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Home My WebLink About01-03295 , ~ , "-~~ "~ " - ~ ' - .' J " ~ ,_,,', ' "ll~;;-i,' 't' .. ,. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, NO. 01-2:1.9$ (!1I.~i.C-r~ vs. CIVIL ACTION - LAW VIOLET M. TROUT, Individually, and G. FRANKLIN EICHELBERGER, Individually, and for VIOLET M. TROUT, 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 ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRIT AABAJO PARA A VERlGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249.3166 _-c, ' _'_';"'.__;'_i, k..L~~~'Y: . , , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, NO. 01- 3.2 95' ~-r~ vs. CIVIL ACTION - LAW VIOLET M. TROUT, Individually, and G. FRANKLIN EICHELBERGER, Individually, and for VIOLET M. TROUT, Defendants. . COMPLAINT AND NOW, this,;;)L( 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 17013. 2. Defendant Violet M. Trout, (hereinafter referred t oas "Defendant Violet"), is an adult individual with a last known address of940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, G. Franklin Eichelberger, (hereinafter referred to as "Defendant Frank"), is an adult individual with a last known address of 32 South ., "' ,. ~, ",', "[',1.",-,'- . '-~.Y"""'-",,~&i," , ' . , r Hanover Street, Carlisle, Cumberland County, Pennsylvania 17013. 4. That Defendant Frank represented himself to be Power of Attorney for Defendant Violet. Defendant is the nephew of Violet M. Trout. A true and correct copy of the General Power of Attorney whereby Violet M. Trout designated G. Franklin Eichelberger as her lawful Power of Attorney is attached hereto, incorporated herein, and collectively marked as Exhibit" A" . 5. That on or about May 28, 1999, through the present, Defendant Violet was a health care resident of Plaintiff, where she did receive and where she continues to 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 "B". 6. That on or about May 28, 1999, Defendant Frank, as Defendant Violet's Power of Attorney and Responsible Party, 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 "C". 7. That Paragraph four (4) ofthe Admission Agreement did describe the various responsibilities of Defendant, which responsibilities did include payment for the daily rate and charges for supplemental services, supplies not paid by any third party, 3 ~ '"~ "L, " h" ,'~--- 'l~IM't.t;I>'ii~,-' , ' t . , as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. See Exhibit "C". 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 "B" and incorporated herein by reference. 9. That Defendants did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 1 O. As of April 23, 2001, the balance due, owing and unpaid on Defendant Violet's account as a result of said charges is the sum of One Hundred One Thousand Five Hundred Sixty-Five and 77/1 00 Dollars ($101,565.77). See Exhibit "A". 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused, and continues to refuse to pay all sums due and owing on the outstanding account balance, which accrued due to residential health care services provided to Defendant Violet, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant Frank, as Power of Attorney and Responsible Party for Defendant Violet, demanding that the sums due and owing to Plaintiff be paid, and Defendant Frank, as Power of Attorney for Defendant Violet, has ignored his fiduciary obligation to pay necessary and appropriate bills and obligations for Defendant Violet. 4 1-"" ' .,"'"" ~ '~"~""'0"~",, . . . , , 1 3. That Defendant Frank has also been uncooperative in providing the necessary information to Plaintiff to assist Plaintiff in completing an application for Medical Assistance on behalf of Defendant Violet. 1 4. Pursuant to Paragraph eight (8) of the Fee Schedule which was attached to 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 tiC". 15. Plaintiff has retained the services of the law firm of Wolfson & Associates, P .c., in the collection of the amounts due from Defendants. 16. 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. 1 7. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Thirty Thousand Four Hundred Sixty-Nine and 73/100 Dollars ($30,469.73). 1 8. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 5 i . ',' ~ ""''''->-'~<i111<"",\" , . ~ 19. 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, Violet M. Trout, Individually and G. Franklin Eichelberger, Individually and for Violet M. Trout, in the amount of One Hundred One Thousand Five Hundred Sixty-Five and 77/100 Dollars ($101,565.77), reasonable attorney fees in the amount of Thirty Thousand Four Hundred Sixty-Nine and 73/100 Dollars ($30,469.73), 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 ,-" -,,'o'~ ~"~~"j."" . , . , , , EXHIBIT "A" /. .'. . .~._,-- '~ ,"~" GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, that I, VIOLET M. TROUT, of 304 Center Street, Frederick, Maryland 21701, do hereby constitute and appoint G. FRANKLIN EICHELBERGER, of 924 Alexander Spring Road, Carlisle, Pennsylvania 17013, my true and lawful general Attorney-In-Fact for me, and generally in my name, place and stead: 1. To enter upon and take possession of any land, buildings, tenements or other structures, or any part or parts th~reof, that may belong to me, or to the possession whereof I may be entitled. 2. To ask, coliect and receive any rents, profits, issues or income of any and all such lands, buildings, tenements or other structures, or of any part or parts thereof. 3. To make, execute and deliver any deeds, mortgages or leases, \ihether with or without covenants and warrantil1s, in respect of any such lands, buildings, tenements or other structures, or of any part or parts thereof, and to sell and manage any such lands and to manage, repair, alter, rebuild or reconstruct any buildings, houses or other structures, or any part or parts thereof, that may now or hereafter be erected upon any such lands. 4. To demand, sue for, collect, recover and receive any goods, claims, debts, monies, interest and demands;whatsoever now due or that may hereafter be due or belong to me (including the right to institute any action, suit or legal proceeding for the recovery of any land, buildings, tenements, or other structures, or any part or parts thereof, to the possession whereof I may be entitled), and to make, execute and deliver receipts, releases or other discharges therefor, under Seal, or otherwise. - .-1 I - '___",._..i,_ ~ ,J...., __ "-,,,,,,,'\.. I\i,~"""'-lf,""h 2 5. To make, execute, endorse, accept and deliver any and all bills of , exchange, checks, drafts, notes and trade acceptances; to execute any and all income tax returns, social Security applications and applications for pension and retirement benefits and disability benefits of every nature, and any and all other instruments, papers and documents as my Attorney-In-Fact shall deem necessary or appropriate; and to enter any safe deposit box in any bank and to withdraw therefrom any and all property therein contained belonging to me. 6. To pay all sums of money, at any time, or times, that may hereafter be owing by me upon ,any bill, account, or any bill of exchange, check, draft, note.or trade acceptance, made, executed, endorsed, accepted and delivered by me, or for me, in my name, by. my said Attorney-In-Fact. 7. To defend, settle, adjust, compound, submit to arbitration and compromise all actions, suits, accounts, reckonings, claims and demands, whatsoever, that now are, or hereafter shall be, pending between me and any person, firm or corporation, in such manner and in all respects as my Attorney-In-Fact shall think fit. 8. To hire accountants, attorneys-at-law, clerks, workmen and others and to remove them, and appoint others in their place and to pay and allow to the persons to be so employed such salaries, wages, or other remunerations, as my Attorney-In-Fact shall thini fit. 9. To enter into, make, sign, execute and deliver, acknowledge and perform any contract, agreement, writing, or thing that may, in the opinion of my Attorney-In-Fact be necessary or proper, to be entered into, made or signed, sealed, executed, delivered, acknowledged or performed: and especially should I suffer any illness or accident, physical or mental, requiring hospitalization or the use of a convalescent home should my present I """ ,. I. "_~~ b..ffii'~~:,.. 3 residential provisions be inadequate, then I do hereby empower my Attorney- In-Fact to make all arrangements necessary and proper, in his sole jUdgment, to place me in a hospital or convalescent home, executing the necessary agreements or contracts therefor, and to pay ali bills and expenses which might be incurred, all to the exclusion of any authority over my person or property by any other person or relative. 10. To buy, receive, lease, accept or otherwise acquire, and to sell, transfer, pledge, mortgage, hypothecate or 9therwise encumber or dispose of, any property whatsoever and wheresoever situate, be it real, personal, mixed , and/or intangible, upon such terms as my Attorney-In-Fact shall think proper; and, in general, to borrow o~ my behalf, any and all sums of money that my Attorney-In-Fact shall determine necessary or appropriate in connection with the management of my affairs. 11. To sell, contract to sell, deed, conveyor otherwise dispose of any and all real estate that I may own, wherever situate; including especially that real estate that I own located in the City of Frederick, Frederick county, Maryland, and being known as 304 Center street, Frederick, Maryland 21701, and in connection with these powers, specifically, I do hereby grant unto my Attorney-In-Fact the right and power to sign, seal, execute, acknowledge and deliver any and a,l instruments in writing of any kind and nature, as may be necessary or convenient, containing such terms and conditions as my Attorney-In-Fact may deem advisable, to completely and effectually complete final settlement under any contract of sale which my Attorney-In-Fact shall deem appropriate for the sale of any and all of my real estate, and my Attorney-In-Fact in connection with any such sale shall have the right to receive full proceeds coming to me as a result of said ",., ~ ~ I -.1 "_"a I.. ,-~ -, Jill-c~_~"-",~,,. " , , 4 sale, without the necessity of the purchaser or settlement officer to see to the disposition of the settlement proceeds or the proceeds of any such sale. 12. Under the terms hereof, I do specifically grant unto mY.Attorney- In-Fact the power to borrow on my behalf any and all sums of money that my Attorney-In-Fact shall deem necessary and/or appropriate; and in connection therewith, I do hereby specifically grant unto my Attorney-In-Fact the power to collateralize any such loan with any and all of my property of whatever nature and description and wherever situate. . Additionally, I do specifically grant unto my Attorney-In-Fact the power to purchase in any amount that my Attorney-In-Fact shall deem appropriate, United States Treasury bonds, bills, notes or other obligations, ~edeemable at par, in payment of any and all Federal Estate taxes that might arise upon my death, with such United States Treasury obligations being more popularly known as "Flower Bonds". 13. Intending: to grant unto my Attorney-In-Fact full power of substitution, I do hereby grant unto my Attorney-In-Fact the power to constitute ami appoint, in his place and stead, as his substitute, one attorney, or more, for him, with full power of revocation vested in my Attorney-In-Fact. 14. Without, in anywise, limiting the aforegoing, I do grant unto my Attorney-In-Fact the power general~y to do, execute and perform any other act, deed, matter or thing, whatsoever, as fully and effectually as I could do, if personally present; and it is my intention and purpose in executing this Power of Attorney to grant unto my Attorney-In-Fact the complete power and authority to bind me in any manner or form by any written and/or oral act or deed as fully and completely as I myself could do if I were personally present and acting. I '<, "-' ~ "'"'~-" " ~- ;: !.iiI,~""#,,,,* 5 15. This General Power of Attorney shall not be affected by my , disability, and I request that no guardianship proceeding for my property be commenced in the event of my disability; but in the event any court appoints a guardian for my person and property, I direct that my Attorney-In-Fact, G. Frankl in Eichelberger, or his appointed substitute or substitutes, shall serve as guardian, without bond. l6. This General Power of Attorney shall not be construed by any court of law or by any other entity or person as a grant unto my Attorney-In-Fact of a general power ?f appointment, and in the use of this General Power of Attorney my Attorney-In-Fact is prohibited from dealing with any of my property for less than valuap'le consideration. And I, the said Violet M. Trout, do hereby ratify and confirm all whatsoever my said Attorney-In-Fact, or his substitute or substitutes, shall do, or cause to be done, in, or about the premises, by virtue of this General Power of Attorney. IN WITNESS WHEREOF, I have hereunto set my hand and seal, in the County t7):J day of ~-1'1?~ , 1992. of Frederick, State of Maryland, on this WITNESS: ~ uJ~~ ~~ -ft;, d.-~n~L) "'Violet ~I. Trout 1 _. , 'f " EXHIBIT "B// . '"""'"""'"'~= ''''''j'': ,','. ;[;-"'~f}~N. , > """''''M _~._- . , . .~=- ~ I L " ' HCR-ManorCare Statement MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)--249-0085 FRANK EICHEL8ERGER fOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE. PA 17013 .J..... ~ ~......~ ,_"="_ ,,__ _'-' ' >~=ml",i > , PRIVATE ROOt1 165 -A ,/ Please Return This Portion With Your Payment (, , . T\Rf~iH.> VIOLET 98139 06/29/99 I DATE OF I ~. I SERVICE COPE SERVICE RENDERED ~1/01/01 NCE FORWARD 01/12/01 30009 PHARMACY NONLEGEND (QTY 1) 01/21/01 61501 WOUND TREATMENT (QTY 11) 01/31/01 51801 TOTAL INCONT-DLY FEE (QTY 31) 01/31/01 53101 NUBASIC JUICE BERRY 163 (QTY 124 ) 01/31/01 5 iO"2 01 NT R T N L / E N T R L S E R V G R P 3 (QXY 93) 01/09(,,!1 2900~~H~RMACYtLEGEND (QTY, J.) 02/01~02'/28It0'i( I'iDoit Rbd.M CH'ARGE"It..Z8,r'D'AYS.'AT. 1-38;'-00'" -===r- . CHARGES I 86,866.13 13.83 88.00 93.00 163.68 372.00 101.62 ,,-! 3,864.00 PAYMENT DUE BY THE 10TH OF THE MONTH i / AMOUNT DUE 01/31/01 CREDITS 91,562.2' -'-, / / .' /- ,/' -'~"- ~~"'" - " ) HCR-ManorCare MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 \ \ \ , FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE, PA 17013 " Statement ", "'~ '_ L _" ~, -'''-;'''W~'''''~'''''''' ~ PRIVATE ROOM 165 -A Please Return This Portion With Your ~ayment _____!~~~~~_~~O~5!_____________________~~~~~___~~[~~(9y___________~3L~~~~~ DATE OF SERVICE 02/01/01 02/01/01 02/01/01 02/01/01 02/01/01 02/01/01 02/06/01 02/05/01 02/28/01 0,2/28/01 0'2/28/01 02/23/01 02/05/01 02/13/01 SERVICE RENDERED BALANCE FORWARD 11100 BEAUTY W & S 1/16 11100 BEAUTY PERM 1/23 11100 BEAUTY W & S 1/30 11100 BEAUTY '~J & S 1/02 11100 BEAUTY W & S 1/09 29001 PHARMACY LEGEND 51501 WOUND TREATMENT 51801 TOTAL INCONT-DLY FEE 53101 NUBASIC JUICE BERRY 163 53201 NTRTNL/ENTRL SERV GRP 3 30001 PHARMACY NON LEGEND 11100 BEAUTY AND BARBER 11100 BEAUTY AND BARBER SUB TOTALS ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY 1 ) 1 ) 1 ) 1 ) 1 ) 1 ) 8 ) 28 ) 112 ) 84 ) 1 ) 1 ) 1 ) CHARGES CREDITS 91,562.26 9.00 36.00 9.00 9.00 9.00 107.91 64.00 84.00 147.84 336.00 10.87 9.00 9.00 92,402.88 . 0 CARRIED F~.. AMOUNT DUE ,;-,- .i i" ,. /.. HCR.ManorCare MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE. PA 17013 ~~. Statement .....~~ -" ~.--. 't ' !/>-.~>t~ri'~. . PRIVATE ROOM 165 -A Please Return This Portion With Your ~ayment 5 ) 31 ) 124 ) 93 ) 1 ) 1 ) 1 ) 1 ) 1 ) 138.00 138.00 ._ _ _ __ ~R_O_U_T.: _ ~~~~E_T_ _ _ ___ _ __ _ _ _ _ _ _ _ _ _ _ _ _y~~~~ _ _ h0_6!'l'!!.~~ _ _ _ _ _ _ _ __ __0.3J_3}: l~~_ SERVICE RENDERED BALANCE FORWARD L.JOUND TREATMENT TOTAL INCONT-DLY FEE NUBASIC JUICE BERRY 163 NTRTNL/ENTRL SERV GRP 3 PHARMACY NON LEGEND BEAUTY AND BARBER BEAUTY AND BARBER BEAUTY AND BARBER BEAUTY AND BARBER REV LAST MO RC ROOr.1 CHARGE ADV ROOM CHARGE CORRECT R&B FOR 31 30 2/01 DAYS AT DAYS AT DATE OF SERVICE 03/01/01 03/05/01 51501 03/31/01 51801 0:i/31/01 53101 03/31/01 53201 03/23/01 30001 03/07/01 11100 03/13/01 11100 03/20/01 11100 03/27/01 11100 03/01/01 03/01-03/31/01 04/01-04/30/01 02/28/01 ADJ SUB TOTALS ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY , CHARGES CREDITS 96,811.38 40.00 93.00 163.68 372.00 13.71 9.00 9.00 9.00 9.00 4,123.( 4,278.00 4,140.00 4,123. ( 105,947.77 8,246.( CARRIED Fl. AMOUNT DUE "n_", . ."~. ~- - ... ~~~ '--!W! - "'ir~~flI>.~f'11#':,; lJ ), . HCR-ManorCare Statement .. j MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 PAGE 2 PRIVATE FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE. PA 17013 Roor.1 165 -A Please Return This Portion With Your Payment TROUT, VIOLET 98139 06/29/99 03/31/01 ------------------------------------------------------------------------- I DATE OF I SERVICE SERVICE RENDERED CHARGES CREDITS 02/28/01 FWD FROM PRECEDING STMT ADJ CORRECT R&8 FOR 2/01 105,947.77 3.864.00 8.246.0( PAYMENT DUE UPON RECEIPT 101,565.7i AMOUNT DUE ~,~- ~. - '. " , , fiJ""'-" EXHIBIT "e" ~~ . lol-""""~""::.-"e . . ~.~ ~ ~ ~, ~l_l_fQ" "~ -~~~.~-~ j';',iI m"""""j -iIili@;hfl!'...."".\>,<!o \, !...> ADMISSION AGREEMENT CONTRACT BETWEEN PATIENT/RESIDENT AND FACILITY tJ: ~ -... Manor<:are Health Services THIS ADMISSION AGREEMENT (the "Agreement") is entered into this t)8' C1..-JI . day of r:;,~ ,19 99 ,between mOn.O! ('0JU2. I-Iea N-A ~rft'~~6rlity"), and VI~E::_ Tro l.l-r (the "Patient/Resident"), and/or (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible Party, if any. The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. . b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the. health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's discharge. . 3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records or information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. MHc-ooe.20 (Rev. 7/96) pg 3 1 of 3 , .... < _-~"',L' ~".~ ~~.~ ~-"li:'" .- l".'~1ili'i!Jl- ~~"<',L.~.";':C>^,.'_ . L.... Conditions (collectively referred to as "Conditions") .. .. 1: The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by theFacility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated mo..y" 28- ,199 91 ,and which is attached hereto and made part of this Exhibit afr'd of the Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. 4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the' Patient/Resident's assets and/or assets which are available for the Pat- ient/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. 5. When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. 6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives. 7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges n9t covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above warranties and representations are not true, or if the abov ovenants and agreements are not complied with, the Facility will have detrimentally relied upon and the Facility will suffer financial harm and loss. MHc-ooa.20 (Rev. 4/96) pg 7 2 of 2 " -~ ~ =_ '~"M ~ - , ~ - I _" ~, '^ ~ L,. ~ ~-"~ 1_ 1Iilio'lh'lO!!:''''''''00'.!;'%' . > · Federal Resident Rights .. Resident Responsibilities . Life Sustaining Treatment Policy · Medical/Nursing Education . Dental, Vision and Hearing Services . Interdisciplinary Care Conference · Utilization Review Meetings (if applicable) . Personal Laundry Policy . Barber/Beauty Services - . . Mail Policy . Voting Materials . Photo/Media Events . Personal Fund Account Procedure . Tobacco Policy . Grievance Procedures . State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or .default of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day and year above written. ~ 7 0-'~~o/ ;:;Q~q/- Facility Representative - sfQnature Date MHc.ooe-20 (Rev.4/96) pg 5 3013 ,;,~.>,,,,,, ';"""~,c;,,,,,x,:O"';;'~M-i;'{;fu';~Iil.iIW!i;JW.dl.bli4~~~i~Jl;!~~""3..%i:c;~~1il!Il1I!il .. ~ T, mI." ': U 'UL L, - l...~lflmU ,U:Jj(t,~.""",,.__ J l, ~ ~,F-;<'~AC'",',~,',~ ~~.." lI!i1IIl!II1J . .. C) C"} l:' C -:, lJi (:J "& ~ i ~ C)i'--- - ~ -','r- "., D .:::... (j . f'::: ;.~ ,j 8 8 ~.,~ "- ~ .J "- c',i" II IV ',-. ':.-- -~ ...... /. , I "7 1J ........ ( f/J -""'1 r.- ~o -., CD -< ~ ~ ~ ~~ "~- IS'\) " - . j ."~. -~"""-""",,,,-"-' SHERIFF'S RETURN - REGULAR CASE NO: 2001-03295 P I COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS TROUT VIOLET 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 TROUT VIOLET M was served upon the , 2001 DEFENDANT , at 1011:00 HOURS, on the 4th day of June at 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 VIOLET TROUT by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 6.20 .00 10.00 .00 34.20 Sworn and Subscribed to before me this /3~ day of q'4:~ ~A~~", P othonotary , .- r I So Answers: ~~vt:~ R. Thomas Kline 07/06/2001 WOLFS::: & A?J:1!JS tfJ, Deputy Sheriff -'1"~= ~- - __1_. '._ 'U]-~-"~i". SHERIFF'S RETURN - NOT FOUND CASE NO: 2001-03295 P COMMONWEALTH OF PENNSYLVANIA , COUNTY OF CUMBERLAND HCR MANOR CARE VS TROUT VIOLET 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 inquiry for the within named defendant, DEFENDANT EICHELBERGER G FRANKLIN but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND , as to the within named DEFENDANT , EICHELBERGER G FRANKLIN UNABLE TO SERVE PRIOR TO EXPIRATION. Sheriff's Costs: Docketing Not Found Affidavit Surcharge 6.00 5.00 .00 10.00 .00 21.00 So an_~w~r . ~../.""". _ ~ ." ~" .' ~~ R.~ homas Kline Sheriff of Cumberland County WOLFSON & ASSOCIATES 07/06/2001 Sworn and subscribed to before me this -t;r:; /3- day of 0-1 c1u-vJ A. D. ~ (2 fvt-<.R),.. . ()~ Pro notary I ''f7 "iii "-~,~ ,~- .. ~v "~ ,~.t_ ~. 'I-k-a' ~t"('!l~~-_ " . , > IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, NO. Dl- ~:t.7'S c.-LU\,~L ~ vs. CIVIL ACTION. LAW VIOLET M. TROUT, Individually, and G. FRANKLIN EICHELBERGER, Individually, and for VIOLET M. TROUT, 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 .el1tered 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, GOTO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la corte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation. Used debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra used sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda. Used puede perder dinero 0 sus propiedades 0 otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TALSERVICIO VA Y A EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE ENCUENTRA ESCRITAABA]O PARA A VERIGUAR DONDE SEPUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service cumberla~dL~~:~~:~~oCiatiOn TRUE COPY FROM RECORD Carlisle, Pennsylvania 17013 If1J~imOIlyWl1f1fOOI. Il)8riHif'!tll Hi my hand (717) 249.3166 IlIfilf\M _llf ~ COOrtatCai1~. Pa. C T~OP~fi~'~ .. . . . .. Pml!lonOilll'y ,';-~"""".~"-~ . .~ ~~ 'Il~,~ , , '\ . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, NO. vs. CIVIL ACTION - LAW VIOLET M. TROUT, Individually, and G. FRANKLIN EICHELBERGER, Individually, and for VIOLET M. TROUT, Defendants. . COMPLAINT AND NOW, this ~ day of 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, aniel 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 17013. 2. Defendant Violet M. Trout, (hereinafter referred t oas "Defendant Violet"), is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, G. Franklin Eichelberger, (hereinafter referred to as "Defendant Frank"), is an adult individual with a last known address of 32 South ;.'" ~ ~ , l~ " ., , , t~jA; \. \ , Hanover Street, Carlisle, Cumberland County, Pennsylvania 17013. 4. That Defendant Frank represented himself to be Power of Attorney for Defendant Violet. Defendant is the nephew of Violet M. Trout. A true and correct copy of the General Power of Attorney whereby Violet M. Trout designated G. Franklin Eichelberger as her lawful Power of Attorney is attached hereto, incorporated herein, and collectively marked as Exhibit "A". 5. That on or about May 28, 1999, through the present, Defendant Violet was a health care resident of Plaintiff, where she did receive and where she continues to 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 "B". 6. That on or about May 28, 1999, Defendant Frank, as Defendant Violet's Power of Attorney and Responsible Party, 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 "C". 7. That Paragraph four (4) of the Admission Agreement did describe the various responsibilities of Defendant, which responsibilities did include payment for the daily rate and charges for supplemental services, supplies not paid by any third party, 3 ,,~-~ "", ~~ ,,1 ,i.~~;' . _ ',__ _ " ' ','f;;, \- 1 \ ) as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. See Exhibit" C", 8. That Plaintiff submitted to Defendants a copy ofthe itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously identified as Exhibit "B" and incorporated herein by reference. 9. That Defendants did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 1 O. As of April 23, 2001, the balance due, owing and unpaid on Defendant Violet's account as a result of said charges is the sum of One Hundred One Thousand Five Hundred Sixty-Five and 77/100 Dollars ($101,565.77). See Exhibit "A". 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused, and continues to refuse to pay all sums due and owing on the outstanding account balance, which accrued due to residential health care services provided to Defendant Violet, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant Frank, as Power of Attorney and Responsible Party for Defendant Violet, demanding that the sums due and owing to Plaintiff be paid, and Defendant Frank, as Power of Attorney for Defendant Violet, has ignored his fiduciary obligation to pay necessary and appropriate bills and obligations for Defendant Violet. 4 ,'~""'''-~''. . . .. L~,~" ,< L- .~ 'R J~iilllr~,?' \, , , 13. That Defendant Frank has also been uncooperative in providing the necessary information to Plaintiff to assist Plaintiff in completing an application for Medical Assistance on behalf of Defendant Violet. 14. Pursuant to Paragraph eight (8) of the Fee Schedule which was attached to 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 "C". 15. Plaintiff has retained the services of the law firm of Wolfson & Associates, P.c., in the collection ofthe amounts due from Defendants. 16. 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. 17. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Thirty Thousand Four Hundred Sixty-Nine and 731100 Dollars ($30,469.73). 1 8. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 5 ^,{..... , . =-~~~,~ .~ - i ~'. ,"~ , ", ,""'t:, \ l '1 l 1 9. 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, Violet M. Trout, Individually and G. Franklin Eichelberger, Individually and for Violet M. Trout, in the amount of One Hundred One Thousand Five Hundred Sixty-Five and 77/100 Dollars ($101,565.77), reasonable attorney fees in the amount ofThirty Thousand Four Hundred SiJtty-Nine and 73/1 00 Dollars ($30,469.73), 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 ., i _. -' . _ "- _~. l' ~'[it':' \-) . , , EXHIBIT 1/ A" l' .- ~=- ~ -.- d -'0. _, ~l - ~ - ~l i;., \ , , . GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, that I, VIOLET M. TROUT, of 304 Center Street, Frederick, Maryland 21701, do hereby constitute and appoint G. FRANKLIN EICHELBERGER, of 924 Alexander Spring Road, Carlisle, Pennsylvania 17013, my true and lawful general Attorney-In-Fact for me, and generally in my name, place and stead: l. To enter upon and take possession of any land, buildings, tenements or other structures, or any part or parts th~reof, that may belong to me, or to the possession whereof I may be entitled. 2. To ask, coliect and receive any rents, profits, issues or income of any and all such lands, buildings, tenements or other structures, or of any part or parts thereof. 3 . To make, execute and del i ver any deeds, mortgages or leases, \ihether with or without covenants and warrantil1s, in respect of any such lands, buildings, tenements or other structures, or of any part or parts thereof, and to sell and manage any such lands and to manage, repair, alter, rebuild or reconstruct any buildings, houses or other structures, or any part or parts thereof, that may now or hereafter be erected upon any such lands. 4. To demand, sue for, collect, recover and receive any goods, claims, debts, monies, interest and demands;whatsoever now due or that may hereafter be due or belong to me (including the right to institute any action, suit or legal proceeding for the recovery of any land, buildings, tenements, or other structures, or any part or parts thereof, to the possession whereof I may be entitled), and to make, execute and deliver receipts, releases or other discharges therefor, under Seal, or otherwise. I. ,..J ~~ _l""" =-,1,.,.;-, '" '1."""""~-' i \ . y . , 2 5. To make, execute, endorse, accept and deliver any and all bills of , exchange, checks, drafts, notes and trade acceptances; to execute any and all income tax returns, Social Security applications and applications for pension and retirement benefits and disability benefits of every nature, and any and all other instruments, papers and documents as my Attorney-In-Fact. shall deem necessary or appropriate; and to enter any safe deposit box in any bank and to withdraw therefrom any and all property therein contained belonging to me. 6. To pay all sums of money, at any time, or times, that may hereafter be owing by me upon ,any bill, account, or any bill of exchange, check, draft, note 'or trade acceptance, made, executed, endorsed, accepted and delivered by me, or for me, in my name, by my said Attorney-In-Fact. 7. To defend, settle, adjust, compound, submit to arbitration and compromise all actions, suits, accounts, reckonings, claims and demands, whatsoever, that now are, or hereafter shall be, pending between me and any person, firm or corporation, in such manner .and in all respects as my Attorney-In-Fact shall think fit. 8. To hire accountants, attorneys-at-law, clerks, workmen and others and to remove them, and appoint others in their place and to pay and allow to the persons to be so employed such salaries, wages, or other remunerations, as my Attorney-In-Fact shall thini fit. 9. To enter into, make; sign, execute and deliver, acknowledge and perform any contract, agreement, writing, or thing that may, in the opinion of my Attorney-In-Fact be necessary or proper, to be entered into, made or signed, sealed, executed, delivered, acknowledged or performed; and especially should I suffer any illness or accident, physical or mental, requiring hospitalization or the use of a convalescent home should my present I ~.-" ~ , -~ ~~: " , , , 3 reaidential provisions be inadequate, then I do hereby empower my Attorney- In-Fact to make all arrangements necessary and proper, in his sole jUdgment, to place me in a hospital or convalescent home, executing the necessary agreements or contracts therefor, and to pay ali bills and expenses which might be incurred, all to the exclusion of any authority over my person or property by any other person or relative. lO. To buy, receive, lease, accept or otherwise acquire, and to sell, transfer, pledge, mortgage, hypothecate or 9therwise encumber or dispose of, any property whatsoever and wheresoever situate, be it real, personal, mixed and/or intangible, ~pon such terms as my Attorney-In-Fact shall think proper; and, in general, to borrow on my behalf, any and all sums of money that my ., Attorney-In-Fact shall determine necessary or appropriate in connection with the management of my affairs. l1. To sell, contract to sell, deed, conveyor otherwise dispose of any and all real estate that I may own, wherever situate; including especially that real estate that I own located in the City of Frederick, Frederick County, Maryland, and being known as 304 Center street, Frederick, Maryland 21701, and in connection with these powers, specifically, I do hereby grant unto' my Attorney-In-Fact the right and power to sign, seal, execute, acknowledge and deliver any and a~l instruments in writing of any kind and nature, as may be necessary or convenient, containing such terms and conditions as my Attorney-In-Fact may deem advisable, to completely and effectually complete final settlement under any contract of sale which my Attorney-In-Fact shall deem appropriate for the sale of any and all of my real estate, and my Attorney-In-Fact in connection with any such sale shall have the right to receive full proceeds coming to me as a result of said '1 ,-, l-'-""""~-1.UIlli~'~";' , , 4 sale, without the necessity of the purchaser or settlement officer to see to the disposition of the settlement proceeds or the proceeds of any such sale. 12. Under the terms hereof, I do specifically grant unto my.Attorney- In-Fact the power to borrow on my beha.lf any and all sums of money that my Attorney-In-Fact shall deem necessary and/or appropriate; and in connection therewith, I do hereby specifically grant unto my Attorney-In~Fact the power to collateralize any such loan with any and all of my property of whatever nature and description and wherever situate. . Additionally, I do specifically grant unto my Attorney-In-Fact the power to purchase in any amount that my Attorney-In-Fact shall deem appropriate, united states Treasury bonds, bills, , notes or other obligations, r.edeemable at par, in payment of any and all Federal Estate taxes that might arise upon my death, with such United States Treasury obligations being more popularly known as "Flower Bonds". 13. Intendin9 to grant unto my Attorney-In-Fact full power of substitution, I do hereby grant unto my Attorney-In-Fact the power to constitute and appoint, in his place and stead, as his substitute, one attorney, or more, for him, with full power of revocation vested in my Attorney-In-Fact. l4. Without, in anywise, limiting the aforegoing, I do grant unto my Attorney-In-Fact the power general~y to do, execute and perform any other act, deed, matter or thing, whatsoever, as fully and effectually as I could do, if personally present; and it is my intention and purpose in executing this Power of Attorney to grant unto my Attorney-In-Fact the complete power and authority to bind me in any manner or form by any written and/or oral act or deed as fully and completely as I myself could do if I were personally present and acting. I. , - .'- ! "" , ._-~ ~ iji~l%' " , , 5 15. This General Power of Attorney shall not be affected by my , disability, and I request that no guardianship proceeding for my property be commenced in the event of my disability; but in the event any court appoints a guardian for my person and property, I direct that my Attorney-In-Fact, G. Franklin Eichelberger, or his appointed substitute or substitutes, shall serve as guardian, without bond. 16. This General Power of Attorney shall not be construed by any court of law or by any other entity or person as a grant unto my Attorney-In-Fact of a general power of appointment, and in the use of this General Power of Attor.ney my Attorney-In-Fact is prohibited from dealing with any of my property for less than valuab.le consideration. And I, the said Violet M. Trout, do hereby ratify and confirm all whatsoever my said Attorney-In-Fact, or his substitute or substitutes, shall do, or cause to be d~ne, in, or about the premises, by virtue of this General Power of Attorney. IN WITNESS WHEREOF, I have hereunto set my hand and seal, in the County t1{fJ. day of ~-1Jj~ , J.992. of Frederick, State of Maryland, on this WITNESS: ~w~ ~~ -in, ~L) ~Violet M. Trout - 'e, , - ~ "","' - ,- _-"",.l " . . EXHIBIT "B11 . .~- { li!:illLll<l-'; , , ' ii:m~~ ~ - I..., HCR-ManorCare Statement MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA. 17013 (717)-249-0085 FRANK EICHELBERGER fFOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE, PA 17013 I.. ~( ~'- -.~~,: . . PRIVATE Roor.1 165 -A ,/ Please Return This Portion With Your Payment I. T\R1~.u(T.' VIOLET .' . 98139 06/29/99 I ~~~~Ig~ I CODE I. SERVICE RENDERED ~1/01/01 ~ALANCE FORWARD 01/12/01 30009 PHARMACY NONLEGEND (QTY 1) 01/21/01 51501 WOUND TREATMENT (QTY 11) 11/31/01 51801 TOTAL INCONT-DLY FEE (QTY 31) 01/31/01 53101 NUBASIC JUICE BERRY 163 (QTY 124 ) 01/31/01 Sli201 NTRTNL/EtHRL SERV GRP 3 (o;ry 93) 01/09(,,=\1 2900~ PHi)RMACYtLEGEND (QTY .J) 02/01~02/28~t0-'i.IA'D~ Rbd.M CH~R(jE''''/(-28'''D<AYS.'tiT. '1-38;'"00',<,'-1. --I PAYMENT DUE BY THE 10TH OF THE MONTH , i I I B6,866.13 13.83 88.00 93.00 163.68 372.00 101.62 3,864.00 CHARGES AMOUNT DUE 01/31/01 CREDITS 91,S62.2' -"., i / / ~ - , - , ,J.. " , ~" ~-- .,-"~~kt,, ~," Statement HCR.ManorCare . . MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 ' \ PRIVATE FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE, PA 17013 ROOM 165 -A Please Return This Portion With Your ~ayment _ __ _ _.!.!'9~"!:,- _VJ_O~!! __ _ __ _ _ _ __u _ _ _ ___ __ _ _ ~~,=-3_9_ _ _ _ ~~L~9j_9Y_ _ _ __ ___ ___ ~?:g8)_0_1__ DATE OF SERVICE 02/01/01 02/01/01 11100 02/01/01 11100 02/01/01 11100 02/01/01 11100 02/01/01 11100 02/06/01 29001 02/05/01 51501 02/28/01 51801 0,2/28/01 53101 0'2/28/01 53201 02/23/01 30001 02/05/01 11100 02/13/01 11100 SERVICE RENDERED CHARGES CREDiTS 8ALANCE FORWARD BEAUTY W & S 1/16 BEAUTY PERM 1/23 BEAUTY W & S 1/30 BEAUTY '~J I< S 1/02 BEAUTY W & S 1/09 PHAR~1ACY LEGEND ~.OUND TREAHIENT TOTAL INCONT-DLY FEE NUBASIC JUICE BERRY 163 NTRTNL/ENTRL SERV GRP 3 PHARMACY NON LEGEND BEAUTY ANO 8ARBER BEAUTY AND BARBER 91,562.26 9.00 36.00 9.00 9.00 9.00 107.91 64.00 84.00 147.84 336.00 10.87 9.00 9.00 ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY 1 ) 1 ) 1 ) 1 ) 1 ) 1 ) 8 ) 28 ) 112 ) 84 ) 1 ) 1 ) 1 ) SUB TOTALS 92,402.88 . 0 CARRIED Fl. AMOUNT DUE / HCR.ManorCare . MANORCARE CARL!SLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE. PA 17013 " ~ ,. Statement ":,,- , . PRIVATE ROOM 165 -A Please Return This Portion With Your ~ayment _____~~~U!:_~:~~~~____________________!~~~~___}~j!~l~~___________~3jY!1~~_ DATE OF - SERVICE 03/01/01 03/05/01 51501 03/31/01 51801 03/31/01 53101 03/31/01 53201 03/23/01 30001 03/07/01 11100 03/13/01 11100 03/20/01 11100 03/27/01 11100 03/01/01 03/01-03/31/01 04/01-04/30/01 02/28/01 ADJ SERViCE RENDERED BALANCE FORWARD L~OUND TREAn1ENT TOTAL INCONT-DLY FEE NUBASIC JUICE BERRY 163 NTRTNL/ENTRL SERV GRP 3 PHARMACY NON LEGEND. BEAUTY AND BARBER 8EAUTY AND BARBER BEAUTY AND BARBER BEAUTY AND BARBER REV LAST MO RC ROOI.1 CHARGE ADV ROOM CHARGE CORRECT R&B FOR 31 30 2/01 SUB TOTALS ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY ( QTY DAYS AT DAYS AT , 5 ) 31 ) 124 ) 93 ) 1 ) 1 ) 1 ) 1 ) 1 ) 138.00 138.00 CHARGES 96,811.38 40.00 93.00 163.68 372.00 13.71 9.00 9.00 9.00 9.00 4,278.00 4,140.00 105,947.77 AMOur~T DUE CREDITS 4,123.( 4,123.( 8,246.( CARRIED Fl. '.."~"""ll_ ~ .. , -' ", ^ . , ~ii ' -fl~<-~k ;1k~~' HCR.ManorCare Statement , . MANOR CARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717) -249-0085 PAGE 2 PRIVATE FRANK EICHELBERGER FOR VIOLET TROUT 32 S. HANOVER ST. APT. 2 CARLISLE, PA 17013 Roor.1 165 -A Please Return This Portion With Your Payment . _ _ _ _~R_OY_T...' ~ ~~~~E_T_ _ _.. _ _ _ _ _ n.. _ ____.. _ _ _y~~~~ _ _ _ _0_6j~'}. i~~ _ ___ _ _ _ _ _ _ _0_3L3Y:l~~._ DATE OF SERVICE SERVICE RENDERED CHARGES CREDITS 02/28/01 FWD FROM PRECEDING STMT ADJ CORRECT R&B FOR 2/01 105,947.77 3,864.00 8,246.0( PAYMENT DUE UPON RECEIPT 101,565.7i AMOUNT DUE .~~ ~- , l->'~;, -.,<. :. " "~. . j~; . . . . . EXHIBIT "e" .J.ffil,~,.~~ ".~ , - " "..wJ L _. , L ," ~L '_0 - .' '~'~li!fJJ:-~~{fi>: tJ: ManoiGre Health Services ADMISSION AGREEMENT CONTRACT BETWEEN PATIENT/RESIDENT AND FACILITY THIS ADMISSION AGREEMENT (the "Agreement") is entered into this.;)8' c:v-. . day of ~o..;J 11,19 99 ,between mOnOr ('oJLQ. l-1eaNA 'tf}{"~..fp~6rlitY"),and v'/~ e_ _ r-O l.,~+- (the "Patient/Resident"), and/or (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible Party, if any. The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this .Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually . leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agre~ to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. .' b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's discharge. . 3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit 8, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records or information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. MHo-coe-.. (Rev.7/961 P9 3 1 of 3 .... ~ "~~~ . ~. ,--, -:...J.","" ' ~ - ,., ._ i~<- -.. ~,- ,... ~,:-,,~- Conditions (collectively referred to as "Conditions") I. '. .. , . 1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated "'1YIo...Ij, ;: 8- , 199 . 91 ,and which is attached hereto and made part of this Exhibit at1d of the Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. 4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the' Patient/Resident's assets and/or assets which are available for the Pat- ient/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. 5. When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. 6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives. 7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges n<;>t covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above warranties and representations are not true, or if the abov ovenants and agreements are not complied with, the Facility will have detrimentally relied upon and the Facility will suffer financial harm and loss. MHc-ooa-20 (Rev. 4/98) pg 7 2 of 2 -- ----,-~ .~~ < "' ...,- ,..,,;~' i,,-, ~" ---'. J~'_"'-_I ~:)'~4j '. Federal R~siden.t Rights . Resident Responsibilities '. Life Sustaining Treatment Policy · Medical/Nursing Education . Dental, Vision and Hearing Services · Interdisciplinary Care Conference · Utilization Review Meetings (if applicable) . Personal Laundry Policy · Barber/Beauty Services . Mail Policy · Voting Materials . Photo/Media Events · Personal Fund Account Procedure . Tobacco Policy · Grievance Procedures · State Resident Rights (if applicable) . . . 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or .default of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day and year above written. - 7.,u..tud ;;Q~q-- Facility Representative - s!9nature ,...., Date , MHC-008-20 (Rev.4/96) pg 5 3013 ~.~~~~ ~ ~.. ~ . - <"" -~ - ~, 'q~"~" ".-- > .- ~,- "~~.. ,", , .I~ " \\t\l\'~ \\r~ ~ ':'0,1.\ ,.,"1:.,\,.. <.,l,::t_ ":)...., ,('., ..: $\\ fJ'C\\\\.<'\' IV \ $,1."<';\ \, ~'I.'\~\ \ ,,: ..,. ',1\ . < ,--\ ,,- '\ ," \ -',j 1'''-\ ~ ~ :,;..:. ~.:;'\ .~.~ ,?~}" . to " . . . il!\ilffi~'W'li!oh_ .._ . _~"~, ll!'!?f_~~1m-\l~(. ~p,:: _o_~r"" _ ,,,,,..,,,,,,",,,1~~~f$'I'.lfflHilf'(iIi""'--m''''>''~'"'}''''''''''(!'o:''~1'''i'"",:;,_,,,_,CJ__''l'e-:;T-'''''i~~i'''4<!l~'''~F,~-jl'lif~n",,f'l~~~l'\1I~"V<<lf!l!~ ~ ~ ~. , '.---.,' ,-~-,~' ~', .' _, - ..c-, , lC-,; , ",,' , _ " ,.~~' ,',' '.~~,. ,,' i., .:"'Iif-:~ THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01.3295 Plaintiff vs. VIOLET M. TROUT, Individually, and G. FRANKLIN EICHELBERGER, Individually, and for VIOLET M. TROUT, Defendants. CIVIL ACTION - LAW PRAECIPE TO DISMISS COMPLAINT Please dismiss the above filed Complaint without prejudice in the above captioned matter. Respectfully submitted, WOLFSON & ASSOCIATES, P.c. Dated: '1 t~/a1 ~~ Daniel F. Wolfson, Esquire 267 East Market Street York, Pennsylvania 17403 717/846-1252 I.D.#20617 Attorney for Plaintiff '~__~!iWiidt>fi!H41'/i1/!;~$ilim'l_~"4Jj\mr.k';';-,;".'!":l!!l~2!~,~~:w~'__tt-~:_.iiil~*"'l ,,", ~-,",,;.... ~s-' {f) it,...U .. ~,~~ rn_ <p_ .,,~ .,,__" ". ~~ """'~..- " . .""'--' . ... ;-~, '.. t'...,) " .,~~< c::., Jill