HomeMy WebLinkAbout07-2333SHIPPENSBURG/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v. No. 2007- ~3 33 CIVIL TERM
CLARA R. JONES and
LAURA B. JONES,
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 are
served, by entering a written appearance personally or by an attorney and filing in writing with
the court, your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so, the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other claim
or relief requested by the plaintiff. You may lose money or property or other rights important to
you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
CLARA R. JONES and
LAURA B. JONES,
Defendants
No.2oo7- X333
COMPLAINT
CIVIL TERM
NOW, comes Shippensburg/South Hampton Manor Limited Partnership ("Shippensburg
Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within
Complaint and, in support thereof, sets forth the following:
Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Laura B. Jones, is an adult individual with a residence address of 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257.
3. Defendant, Clara R. Jones is an adult individual with a residence address of 345
East Queen Street, Chambersburg, Franklin County, Pennsylvania 17201.
4. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
5. On or about January 5, 2004, Clara R. Jones, sought to have Laura B. Jones
admitted to the Shippensburg Health facility.
6. On or about January 5, 2004, Clara R. Jones executed an Admission Agreement
on behalf of Laura B. Jones. A true and correct copy of the Admission Agreement is attached
hereto as Exhibit "A" and is incorporated.
7. Pursuant to the Admission Agreement, Laura B. Jones would be responsible to
pay any costs of care which were not covered by a third party payer.
8. On or about January 5, 2004, Laura B. Jones became a resident of the
Shippensburg Health facility and remains a resident to the date hereof.
9. In May, 2005, the Cumberland County Assistance Office determined that Laura B.
Jones was eligible for Medical Assistance and Laura B. Jones would be responsible to pay
Shippensburg Health a monthly private pay portion from her income.
10. As of February 12, 2007, Laura B. Jones owed Shippensburg Health the sum of
$2,500.01 for the costs of care provided by Shippensburg Health to her. A true and correct copy
of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is incorporated.
Moreover, the costs and resultant balance owed continue to accrue.
11. Demand has been made upon Laura B. Jones to pay the amount due.
12 Upon information and belief, since January 5, 2004, Clara R. Jones has been the
representative payee for Laura B. Jones and has been receiving social security benefits on behalf
of Laura B. Jones.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. LAURA B. JONES AND CLARA R. JONES
13. Plaintiff incorporates by reference paragraphs one through twelve as though set
forth at length.
14. Laura B. Jones has breached her obligation to pay for the costs of care as provided
by Shippensburg Health.
15. As a consequence of that breach, Shippensburg Health is owed the sum of
$2,500.01 to February 12, 2007 and the debt continues to accrue.
16. The accrued debt consists of the monthly private pay portion to be paid from the
social security benefits of Laura B. Jones. Clara R. Jones has failed to pay the private pay
portion from the benefits she has received from Laura B. Jones.
17. The Admission Agreement provides in relevant part as follows: "if you or your
representative do not pay the money you owe us and we hire a collection agency or attorney, you
agree to be liable for their fees and court costs."
18. The Admission Agreement provides for the recovery of a 5% penalty for late
payments.
WHEREFORE, Plaintiff requests judgment in its favor and against Laura B. Jones for the
sum of $2,500.01 plus interest, costs and expenses, late fees and any additional amount coming
due to the date of award and attorney fees and costs.
COUNT II-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. CLARA R. JONES
19. Plaintiff incorporates by reference paragraphs one through eighteen as though set
forth at length.
20. During the period of Laura B. Jones residence at the facility, Clara R. Jones has
been receiving social security benefits of Laura B. Jones.
21. The proper use of those funds would have been to pay the costs of care accruing
for the care of Laura B. Jones at Shippensburg Health.
22. At the time of receipt of those funds, Clara R. Jones knew that these funds should
be paid over to Shippensburg Health for the costs of Laura B. Jones care.
23. Clara R. Jones gave no consideration for the funds of Laura B. Jones she has
received.
24. Demand has been made upon Clara R. Jones to tender the funds of Laura B. Jones
to Shippensburg Health and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Clara R. Jones
requiring her to:
a) return the subject matter in specie;
b) pay over the value if Clara R. Jones has consumed the money in beneficial use;
c) pay its value if Clara R. Jones has disposed of the funds received; and
d) award costs, expenses and interest.
COUNT II-QUANTUM MERUIT
SHIPPENSBURG HEALTH v. LAURA B. JONES
25. Plaintiff incorporates by reference paragraphs one through twenty-four as though
set forth at length.
26. During the period of her residency at the facility, Laura B. Jones has enjoyed the
benefit of care and services provided to her by Shippensburg Health.
27. Laura B. Jones has failed and refused to pay for the costs of her care and services
provided by Shippensburg Health.
28. Laura B. Jones has been unjustly enriched by her use and enjoyment of the
services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Laura B. Jones for the
sum of $2,500.01 plus interest, costs and expenses, late fees and any additional amount coming
due to the date of award and attorney fees and costs.
Respectfully submitted,
' RIEN, BARI SCHE
?~
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/j ones-laura/complaint.pld
04/16/2007 02:16 7172495755 OES PAGE 09
VERIFICA~'ION
The stateno.en.ts in the foregoing Complaint are based upon infortxxati.on which lias been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have xead the statements; and to the extent that they are based upon information. which 1 have
given to my counsel, they are true and correct to the best of my knowledge, information and
belief- I understand that false statements hereir- are made subject to the penalties of 18 Pa~.C.S. §
4904 relati.x~g to unsworn falsifications tv authorities,
DATE: ~ I~ t'~
~1~
~~~
HEALTH CARE CENTER
121 Walnut Bottom Road (717) 530-8300
Shippensburg, Pennsylvania FAX (717) 530-8304
17257-9005 'TT'Y 1-800-654-5984
ADMISSION AGREEIVIENT
This Agreement is between Slrippensburg Health Care Center (the `'Facility" or "we" and)
i.~. ~. ~e.~~s ~ (the "Resident" or "you"} and, if you or the court have
desi;nated an individual to act on your behalf, or there is another individual to act on your
behalf, or operation of law, ~ ~a-~ES __ ("your representative"). A
checklist of the rights and responsibilities applicable to your representative is listed in E:chibit 1
and is incorporated into this Agreement.
Fayin~ for k taur Care
If you are applying to this facility as a private-pay resident, you must provide all financial
information requested by us. If we later find that the information you or your representative
provided was incomplete or inaccurate; we hill consider that as a breach of this Agreement
wluch gives us the right to pursue all legal remedies agairst you or your representative.
`~vh~ C'an Be Required to Pay for Your-Care
'Only you and your i::surer-can be required to pay for your care. No .other person, (i.e. a family
ntemb er, riend, neighbor, le~~rl representative or guardian} car. be required to pay f_~-oi:i their
o:vn li:n ati fir your care, although he or she may knotvinvy a.rd voluntarily agree to guarantee
payrr.4n_ for the cast of your care. We require the person responsible for making payments on
ti~our behalf to pay for your care under the terms of this contract in a timely manner.
:r you are a beneficiary of Medicare, Medicaid or any a~her third-party payment p1.ar,, your
rcprevcntative agrees to make all necessary payments from your funds. Your representative
could fzce a civil penalty for intentionally failing to pay required amounts from your funds and
could face a criminal penalty for abusing year funds.
Private Pav Residents
The items and services included in our daily rate is basic room, board and general nursing care as .
required by ~,~our medical condition. Payment for items and services that are included in the
daily ratti and is payable one month in advance and due on the first of each month. Items and
services included in your daily rate are listed in Exhibit 2.A.
You will be charged separately for additional itenns and services not included in our daily rates
such as special nursing carp, sl;ecial equipment, pharmacy charges, laboratory charges, medical
tran~p~~rtation gird additional services such as telephare expe~:se, dry cleaning, beauty and barber
se:vices and newspapers. Items and services for wliicli ~.~o~i wili be charged are listed in Exhibit
?.B. i=ayrnent for these additional items and services are due after you have requested them, and;
you have received and have beery billed for them. ~~'ithin 30 days of i•ecei~~irg an item or service,
EXHIBIT "A"
you have the right to ask us for an itemized financial statement that briefly but clearly describes
each item and the amount charged for it. You will be given an updated listing of services and
related charges, including any charges for services not covered under Medicare or by the
facilities basic per diem charges, annually on or about January I of each year.
Medicare Residents
We participate in the Medicare Program. Medicare may pay for some or all of your nursing
home care. For information on Medicare, see Exhibit 3. If you are eligible for Medicare, you
have the right to have claims for your nursing home care submitted to Medicare.
~~ Medicaid Residents
~ ,~'~~ We `participate in the Medicaid program. For information on Medicaid, see Exhibit 3. You are
not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If '
your private funds are used up during your stay here and you are eligible for Medicaid; we will
accept Medicaid payments although Medicaid may require you to pay some amount, in addition
to what Medicaid pays for your care. If you are planning on applying to Medical Assistance
later, you may want to find out now if your are "medically eligible" for nursing home payment
by Medicaid.
You are responsible for applying for and obtaining Medicaid benefits and we will assist you. We
may not charge, ask for, accept or receive any gift, money, donation or consideration other than
Medicaid reimbursement as a condition of your admission or continued stay here except that
Medicaid may require you to pay certain amounts from your private funds.
If you receive Medicaid, most of your nursing home charges such as room, board, and general
nursing care are covered. For a list of services covered by Medicaid, see Exhibit 4.A. The local
Board of Assistance will tell you whether you have to pay part of the charge for your care and, if
so, how much. Some of the items and services that we offer are not covered by Medicaid. If you
want any items or services, which are not covered by Medicaid, you or your representative will
have to pay for them. A list of the items and services not covered by Medicaid and the charges
for them are in Exhibit 4.B. Payment for items and services that are not covered by Medicaid is
due after you have requested them, and; have received and have been billed for them. Within 30
days of receiving the item or service, you have the right to ask us for an itemized statement that
briefly but clearly describes each item and the amount charged for it.
Increases in Charges acrd Fees
Any time we increase a fee or charge for item or service or add a new item or service, we will
provide you and your representative with 30 days advance written notice.
Penalties
We may not charge you interest if you pay your bill in time. Your payment is on time if it is
made within 45 days of the date the bill is post marked, or 30 days after the end of the billing
period, whichever is later. The penalty we charge is 5% of the amount due, calculated on a per
day basis.
If you or your representative do not pay the money you owe us and we hire a collection agency
or attorney, you agree to be liable for their fees and court costs. .
Private Duty Nurses Geriatric Aides
If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting
a person licensed and/or certified according to Pennsylvania laws and regulations. You are also
responsible for paying him or her and for letting us know that you have hired one. The person
you hire is not an employee or agent of the facility, but he or she must meet our standards and
follow our policies and procedures. Employees of the Facility may not serve as private duty
nurses or private duty geriatric aides.
Holding Your Bed if You Leave the Facility
If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows:
;.,~,
A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare
Program (and you are not covered under Medicaid), unless you notify us otherwise, we
will hold your bed for as long as you pay for it at the daily rate you are currently being
charged.
B. If Medicaid pays for part or all of your nursing home care and you need- to be
hospitalized, we will hold your bed for up to the maximum number of days required by
this state, currently 15 days. If you leave for any other reason, we will hold your bed for
up to the maximum number of days required by this state, currently 18 days. You have a
right to be readmitted to the facility to the first available appropriate bed. While we are
holding your bed, you are still required to pay the Facility any amount for which you are
liable as determined by the Medicaid Program.
C. If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph
B. However, if you are found to be ineligible for Medicaid, then you are required to pay
for the bed as a private pay resident as described in Paragraph A.
D. Other third-party payers may or may not have a bed hold policy. We will discuss this if it
applies to you.
Your Right to iylake Complaints and Suggest Changes in Policies and Services
As a nursing home resident, you have many rights according to State and Federal law. These are
described in detail in Exhibit 6, which is attached and is part of this Contract.
You may make complaints about your care in the Facility and you may also suggest changes in
the policies and services of the Facility. You will not be harassed or discriminated against for
making a complaint or suggesting a change in a policy or service. You may present your
complaints to facility, management company or to one of the following State agencies:
Larry D. Cottle, LNHA
Administrator
Shippensburg Health Care Center
121 Walnut Bottom Road
Shippensburg, PA 17257
717-530-8300
Ombudsman
Office of Aging
16 West High Street
Carlisle, PA 17013
717-240-6110
717-532-7286 Ext. 6110
Peter E. Perini, Sr.
President
Magnolia Management, Inc.
1710 Underpass Way
Hagerstown, MD 21740
301-745-8700
Department of Health
100 North Cameron Street
2°d Floor
Hamsburg, PA 17101
717-783-3790
Your Right to Make Decisions
You have the right to make your own medical decisions and to manage your personal affairs. If
you become disabled, it may be necessary for someone else to make decisions for you. For this
reason, we recommend that you have a living will and/or advance directive for medical decisions
and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a
description of your legal rights to decide about your future medical treatment.
Transfer. Relocation and Discharge
You have the right to remain here, and you may not be transferred, relocated or discharged
against your will, except for the following reasons: (1) A medical reason (i.e. the facility cannot
provide the kind of care that you need, your condition has improved so that you no longer need
the care we provide, or a medical emergency arises; (2) Your welfare or the welfare of other
residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate.
If we decide that you should be transferred or discharged, we will notify you, and an immediate
family member or legal representative, by letter 30 days in advance. If you are transferred
because of an emergency situation, we will provide the required notice as soon as practicable.
The letter will contain the reasons for the transfer or discharge and its effective date. The letter
will also tell you how you can appeal our decision to transfer or discharge you.
If you are discharged involuntarily, we will attempt to make other appropriate arrangements for
your care. However, if other arrangements are not available, your representative agrees to accept
you into his or her custody if it is medically appropriate.
Your Right to End This Contract
If you decide to end this Contract and leave the Facility, you must pay your bill before you leave.
You must give us five (5) days written notice to terminate this contract. If you leave before the
end of that time, you must still pay for each day of the required notice.
In the event you die while a resident of the facility, your representative is responsible for making
the funeral arrangements. We will notify your representative immediately. If we.are unable to
reach your representative, we will contact the funeral home of your choice to facilitate
arcangements.
Additional Documents
It is not possible to cover everything that is important to your stay in our Facility in the body of
this Contract. Therefore, we have included additional important documents as Exhibits. These
Exhibits are part of this Contract. Please verify that you received the Exhibits and that the
contents of the Exhibits were explained to you by placing your initials on the line next to the
description of each Exhibit.
~~ Exhibit 1. Rights and Obligations of Representatives.
Exhibit 2. For Private Pay Residents:
(a) Items and services covered by daily rate. .
(b) Items and services not covered by daily rate.
Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits.
e--I~.J Exhibit 4. (a) Items and Services Covered by Medicaid.
(c) Items and Services Not Covered by Medicaid.
Exhibit 5. Physicians Who Practice at the Facility.
Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment.
~S Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your
Personal Property.
~~ Exhibit 8. Services Provided by Outside Health Care Providers.
Changes in Law
Any provision of this Contract 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 Contract. If there are
services we have agreed to provide that are later found to be impossible to render as a result of a
change in State or Federal law, it is agreed that to the extent possible, the Resident and the
Facility will continue to fulfill our respective obligations under this Contract consistent with the
law.
IN WITNESS WHEREOF, the parties have executed this Contract on this ~ day of
-~ ~Mi ~ ~+.-1 2ooN
By: ~ ~ G%~c-a~~,
Witness Larry D. Cottle, Administrator
Shippensburg Health Care Center
Witness
Resident
If the Resident has been adjudicated disabled or the Resident's doctor determines that the
Resident is incapable of understanding or exercising his or her rights and responsibilities, the
Facility may require the signature of another person on this contract. The other person may be:
(I) An appointed healthcare agent under an advance d' medical care; (2) A guardian or
Power of Atto~ey o~the ~ rson; (3) A surrogate family member.
~.
Responsible Party (Name)
3
Title: Indicate whether you are (I), (2) or (3)
~5~ti~
i ~,p
~~~ Va A~~ ~ A'If~~ D J~ to W 06ZK- .
AUTHORIZATION TO
RECEIVE SERVICES AND/OR SUPPLIES
AND TO
RELEASE INFORMATION REGARDING BENEFITS
Name ofBeneficiary: I,~~~~- g J~aes
Medicare Number: Zoo 3 n o~L~ g b
I hereby authorize Shippensburg Health Care Center to have the facility physician and whomever
he may designate as his assistant or on-call physician to act as my physician. These duties may
include, but are not limited to, prescribing medications, treatments, rehabilitation therapies, lab .
procedures, x-rays, medical procedures, and/or referrals to other physicians. ,
I certify the information given by me in applying for payment under Title XVIII of the Social
Security Act is correct. I authorize any holder of medical or other information about me to
release to the Health Care Financing Administration and its agents any information needed to
determine benefits for related services and/or durable medical supplies. I request that payment
of authorized Medicare benefits be made on my behalf to Shippensburg Health Care Center for
any services and/or durable medical supplies furnished me by or in Shippensburg Health Care
Center.
I hereby authorize and give permission to Shippensburg Health Care Center to release to my
insurance carrier or its agents any medical information needed to determine benefits payable for
related services and/or durable medical supplies furnished me by or in Shippensburg Health Care
Center.
I understand that I am responsible for any health insurance deductibles and coinsurance not paid
my Medicare, my insurance carrier, or any state Medical Assistance Program.
/ ~S I o ~~I
Signature of Beneficiary or horized Representative Date
r
r
E~~TTS
TABLE OF CONTENTS
Ezhibit 1 - Rights and Obligations of Representatives.
Exhibit 2 - For Private Pay Residents:
A. Items and Services Covered by Daily Rate
B. Items and Services Not Covered by Daily Rate.
Ezhibit 3 - How to Apply For and Use Medicare and Medicaid Benefits.
Exhibit 4 - A. Items and Services Covered by Medicaid.
C. Items and Services Not Covered by Medicaid.
Exhibit 5 - Physicians Who Practice at the Facility. .
Exhibit 6 - Legal Rights of Pennsylvanian's to Decide About Future Medical
Treatment.
Ezhibit 7 - Policies and Procedures Concerning Your Personal Funds and
Your Personal Property.
Exhibit 8 - Services Provided by Outside Health Caze Providers.
EI~TT 1
RIGHTS AND OBLIGATIONS OF REPRESENTATIVE
. ~ -The Representative shall ~ have the right to be notified by the Facility of .any ~ event or. ocaurenee
• :1 ~~ • ~ involving the Resident; ~wluch'directly affects 'any ~ obligations of the~Representative•.under this
• ~ ° Agreement: ~~ ~: y_ Representative agrees to~ ~ assume •~ independently, •• under= ~ thin +Agreement; the
. following:-obligations and••is entitled to thefollowing. rights;~.as~ indicated-~by^Representative's
initials accompanying any of the following provisions:
• • ~ Representative agrees to be' responsible for ensuring. that: any:•payirientrfiroti~~th~'res~dent to•
. which the Facility is entitled pursuant°to this Agreement shall•:be~.paidrto~~the.~seility:ina
timely manner. In the' event the Resident is a beneficiary of Medicare,lVledicaid or any other
third-party payment plan, Representative agrees to ensure that all co-payments, co-insurance
or charges and fees for non-covered items and services, together with any late fees as
.described-under this Agreement,. shall be paid from the Resident's funds... Representative is
' ~ - subject to•a~civilpenalty~forwillful°violation•of•the•°agreement~to~~distribute••the•Resident's
funds to the facility.
• (Unless ~ the Representative voluntarily agrees to act as guarantor), Representative shall be
• • • -responsible for: any payments ~ required under 'this -Agreement only ~ to >the =extent • of the
Resident's funds.
•.. Resident is applying. for admission on private pay. basis, and _.Representative~ agrees to. assist
the Resident in ~ providing all financial • information required by the Facility to determine the
extent. of the Resident's. resources. If it is ever determined the Representative participated in
the disclosure of incomplete or inaccurate information, the incomplete or inaccurate
disclosure shall be deemed a material breach of this Agreement and the Facility reserves the
right to pursue all available legal remedies against the Representative, including but not
limited to an action for breach of contract.
Representative is signing this Agreement as a duly authorized agent such as an appointed
healthcare agent under an advance directive or guardian appointed by a court. A copy of all
supporting documentation fox this representation is attached to this Agreement. _
• Representative . is signing this Agreement on Resident's behalf; based upon a physician's
certificate, a copy of which is attached to this Agreement, certifying that Resident does not
possess the capability to understand his or her rights and responsibilities. '
^., .
Representative agrees that in the event of the Resident's death, Representative shall take
responsibility of all burial arrangements for the Resident and for removal of all personal
property from the Facility.
(Exhibit` 1, Continued)
• If it is the desire of the Resident or Representative to obtain the supplemental services of
private duty nurses in accordance with the requirements described under this Agreement,
• ~ ~ Representative agrees - to ~ be ~ responsible for- arranging ~ independently for those services,
including ensuring any payment.
. - • Representative agrees that in. the event the Resident's private funds •are :exhausted .during the
.. ~ -- ~ Resident's-stay and: the Resident is ~-eligible to apply for. benefits under~.the Medicaid•Program, . ,
. the ~ Representative shall • assist the Resident and • •the-• Facility :with rauyr application for
• • ~ •~ • Medicaid benefits. ~~ ~• Representative . fiuther:. agrees to, act; r oii:.behalf Y•of ~ #he'~Resident,, to .
• ~ ~ ~ " ~ facilitate • any Medicare; • VeteransAdministration ~ or other ~•third=partiy~ benefits, wliiel~ may be
available to cover the cost of Resident's care at the Facility. _
• ~ In the event the resident seeks to terminate this Agreement, the Representative agrees to
ensure that all notices required under thus Agreement are provided to Facility.
.. • In~ the event of an involuntary.. termination of this Agreement; . if ~. other :arrangements
acceptable to the Resident cannot be made, the Representative agrees to accept the.Resident
into the Representative's custody, if medically appropriate.
• -Representative has _ the. right to copies of the following documents and any amendment to
them: 'Representative fiuther~acknowledges receipt of the following ~ documents,• which may
be amended from time-to-time.
1. A copy of this Admission Agreement.
2. A list of the Facility's rates, subject to amendment on thirty-(30) days notice, and a
description of charges for services not included.
3. A list of health care providers offering services at the facility.
~• Representative acknowledges the Facility's right to any legal remedies available under law
for Representative's breach of this Agreement.
,.
EXHIBIT 2.A
Private Pao Residents
A. Items and Services Included in the Daily Rate '
The items and services included in the daily rate, and their related charges, are listed below:
Descriotioa of Items and Services Included iin the Daily Rate
1. ~ Room ~ '
2. Board
3. Social Services _
4. Nursing Care, including:
a. The administration of prescribed medications, treatments and diets.
b. The provision of care to prevent skin breakdown, bedsores and deformities.
c. The provision of care necessary to encourage the resident from accident, injury and
infection.
d. The provision of care necessary to encourage, assist and train theresident in self-care and
group activities.
S. Other: Activities
Total Daily Room Rates (e,,ffective July 1, 2003)
Special Care
~~
Private Rooms $179.00 $189.00
Semi Private Rooms $164.00 ~ $184.00
Triple/Quad Rooms $152.00 $174.00
Medicaze co-pay: $105.00
EIL~3TT 2.B
ITEMS AND SERVICES NOT COVERED BY T~ DAILY RATE
The following items and services are not covered by the Facility's basic daily:rate:
Item or Service
Physician Services
Medications
Prescnbed Dietary Supplements
Personal Dry Cleaning, Personal Linens -
Telephone
Television Service
BeautyBarber Shop Services
Clothing .
Sundry Pharmaceutical
Ambulance Service, Medical Transportation
IV Therapy
X Ray Services
Medical-Nursing Supplies
Dental, Podiatrist and Opthamology Services
Physical, Speech and Occupational Therapy Services
Oxygen .
Newspaper, Periodicals
Lab Services
Specialized and/or specially ordered medical services/equipment
Guest meals
..
y
(Exhibit 2.B, Continued)
ITEMS AND SERVICES NOT COVERED BY T~ DAII.Y RATE
(refer to the Ancillcny Charge List for additional costs)
Item
Telephone
Television/Cablepey month
BeautyBarber Shop Services:
Permanent
Haircuts and Blow-dry
Hair Sets
Cut Only
Color
Personal Laundry
Personal Dry Cleaning
Physical Therapy Service
Occupationa]/Speech Therapy
IV Therapy
Aerosol Therapy
Charge .
Direct bill from telephone company
$7.00 per month
$35.00
$10.25
$8.25
$8.25
$30.00
$45.00 per month
Same as billed by cleaner
Determined by level of care required
Determined by level of care required
Charge list will be provided by contract
pharmacy prior to delivery of services
Determined by level of care required
*********************s********************************************************
Shippensburg Health Care Center cordially invites family members, guests and friends to join
our Resident's at meal times.
The prices for guest trays, effective July 1, 2001 are as follows:
Breakfast A $4.00 Will be served at 7:00 AM
Breal~ast B $4.00 ($3.77 + .23 state tax) served at 7:30 AM
Lunch A $4.00 Will be served at 12:00 PM
Lunch B ~ $4.00 ($3.77 + .23 state tax) served at 12:30 PM
~
Dinner A $4.00 5:00 PM
Will be served at
Dinner B $4.00 ($3.77 + .23 state tax) served at 5:30 PM
*The Resident's will be assigned their meal times upon admission.
Meals can be paid for at the Receptionists' desk. In order to prepare sufficient quantities we
require a 2-hour notice to prepare guest tray.
EI~~TT 3
The following summarizes the Medicare aad Medicaid programs. It also tells you who to call for
more detailed information. If you have questions, our staff will also help you.
What's Covered-Medicare
1. Care in a hospital
2. 100 days of skilled care in a nursing home. Medicare provides full ~ coverage fof the first
20 days. You must make a ~co-payment after that. Th~~following services are. examples
of skilled care:
a. Injections & feedings given through an N
b. Tube feedings _
c. Application of a dressing that involved prescription medication
d. Treatment of stage 3 or 4 bedsores
3. Medically necessary doctor's services.
What's Covered -Medicaid
Medicaid is a comprehensive program that will cover most of the costs'of a nursing home stay.
-• ~S~ee Exhibit:4 for information about covered~and non-covered items.
Your Contribution -Medicare
Medicare does not ~av~ 100% of the cost of covered services. ~:You~will be required to ~ayr part of
the charges. Your payment may be called a "co-payment", `.`deductible" or ~."premium",
depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any
payment that you are responsible for under Medicare.
Your Contribution -Medicaid .
Depending on your income and assets, you may be required to make a contribution toward the
cost of your care. The amount of any contribution will be decided by the local Board of
Assistance.
Who's Eligible -Medicare
People °6S~years old or older. •who~ are eligible to collect old-age benefits under Social' Security are
eligible. Persons. who receive. Social Security disability benefits for at least 24 months,' or have
been found eligible- for- Medicare~by the Social Security Administration because they have end
stage renal disease requiring regular dialysis or kidney transplant are also eligible.
Who's Eligible =Medicaid. ,
Eligibility depends on whether your income and assets are below certain levels:
1. Income: You. should consult the local Board of Assistance to find out whether your
income makes you eligible. That phone number is listed on the next page. If you qualify,
$30 per month of your income is protected for your personal use while in the Facility.
(Exlnbit 3, Continued}
2. ets: The Cumberland County Board bf Assistance will also be able to evaluate your
assets and tell you whether you qualify. The following are examples of things ~
counted as assets.
a. Your house if your spouse lives there.
b. Household goods.
c. A certain amount of cash. .
d. ~~ Personal Property in your possession in the Nursing•home.
e. A certain amount of money for burial arrangements.
- How to Aunly -Medicare
Contact the local Social Security Office at the following address:
Social Security Office
401 E. Louther Street
Carlisle, PA 17013
(800) 772-1213
(717) 243-0085
How to Apply -Medicaid
Contact~the local County Board of Assistance at the following address:
Board of Assistance
33 Westmmister Drive
Carlisle, PA 17013.
(800) 269-0173
(717) 249-2929
Whom to Contact if you have a Question or Problem -.Medicare
If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing
to: Aetna Medicare Claim Administration
501 Office Center Building
Fort Washington, PA 19034
(215) 643-7200
Whom to. Contact if you have a Question or Problem -Medicaid .•
If your application for Medicaid is denied, your coverage is terminated, or a service is not
covered, you may appeal in writing to:
County Board of Assistance Office
33 Westminister Drive
P.O. Box 599
Carlisle, PA 17013
(717) 249-2929 .
(800) 269-0173
(Exhibit 3, Continued)
Whom to Contact if volt have Iucarred Medical Ezoenses urior to vour MA Effective Date
Medicare - Not'applicable
- :ti-+,x~iFhom to G~aontact if vou•-have ~Incnrred ~ Medical -F~enses~ urior to vbar-Mt~. EffccthraDate- ~ . -~, ~ .
__
. - ~• ,-Medical bills-that you received.in the 3 months prior~~to~receiving~lVledicaid~~ay-be.~coveied by - . -
Medicaid. Contact:
County-Board o€A,ssistance Office -
33 Westminister Drive
P.O. Box 599 -
Carlisle, PA -17013
(717) 249-2929
(800) 269-U173
EXHIBIT 4.A
A. Items and Services Covered by the Medicaid Per Diem Rate
.. -. ~ . .:..~ :Regular room;~dietary•services, social services and other:-services°required tameet~. ~ .. .
.certification standards, medical and surgical supplies;' and .the use of equipment
and facilities. .
-~ .:~.~ ~.•._;. General ~nursing~services,t including but not•linyited-to',;.administration=o~;flxygen
. .:. ,..:•and~ related:. medications; ~hand.•feeding,~ incbntinen~rcar..e;3.r~tr~y~:i~service~: and
enemas.
... ... _..: .. •., ..Basic BeautyBarber Services: The .facility must provide' shampooing and hair
care which is considered necessary for hygiene. The facility ~niusf inform the
resident of the types and frequency of the services provided.
• Items furnished routinely and relatively uniformly ~to;.all•.residents, sach.as water
pitchers, basins, and bedpans.
• .Items .furnished, distributed, or used individually in~.,small quantities such as
alcohol, applicators, cotton balls, band aids;°' antacids;•~ aspirin •~(and other
. nonlegend drugs ordinarily kept on hand), suppositories; ~aiid •tongue~ depressors.
• Items used• by individual residents but which ,are reusable• and• expected to be
available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs,
traction equipment, and other durable medical equipment. .
• Special dietary supplements used for tube feeding or oral feeding, such as
elemental high nitrogen diets, even if written as a prescription item by a
physician.
• Laundry services for other than personal clothing. '
• Non-emergency~medical transportation services.
• Other special medical services of a rehabilitative, restorative, or maintenance
nature, designed to restore or sustain the resident's physical and social capacities.
• Personal care items including a patient gown, shampoo, skin lotion, comb, brush,
toothpaste, toothbrush, and denture cream.
EIl`~IT 4.B
B. Items and Services Not Covered by the Medicaid Per Diem Rate
• Medical expenses such as, but not limited to:
• Health insurance premiums.
.... .....:• .... :Visits by anon-participating-physician:other.than:appraved•=b~r;the~nursing care ~ .
facility.
- • •~•~~ •. • •. Ernergency.ambulance services,•iftheambulaneecompany~doesrnot acceptlldA.
• Over-the-counter medications, which are a particular brand not supplied by the
. nursing; facility. For example, the nursing facility must provide aspirin, but the
patient.~:may • request and buy a specific brand o£ pain relieves; such ~ as ~Excedrin
PM, or Tylenol.
• Hearing aids and batteries.
• : Specialized BeautyB~rber Shop services.
~• • Diapers, if•= the resident wants a style or brand.:whiehy is:~not::~provided= by 'the
nursing care facility.
• Personal care items of the resident's choice if he prefers them instead of the items
provided by the nursing care facility: This includes items such as brushes, combs,
toothbrushes, cosmetics, etc.
EXHIBIT 4.B
B. Items and Services Not Covered by the Medicaid Yer Diem Rate
• Medical expenses such as, but not limited to:
• Health insurance premiums. .
.... .....:~ .... ;:Vsits by a non participating-physician= other. thansapproved°b~r ~thexniusing care ~ .
facility.
- ~: ~. • ~. Emergency. ambulance services,~if the ambulance company doesrno~ aceept~ll~A.
• Over-the-counter medications, which are a particular brand not supplied by the
nursing; facility. For example,. the nursing facility must provide aspirin, but the
patient.may~request and buy a 'specific brand o£ pain reliever; stitch~as~Excedrin
PM, or Tylenol.
• Hearing aids and batteries.
• ~ Specialized Beauty/Barber Shop services.
•~ 'Diapers, if the resident wants a style or brand:.whiehti is:~notc=.grovided~ by 'the
nursing care facility.
• Personal care items of the resident's choice if he prefers them instead of the items
provided by the nursing care facility. This includes items such as brushes, combs,
toothbrushes, cosmetics, etc.
E~LH~IT 5
PHYSIQANS WHO PRACTICE AT THE FACILITY
Dr: ~Yogindra. S. Balhara, M.D.
. Dr. William Kramer, M.D.
Dr.` Paul Orange, M.D.
.: • ~ Dr,:~~Ba~€ter Drew Wellmon, II, D.O.; P:C.
Dr.. Hong S. Park, M.D. .
761 Fifth Avenue
Chambersbwg, PA 17201
(717) 261-2583 '
144 South~Eighth Street
Chambersburg; PA 17201 .
(717) 2646511
4225 Lincoln Way East
Fayetteville, PA 17222
(717) 352-3616
.127 Walnut~BottomRoad
Shippensbwg, PA 17257
(717) 532=3211
. 120 North Seventh Street
Chambersbwg, PA 17201
(717) 267-7735
., . .
EXHIBIT 6
LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE
• . • -You Have the Right to Decide About Your Health Care .. ~•
.:. ~. ~° :~: Adults.gen~erally :have•the-right to~ _decide ifthey • want ~.medical:. treatment,~rau~less• they. ue not.: _ ... .
_ ~ .. ...competent°~Z'hisright.includes decisions about treatments.thatextend life,=lif~.supportmachines,• --. ~ : ~:
or feeding tubes.
.. ..~. °~•°-~Sometimes;~an.~accident•or•. illness.takes•awaya•person's~abiiity~to,~nlake~Rhealtl~:car~.ehoices:~ But- ~~ :• ~ ~-
• ~, .-,the -decisions-still= must be .made •• Ifi you are~•unable:to~make them;~othe~.~viil Y=The~mtill:decide •~ ~:..
..:, .:~.: based on your. wishes; ~or your~best interests if your wishes are=unknown. ~ ~ ,
• • ° ~ P ennsylvania law gives • you the right to make many health care decisions in advance: One way ~ • ~• • • ~ ~ '
to do this is by using a written advance directive to name an agent to make your health care •
. decisions if you cannot. A written advance directive can also state your treatment preferences,
• especially about life sustaining procedures.
Naming a Health Care Agent
. You :can. name ~ anyone to ° be your health care ~ agent. The ~•only~: exception is°~•that;=~in: general,
• .someone who:works where you are receiving your care cannot be~your agent. • Your-agenfican be
a family member or a firiend.
. • - • You •.choose::when•ynur agent: cann• decide for you -right away;. if~:you want; on only after two •
. ... = . doctors~•agEee thatyou.~are not able~to: decide for.yourself °You~alsoschoosewthe:kinds.~f:~decisions : ~ ~.•::°
• your agent . can' make. for you.- ~ For example,. if you want, you • can .give your:. agent .very broad•
power to decide about life-sustaining treatment. Pick your health care agent very carefully.
Make sure your agent knows what you want. Your agent will then follow your wishes, even if
your friends or family disagree.
Using Advance Directives
There are many ways to use ari advance directive. A living will is a type of written advance
directive that states your wishes on life-sustaining treatments. It usually comes into affect when
a person will die very soon from an incurable condition. It can also be used when a person is
permanently unconscious (in a vegetative state).
You can make a°broader~written•advance directive for other health care issues too. For example,
you can decide whether you want life-sustaining treatment if you are in an end-stage condition:.
An end=stage condition is an advanced, progressive, and incurable condition resulting in
complete dependency.
What Happens If You Do Not Make an Advance Directive?
No one can deny you health care because you do not have an advance directive. But you should
know what happens legally if you do not.
(Exhibit 6, Continued)
Pennsylvania law allows a surrogate to make medieal decisions for you if you Lave not named a
health care agent and are no longer able to decide treatment issues yourself. Then, your closest
- -. •:. relative: would be asked• to~ make health: care decisions •foryou~r..:Your•.•.spouser •adult:.cLddren; ~ ;,: .
... ~• ~ parents; ~or adult• brothers. and sisters; in that• order, are considered yourclosest relatives:: If these • - .
. • • :relatives.: are ~ not available, another :relative or • close friend ; can ~ make, decisions for :you. • .A .: . .
..~: ~ ~ •:L .• . surrogate; ahough,+ might :have: less authority Ito -decide :against: lifesasf ainin~ Plvicedures xhan~ a• ... ~ .. ; ..~
health care• agent.
. ... 'r t.Ifrthere• is ~ao~ ~ one .to ~ be.' a :surrogate, ~ a' court: might have •.toc«appoint~•a-g~dian°~to:tmalce ~your~ .. .
.. .. ~.,, ~~. medical decisions: ,The.g~,tardian:might~be•somebody ~vho doesfncat:.kno~w*.y~c~i=personall~•"ty:= -. ... .
. r
How Do:Yoa Get 1V~ore Information?
This .summary. does not cover every issue. • If you Lave legal ~ questions about your rights, ~ please
..; .. < speak.to. a lawyer:..Also .talk to your. healthcare provider about.ther,anedical.issues inxolved. in
. : ~:.::• ~, , .t•~yous~~::r ~el~•those~ car-ing~€or.you about -your •decisions andf+givezhem~aj~copy~.~•o~r•,advance ..
directive.
For a free copy of a Living Will or Advance Directive form contact:
State Representative Jeff Coy
39 West King Street
Sluppensburg; PA 17257
(717) 532-1707
or
Cumberland County Office of Aging
Human Service Building
16 West High Street
Carlisle, PA 17013
(717) 532-7286 Ext. 6110
(717) 240-6110
E~iHIBIT 7
POLICIES AND PROCEDURES CONC'ERNIl~iG YOUR PERSONAL FUNDS
AND YOUR PERSONAL PROPERTY
A. Your Rights:
. - ., ' . 1: ~ You- have.~theright •to, keep and use your•~personal::property,.:inEludingsome ...
• • ~ ~ fiucushings• and clothing, so' long as there is en~ughspacetandmther.tesideats are • • .
.. not. inconvenienced. ~ You also have the ' right~• to security : for. ~your~ personal
possessions.
.. ... ' . ~ - 2,: ~ .:.Y`ou• ha~re=the•.right:~t~manageyour financial•~ff~aiF~vnt~,cs=a':eo•detaermii~e~.that~ : ' . • .. .
.. .you . are-.~< incapacitated . or•. the'.: Social • : °Set~rity~.~stsatia~ls a ... .
.representative to receive Social Security fimds~for.your use and benefit. .
3. We cannot require you to deposit your personal funds with .us. You may,
. however, choose any person to manage your funds, including the Facility.
4. If you. decide to have us manage your ~ personal: funds; :your may. withdraw your
. ~ : money: that ~we keep in the Facility.during.. the~Fa+eility's:business~:hoursa:.::.If we
. ~ .have deposited .any of your funds in a banl~.;you~,may obtain~those.~funds within
three banking _ days; provided the funds have cleared.
. . -~ 5 . - if you ,need ~ ~ help to • ~ perform your. ~ banking-~;transactions;.:.you •~ may ::give .the
.administrator- ~ of : our...Facility legal .authority to '. access• your account, This
authority: ~ is called "representative ~ payee:" To gee :the administrator this
authority, you will need to complete a special form.
6. You and your personal representative have the right, during normal business
hours, to inspect our written records that concern your personal funds.
7. You and your personal representative have a right to file a complaint if either of
you believes that your funds, valuables or other assets have been stolen or
damaged. The agencies to contact in order to make a complaint aze listed below:
a. The Cumberland County Office of Aging
Attn: Ombudsman
Human Services Building
16 West High Street
Cazlisle, PA 17013
(717) 532-7286 Ext. 6110
(717) 240-6110
(Exhibit 7, Continued)
b. Cumberland County Board of Assistance
33 Westminster Drive
P.O. Box 599
Carlisle, PA 17013
(717) 249=2929
(800) 269-0173
c. ~ ~ Tlie Department of Health
.Division of Nursing Care Facilities
1fl4 North Cameron Street
2~ Floor
Harrisburg, PA 17101
(717) 783-3790
B. Our Responsibilities:
.. ~ ~:1: ~:•- ~ , We•: ~~vi11~ provide~~a~ .reasonable •amout~t~~ of~•~seectre~~space:~or~you.~ta.lr~p:~our
• - ~ ~~clothing- and other personal property.° • We :must: investigate =an3c :damagext~`or• loss
of your personal properly.
. .. ~ .. • •.2. ~ :, °~: ~:•If•:you~•want us .to: manage' $SO:OO~or;,less:of~yourapersonal::-fiuids~~we will:deposit~. .
..
.... ~ ..-~ thiamQneyin:anoninterest.bearingpaccnunt~ora~petty~c~sh:fund.• _ ' .
•-• 3. ~< ~: ~- I£:you••~vantf~us :to- manage mores than.~'DSOQ4:~of.your;persaEnal~funds,;.~we~~~wi11:. .
deposit this •money.in• ari interest:bearing:.account•that-.is: insured.by.the:£ederal..:•
government. This account will be sepazate from the accounts we use to operate
the facility. In addition, we will credit ~ you- with all • interest earned on your .
money.
4. We will maintain a full, complete and sepazate accounting of your personal funds.
• We will also provide you with a quarterly statement of the activity of your
account.
5: If you -receive Medicaid benefits, we will notify you if your account balance
becomes. too high: If you are to remain eligible for Medicaid, your account
balance must be under a certain dollar limit that is established by the Federal
. government and changes periodically.
6. We may not use• your personal funds to pay for an item or service that Medicare
or Medicaid covers.
7. We will maintain adequate fire and theft coverage to -protect your funds and
personal properly that aze kept at the Facility. We shall also obtain a surety bond
or otherwise assure the security of your personal funds that are deposited with the
Facility.
it ~
(Exhibit 7, Continued)
8. If you are discharged, there are several things we must do:
a.~ . We will ensure the return of your personal funds in our;possession..If we
• ~. have deposited.your..personal funds.in a~bank aceount;.we:will•ensure.that
. thin money is' made available to •youY os •your.•authorized representative
within 30 days.
:. -~ b<~~ ~-If°:we.are.your~representative: payee.~•for::Social=`Se~rity`:benefits;":we.will
. ~ .promptly • ask ~ ~ the Social Security i ~ Adrninistration•~: to: ~~name ~ a ~ new
• . , . •: representative payee and=we wilt ttansfers3~ou;'=money~,to :t~iat•person~ ~ .. .
9. In the .event of your death, there are several things we must do:
a. We will convey your personal funds and a' final accounting of those fluids
to the: person-in charge of administering,your:esta#e withm•30: days.. We
. will;immedrately~notify.any~government.cyfi:that:~~aii};.for.~~l:'oi.liart~of
your care. in our Facility. That agency shall: have 'thee right to assist us in
.. deterrnining•what to do with your property.
b. .~ • ~ ' ; Tf .a• government ~ agency . did not pay • for .your care;- we ~: will: immediately
~~ notify~your.representative or next o£kin:to:~determirie:what:fo:do••with.your
.properly.
c. If we. have your funds, valuables or other assets, in our possession, we will
hold them until ~ the appointed personal representative of your estate
presents a copy of the certified Letters of Administration to us. All
conveyance of personal funds will be by check made payable "To the
Estate of ..".
d. We will make reasonable attempts to locate your personal representative
and your heirs. If no claim is made on your funds, valuables or other
assets in our possession within six weeks of your death, we will write the
State Office of the Comptroller for direction.
10. >f we are in possession of your funds, valuables or other assets for more than one
year from the date of your transfer or discharge, we will transfer your funds, any
interest on your funds, and your valuables or other assets to the State Office of the
Comptroller's Office of any account(s) in your name of which we have
knowledge.
i.~ ~
L' A.[i.~ull S
SERVICES PROVIDED BY OUTSIDE HEALTH CARE PROVIDERS
::,. •:. •e- ~ ~ ...:.; ,Some. o€tha• services available.in. the Facility; such as pharmacyc. servi~~ are:prca~rided by..outside • .. ... _
.. ~ : r: •healdr ca=e~providers:-+These services; and information:about=the•providers;'appear below.. You •• • •., .
.... are~free to pick your owa provider or to use one of those listed below: • .
. ~~ Tvue°of.Service
..Provider's Name,
Address and
Tele~phone~Number
Physician Dr. Yogindra Balhara
761 Fifth Avenue
• Chambersburg, PA 172b1
(717) 264-6185
X-Ray Services Mobil X-Ray Services
The Chambersburg.Hospital
112 N. Seventh Street
Charnbersburg, PA 17201
(717) 267-6356
Eab Services ~ The Chambersburg Hospital
112 N. Seventh Street
Chambersburg, PA 17201
(717)267-7153
Pharmaceutical Pharmacare
Route 3, Box 3-A
Cumberland, MD 21502
(301) ?77-1773
Podiatrist Dr. Peter Holdaway
1936 Scotland Avenue
Chambersburg, PA 17201
(717) 264-5211
Podiatrist Dr. Kirk Davis, D.P.M.
601 Wayne Avenue
Chambersburg, PA 17201
(717) 267-2255
;~ ~ V~hether•vve~ have
. ~ a•~nancial
- . GInterest in
.• fihu~Provider
No
No
No
No
No
No
,.. ,.~.
. r
. .
(Exhibit 8, Continued)
Whether we have
Provider's Name, a financial
Address and Interest in
Tune of Service Telephone Number .the Provider
• Dentist Health Drive
' 928~Jaymor Road
.No
Suite C-190
Southampton, PA 18966
(215) 942-9950 FAX (215) 942-9954
Hosspital
Inpatient or
Carlisle Hospital No
Emergency
Chambersburg Hospital No
No
Room Fulton Co: Medical Center
Hershey Medical Ceater No
Waynesboro Hospital No
JIHItNItNI
__ _
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Facility Phone: 717-530-8300
Resident: LAURA JONES
Statement Date: 01 /31 /07
RFMS
CAARA JONES
345 EASR QUEEN ST
CHAMBERSBURG, PA 17201
Date Service Through Qty Description Amount
Sub Total as of 12/31/06 2,500.01
Chars>les
01 /04/07 01 /01 /07 01 /04/07 4 Patient Liability 571.04
Sub Total 571.04
Balance 3,071.05
Cash Recei pts/Adjustments
01/09/07 11/04/06 12/04/06 Payment -440.00
01/09/07 11/06/06 11/06/06 Payment -7.00
01/03/07 12/03/06 12/03/06 Payment -150.00
Sub Total -597.00
Balance 2,474.05
Ancillary/Other Chars~es
01/18/07 01/18/07 01/18/07 1 CABLE 7.00
Sub Total 7.00
Balance as of: 01/31/07 2,481.05
Total Amount Due 2,481.05
EXHIBIT "B"
Page 1
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SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
v.
CLARA R. JONES and
LAURA B. JONES,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2007-2333 CIVIL TERM
PRAECIPE TO REINSTATE
TO THE PROTHONOTARY:
Please reinstate the Complaint filed in this matter on Apri123, 2007.
Respectfully submitted,
Date: May 30, 2007
RIEN, BARI SCHE
i
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/j ones-lau ra/reinstate. pra
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e
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cu ~.N ~ ~` (~ ~
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..~
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
v.
CLARA R. JONES and
LAURA B. JONES,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
N0.2007-2333 CIVIL TERM
PRAECIPE TO DISCONTINUE
TO THE PROTHONOTARY:
Kindly mark the above-captioned action as having been settled and discontinued without
prejudice.
Respectfully submitted,
O' N, BARK & ERER
Date: July 18, 2007
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, PA 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/Jones-Laura/discontinue.pra
CERTIFICATE OF SERVICE
I hereby certify that on July 18, 2007, I, David A. Baric, Esquire of O'Brien, Baric & Scherer,
did serve a copy of the Praecipe To Discontinue, by first class U.S. mail, postage prepaid, to the
parties listed below, as follows:
Clara R. Jones
P.O. Box 416
Chambersburg, Pennsylvania 17201
Laura B. Jones
121 Walnut Bottom Road
Shippensburg, Pe sylvania 17257
David A. Baric, Esquire
~
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SHERIFF'S RETURN - REGULAR
CASE NO: 2007-02333 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON
VS
JONES CLARA R ET AL
RICHARD SMITH Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
JONES LAURA B the
DEFENDANT at 1005:00 HOURS, on the 27th day of April 2007
at 121 WALNUT BOTTOM ROAD
SHIPPENSBURG, PA 17257
LAURA A JONES
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
~1D3'b~
Sworn and Subscibed to
before me this
of
So Answers:
6.00
19.2 0 ~,,~iy~...~-rn-~'~eC ~_.(c1..+'-A
.00
10.00 R. Thomas Kline
.00
35.20 07/20/2007 ~
OBRIEN BARIC SCH,~RER
By:
day Deputy Sheriff
A.D.
`~
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2007-02333 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON
VS
JONES CLARA R ET AL
R. Thomas Kline
I x 1. - t ~ *1'a.
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:
JONES CLARA R
but was unable to locate Her
deputized the sheriff of FRANKLIN
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 20th 2007 this office was in receipt of the
attached return from FRANKLIN
S eriff'9 Costs: So a~swers: ,, f ^.
Docket in 6 . 0 0 ~!""''`~~-~~
_--
Out of County 9.00 ~/' ,=~, --'/ ~ ---
Surcharge 10.00 R~' Thomas Kline
Dep Franklin Co 36.20 Sheriff of Cumberland County
.00
61.20 / Blo3Jb 7
07/20/2007
OBRIEN BARIC SCHERER
Sworn and subscribe to before me
this day of
A.D.
in his bailiwick. He therefore
S
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2007-02333 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON
VS
JONES CLARA R 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:
JONES CLARA R
but was unable to locate Her
deputized the sheriff of FRANKLIN
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 20th 2007 this office was in receipt of the
attached return from FRANKLIN
Sheriff's Costs:
Docketing
Out of County
Surcharge
Dep Franklin Co
Postage
18.00
9.00
10.00
28.10
n nr
So answe~ ~`'
r' _ ~"",
r ~r°J! ~~
R . ` Thomas Kline ~,
Sheriff of Cumberland County
67.~95~/ B/~3Ip~
07/20/2007
OBRIEN BARK SCHERER
Sworn and subscribe to before me
this day of ,
in his bailiwick. He therefore
~-
A.D.
A ,
~ S ~ ' ~
In ~'he Court of Coanmon Pleas of Cumberland Country, Penmmsylvania
Shippensburg South Hampton Manor LP
VS.
Clara R. Jones et al
N o . 07-2333 civil
April 24, 2007
Now, , I, SHERIFF OF CUMBERLAND COUNTY, PA, do
hereby deputize the Sheriff of
FYanklin
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff:
~~ -."P
Sheriff of Cumberland County, PA
Please mail return of service to Cumberland County Sheriff. Thank you.
Aff davit of Service
Now,
within
upon
at
by handing to
a
and made known to
copy of the original
the contents thereof.
So answers,
Sheriff of
Sworn and subscribed before
me this day of , 20
COSTS
SERVICE $
MILEAGE
AFFIDAVIT
County, PA
20 , at o'clock M. served the
~.
SHERIFF'S RETURN - NOT FOUND
CASE NO: 2007-00090 T
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN
SHIPPENSBURG/SOUTH HAMPTON MAN
VS
CLARA R JONES ET AL
ANGEL L LAVIENA
C~ m~c'~o~r<~ '~~~`'~
Deputy Sheriff, who being duly sworn
according to law, says, that he made a diligent search and inquiry for
the within named DEFENDANT to wit:
JONES CLARA R
but was
unable to locate Her in his bailiwick. He therefore returns the
COMPLAINT
the within named DEFENDANT JONES CLARA R
NOT FOUND as to
345 EAST QUEEN STREET
CHAMBERSBURG, PA 17201
NO LONGER AT THIS ADDRESS, RETURNED PER ATTY'S REQUEST
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
S n
.00
. 0 0 '-
.00 L LA
.00 ROBERT WOLLYUNG, Sheriff
nn
.00 CUMBERLAND CO SHERIFF
05/31/2007
Sworn and subscribed to before me
S~
this ~ ~ day of
~~ ~ A.D.
Nota `
NoheW ~I
Wch~M D. McCw1f1, Naf~ry Public
3
~ I
In 'The Court of Corn~non Pleas of Cumberland County, Pennsylvania
Shippsnsburg South Hampton Manor LP
VS.
Clara R. Jones et al
No. 07-2333 civil
Now, ~Y 31, 2007
I, SHERIFF OF CUMBERLAND COUNTY, PA, do
hereby deputize the Sheriff of Franklin County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff. ~j
~ir~'~y.I~ ...~~-P
Sheriff of Cumberland County, PA
Please mail return of service to Cumberland County Sheriff. Thank you.
Affidavit of Service
Now,
within
upon
at
by handing to T
a
and made known to
copy of the original
the contents thereof.
S o answers,
Sheriff of
Sworn and subscribed before
me this day of , 20
COSTS
SERVICE _
MILEAGE _
AFFIDAVIT
20 , at o'clock M. served the
County, PA
SHERIFF'S RETURN - NOT FOUND
CASE N0: 2007-00119 T
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN
SHIPPENSBURG/SOUTH HAMPTON MAN
vs
CLARA R. JONES ET AL
RICHARD L NORTH Deputy Sheriff, who being duly sworn
according to law, says, that he made a diligent search and inquiry for
the within named DEFENDANT to wit:
JONES CLARA R.
o'~ ~''' 3
but was
unable to locate Her in his bailiwick. He therefore returns the
COMPLAINT
the within named DEFENDANT JONES CLARA R.
1781 LINCOLN WAY APT D
CHAMBERSBURG, PA 17201
HASN'T LIVED THERE FOR TEN YEARS.
NOT FOUND as to
Sheriff's Costs: So answers:
Docketing .00
Service .00 G~~~~
Affidavit .00 RICHARD L NORTH
Surcharge .00 ROBERT WOLLYUNG, Sheriff
.00
.00 CUMBERLAND CO SHERIFF'S OFFICE
07/05/2007
Sworn and subscribed to before me
~~~
this ~~ day of
Q~~ A.D.
~k~' ~.~.
Rich~Nd D. McCtrt~t, Notary PubNc
dambanbury 9oro, Franklin DAY
IW Canmission ExMrea Jan. ~, 2011
`1