II. RIGHTS AND RESPONSIDILITY OF THE LEGAL REPRESENTATIVE 2,01 Legal Authority. 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 fails 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 al~ ch.arges and fees ,not covered by Medicaid which otherwise would have been covered had applIcatIOn been made In a timely and proper manner. 4 ----- - - -- -- -- -- - -- - - -- - ,~.J",-_ '~" 'J J. "'" i~ -.~.=,.';i-~L~:~'::;":'c;.', '~'~;_~O:5 '-';-'~~::a;~;::~~~~~~~~ji~~:'~:~~::~i~~:::J!~~~1:~?)~~;h~;-,'4-~; ',. '!';1b;~' , Legal Rep~esentalive sh~I1 provide .such information abo~t the R-esident's finances as Medicaid representatIve shall.reqUlre for continued coverage of the Resident and be personally responsible for any charges dented the Center due to any lack of cooperation, ;r 2,06 Acceptance U(lon 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, :] 1 l I( ~ ~, q, 2,07 Additional Responsibilities, The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments, , ~- ~ III. RIGHTS AND RESPONSIBILITIES 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 dischilrge 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 Information, The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following pe~sons:. 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 quahty assurance 5 , ~ ~ - --- ,~ )i~~~i:""vifi.";;-~~~\'~;:H!~';-'fMt~j:'i:;'i;')ir),;:i:.:,t:;~,~,;,,;';.~::'.:;;;2S.M..~::1:~L:..:.;,;'~:O;:;'k~~lc~:~'?'~~ ii;;.,-ti,.',-, ;i:', it~' '-",{;~.1." 0 ',". '-'" '/ ,',,' ,:; , ',~ . ':.:.'" .:~., ~":-'",;;. -: ,,: , -,':' ," '., ' ".'" , . . ,. _4_,_,_"__~"_,~"__~,,-,_,,,,,,",,,_~""N__ J ';: revic::'\.Vs 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 weH-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 Photograph, 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 Admini~tration Appointment. See Attachment E, d, SNF Medicare Determination 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 6 "."j#""n_"- -, -~-"""""""'~~"" '- ~: ~ 'H~~2'~'h,-~ -'~;~-~ita*~~i'a'\'_'.'~~"'4,~;i~:;'i~;2~~1-,,'~~:,:p:;~~~~."-::>:,~;),.,,;,'!". "/{,, -- '" 'k" "'--" , "'&';;~1tt~lb-'"i*J;'*ft" '" "~ ,-," 1 ~ 5' ~.-.~~_.. ~ .. ....;~;t"~~;",dr,;',:'$;~~i;i~.i~~~,J,'tr;'ili..";.!i&\~ ' 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), 1. 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 certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property, See Attachment I (Center Supplement), m, The Resident Handbook. See Attachment J. n, ResidentlPatient Rights. See Attachment K. o. MedicarelMedicaid 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. .I p, Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HeR 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 his/her medical treatment. See Attachment M-l and M-2. q. Privacy Act Notification, See Attachment N. r. Inventory sheet and/or policy of personal items, See Attachment O. 7 . .~--,~~.....,...,-. s, ASM Form, See attachment p, "-,.'"'"-,-~---~..~,.~,-- t. Consent to Photo'):raph 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. Discharge 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 seven (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 Atlmission 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 8 """- - -Ji ................ ,..~".'.. eel I ,'-, '. "" '-,.',' _ '.' 0,,', _ "",,,,~,,~_,,~ " _'0, '" _ -:i~~~*;:r0:i~;~,~~t;"\'-i', iiii';~"j~~~(if.,~~,l:t,~i:,Pl;~i~>~;~\\;;..;,;:';<~\xt~:'::;i;';Jil~:~ii~~~i.~~i.i~0t~<~':;~:~:i": _,,;~;, ~:,L':,>..... ,:', -.-, ," '_, c, c, ,__, '" or any per-son or entity (including the Center), except in the caseol neg~igen';-e"otf'.t6e:-'-ceI'l.t:er's-- employees and agents, 4,08 Changes 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 remainina <> 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. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: ,>! yhjf, ~.. ~/A)~ Signature of Legal Representative, signing on his/her own behalf: Date: /~:J9-{)O I Date: Center Representative: o p~ tA)(nltL()~ 1M!'! Date: / - d- ).o() ,I 9 - ",J~ <1/&>-.;,<,-,_._'" ',--."-:--,,"-,' "-"",,, ~",,:;w.' ;,t1<,,-~~}:_:),_"~:-::_- . ~ L ,. 1. l' l{ i~ ~ " i, '3, ~ "",' '*'''-''~' ~ -..m, "'--. " OfI'J"1': ~'f "'f :L/WIIf1 CI)"":':~WJfr "130 228PN'OI '-.i <~', i , I~! <_< '- '_ PENiiS /L'r'I~NIA <, '_.~,;-"--.,, ...-rJI'".. 1 tiIf.;i";)'.d"",;"'."'~'~j" .,...i_l!Il~~~!lAiil~iwti-;~'l&.:krl<~":'hillJl;,jit;l~i~ S5 iC.p "" ~>'"," ^ '~,'v'_"".",~'~ ~'". '^...~.~ ..' -~..,~.~. t.., ~~rll"~ ~ ~ ~ - -"^,,' ~1llIt1 (') ~~i~ rr;i (; -7 _. 2: (i;, f~ ~.-;() )>\~ -/ =:) -- "'..1 (c I^,^ :~ ~. ~: 1^ -' -.') 1...:1 ;I\::~ -~''-'' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01.3280 vs. CIVIL ACTION - LAW RUTH M. GILBERT, GAIL E. HAYWOOD and JOHN E. GILBERT Jointly and Severally, Defendants PRAECIPE TO DISMISS COMPLAINT WITHOUT PREJUDICE III ill ij TO THE PROTHONOTARY: U Iii! p i ~ Please dismiss the above-captioned Complaint without prejudice. II Respectfully submitted, II ! 'Dated: July 17,2001 ~~.c Daniel F. Wolfson, Esquir WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff 11 ~ ~ ~.i"k.'\l!~"lI!!~in)~;t.;";,"Js;!,.""i;l~i:r"'~~.'o!~,*""iMN~"'~""ll ""l,""H','",ii",j,OA",,,",,,;i;I!:,~~'i'''",,;i''''''',",,b~~''~Imi)MiliMi>lll",''''l,i".W!,,~~~~~A hjL ill.. ~ ~",'"~~'"'~,~~, ~<, o o~H' '"~,# _. .,,""~~~ ",,",,.,,,,,,V, =," ",~, ~, ,~,"'.'--"'"- "-" -"" -.'. >, >- r~ "..' '.. !~D: (i:' ~c-~ ~~ ~.,.., -, ,_.' ..~=rC- .' .~ :~ .. tk,:&..ll.\llliltl- ,), 1'1' rii li' :I' Ii! :ii 1i: 'Ii I: 'Ii " Ii ji 'I: j: " " 'I, " '1: ':::) cc' II r