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HomeMy WebLinkAbout07-3540IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. ~~ -35~/b GRADY WALKER, Defendant. e~~.c`r~ CIVIL ACTION -LAW NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 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 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 YOt;f DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. GRADY WALKER, Defendant. CIVIL ACTION -LAW AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/ A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar action dentro de los proximos veiente (20) dias despues de la notification de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar action Como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamation o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/ b/ a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. GRADY WALKER, Defendant. No. O'7 - 3 5~/0 CIVIL ACTION -LAW COMPLAINT ~~:~~~ AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services -Carlisle, ("Plaintiff ManorCare"), by and through its attorneys, SCHUT)ER BOGAR LLC, and files the within complaint against Defendant, Grady Walker, and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Defendant Grady Walker is an adult individual who currently resides at 23 McClay Street, Harrisburg, Pennsylvania 17110. 3. On or about January 19, 2006, Defendant made application on behalf of his wife, Lucinda Walker, for admission to Plaintiff's skilled nursing facility. 4. On or about January 19, 2006, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Lucinda Walker with skilled nursing care and services in exchange for, among other things, the promise to either pay a specific monetary fee from Mrs. Walker's assets, or make application for Medical Assistance benefits if Mrs. Walker could not afford to pay said fee. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. As part of the Agreement, Defendant contractually agreed to be Mrs. Walker's Responsible Party and to cooperate in the Medical Assistance process by providing any and all financial records requested by the County Assistance Office. 6. After Mrs. Walker's admission to Plaintiff's skilled nursing care facility, she allegedly became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that he needed to apply for Medical Assistance benefits on Mrs. Walker's behalf. 7. An application for Medical Assistance benefits was subsequently filed on behalf of Mrs. Walker. 8. The application was denied because Defendant failed to provide the County Assistance Office with those documents necessary to determine Mrs. Walker's eligibility for Medical Assistance benefits. See the attached PA-162, Exhibit "B." 9. Subsequently, Plaintiff filed an appeal of the County Assistance Office's denial of the application for Medical Assistance benefits, and that appeal is currently pending before the Pennsylvania Bureau of Hearings and Appeals. 2 10. If Defendant fails to provide the documents requested by the County Assistance Office prior to or at the time of the hearing scheduled on the aforementioned appeal, it will be denied, and any further appeal to the Commonwealth Court will be without merit. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 11. The allegations contained in Paragraphs 1 through 10 are incorporated herein by reference as if fully set forth at length. 12. Defendant breached the Agreement attached hereto as Exhibit "A" when he refused to make complete and proper application for Medical Assistance benefits, in particular, by failing to provide the County Assistance Office with the requisite financial documentation to determine Mrs. Walker's eligibility for benefits. 13. Upon information and belief, at all times material hereto, neither Mrs. Walker nor Defendant has been financially able to fully compensate Plaintiff for the care and services that it has rendered to Mrs. Walker in accordance with the terms and conditions of the Agreement. 14. Because a legal remedy against Defendants is inadequate, an equitable remedy is appropriate. 15. Defendants' breach of the Agreement attached hereto as Exhibit "A" has irreparably harmed and continues to cause irreparable harm to Plaintiff. 3 16. Only a decree of specific performance ordering Defendant to fulfill his obligations under the Agreement will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. COUNT II STATUTORY DUTY OF SUPPORT 17. Paragraphs 1 through 17 are incorporated by reference as though restated in full. 18. Defendant is the husband of Mrs. Walker. 19. Defendant has a statutory duty to care for, maintain, or financially assist his wife. 20. The statutory duty of Defendant must reasonably include the duty to assist with securing financial support through the Medicaid system and the duty to not actively work against Medicaid approval. See e.g., Savoy v. Savoy, 641 A.2d 596, 553 (Pa. Super. 1994). 21. At all times material hereto, Defendant has failed to care for, maintain, or financially assist his wife by refusing to provide the documents requested by the County Assistance Office. 4 WHEREFORE, Plaintiff respectfully requests that this Court order Defendant to produce the documents necessary to establish the eligibility of Lucinda Walker for Medical Assistance benefits, consistent with his duty to secure financial support for his wife. Respectfully submitted, SCHUT7ER BOGAR LLC Dated: ~-- a~ By: ~ Bradley A. Sch tjer Attorney I.D. No. 75954 305 North Front Street, Suite 401 Harrisburg, PA 17101 (717) 909-5921 Misty D. Bartel Attorney I.D. No. 204190 One Liberty Place 1650 Market Street, 36~ Floor Philadelphia, PA 19103 (267) 207-2869 Attorneys for Petitioner Rx Date/Time JUN-14-2007(THU) 15:40 Jun 14 2007 2:34PM HP LRSERJET FRX JUN-13-2001(YED) 11.57 SCHUTJER 606RR LlC a; i ~ ~~ (PRX126i2072?d4 P. 002 p.2 P. 009/009 't'L~ undersigned hereby verifies that the statements a~f fact in tie foregoing Complaint are true and corarect bo tL~e best of my k~wwl©dge, informatlon and belief. 1 understand ghat any false statements therein arc subject to the penalties contaiixd ~ 1$ Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: Amy Mars usiness Office Manager lVlanorCare Health Services -Carlisle EXHIBIT "A" Rx Date/Time JUN-14-2007(THU) 15:40 Jun 14 2007 2:34PM HP l_RSERJET FR7i P. 003 p.3 `.: ~.~; HCR Ma~eor Care Pennsylva~tia ,;: ADMISSION AGREEMENT ~ ~ + ~. This Agreement is entered into by and among Manor Care Health Services, d.b.a. HCR.. Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if airy, for thee. purpose of providing for the rights and responsibilities of the parties with respect to the'•',~~• Resident's stay at this HCR Manor Care's Center {"Center"). Center:. MCHS-Carlisle Resident; Lucille . ,~~ r A~5 Responsible Party: G~ l I~Ja~~er- ar Admission Date: 1l19,~2006 Deposit: $ 0 _ -•<, Term: This Agrcemern begins on the day the Residern enters the Center and ends on the' day the Resident is discharged unless the Resident is readmitted within fiHeen (15)` y( days of the Resident's discharge date. ~' L RIGHTS AND RESPONSIBII.I:TIES OF THE RESIDENT 1.01 ~oo~ and Board Rate. For the basic services provided for in Section 3.01, the `:'~- Resident will pay the applicable Roorn and Board Rate set forth on Attachmert A hereto. The ~~ Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental ,', program (see Section 1.05) or by a third party payor or managed care organization (see Section:°,;. 1.06). 1.02 Ancillary Charges. The Resident will pay to Center all charges for additional ., medical, therapeutic, or personal care services or supplies that may be requested by the Resident,;.:; ordered by the attending physiciaq or provided in the Resident's .Plan of Care. The Center_=~:=_' reserves the right tv charge for personal care items of the Resident if necessary for the well-being ,. of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current;::. ancillary charge list is maintained at the Center's business office for review during regular business ~_~. hours. Ancillary Charges will be included in the Residern's statement for the succeeding month,;° and are payable in full, along with the Room and Board Rate upon receipt. `" Rx Da'.e/Time JUN-14-2007(THU~ 15:40 Jvn 14 2007 2:34PM HP LRSERJET FRK ~ ~ P. 004 p.4 1.03 CollectionsJi.ate Pavmeats. Payment is due in full within thirty (30} days of billing.' ; Should the Resident's account for arly reason be turned over for collectiaq the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is duectly responsible to independent:;:. providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under aay , governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and : . the Center participates in such program, the Center will accept payments under such program in: accordance with the terms of the progam as set forth in the contract the Centel has with the ' program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident ~ .~ must comply with all program requirements. In the event the Resident's coverage under the ~.: governmental program(s) cease for any reason, the Resident will be charged at the Center's rate.':'' for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: _x Medicare, x_Medicaid and/or VA.' Medicare may pay for some or all of the Residerrt's care. If Medicare agrees to pay for the` ' Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident= - also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which .are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resider and/or Responsible Party are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center .: . charges such as Room and Board and nursing services are covered, although Medicaid may ~ ~: require the Resident to pay a portion of the Room and Board Rate from their monthly income:.. The Resident agrees to pay on a timely basis, as set forth in this Agreement, the conrtribution ' amount as deternrined and periodically adjusted by the State and/or local department(s) handling.., Medicaid. ff the Resident fails to pay the contribution amount, the Center may take such legal: action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations. If a Resident is a participant - in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),..~ .~. Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or ~ . ~~ Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the: ~: Center has executed a provider agreement, the charges are governed by the applicable ageemerlt. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same teams and conditions applicable to private pay residents. ff the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 Rx Date/Time JUN-14-20071THU) b5:40 P. 005 Jun 14 2007 2:35PM HP LRSERJET FRX p.5 L.% ~r will bill the Resident's third party payor as a service, but the Resident remains liable for charges' not paid or covered by that third party payor including charges not paid within a reasonable: period of time. 1.07 Private ay Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party .,. payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is inaufficiem income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible .. Party will notify the Center in writing when application to Medicaid is made. The Resident and/or . Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination . process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Cerner and provide any needed information regarding all third party payors or govemmenta] coverages on admission and throughout the Resident's stay including copies of inswance cards, identification or verification of eligibility and coverage infomnation. The Resident and/or Responsible Party will provide the Center in writing with . notice within five (5~ days of the Resident's disenrolhnent, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Reaident acknowledges that if the Resident fails to provide such information, the Resident may be . responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or :_." other costs associated with the failure to provide such notice in accordance with the terms and ~. `. conditions of this Agreement. 1.09 Application for Benefits. The Resident andlor Responsible Party will apply for . coverage and to establish eligibility under any governmental, third party payor, managed care or .:_ private insurance program. The Center has no obligation to bill any thud party payor other than the Responsible Party and, when applicable, a governmental progam third party payor or nxanaged care organization with which the Center is under contract. 1.10 Primary Resaonsibility for Payment. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Residern remains primarily liable for any and all charges for which the Center may ogee to bsll a third ' party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO; PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its ~: subcontractors. This ageement serves as a written notice that the Center has notified the• Resident and/or Responsible Party that services provided at the Center may not be covered by a ~. Rx Dade/Time JUN-14-2007ITHUJ 15:40 Jun 14 2007 2:35PM HP LRSERJET FR}{ ~.~ governmental payor, third party payor or Responsible Parry will be responsible for maintained at the Center's business office hows. P. 006 p.6 ~, managed care organization. .The Resident and/or non-covered services. A price list of services is and is available for review during regular business 1.11 Personal Physician. The ~ Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and ,policies of the Center. At the time of admission, the Resident must supply the Center with the ~ ~~ name of his/her personal physician. If the Resident changes physicians at any time after .. admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the::.: Resident. 1.12 Pharmacy. The' Resident and/or Responsible Party has the .right to choose a pharmacy of choice, provided the pharrna,cy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND ]ItESPONSIlBIlLTTY OF THE RESPONSIBLE PARTY 2.01 Legal Authority. The Responsible Party represents that helshe has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on :. behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resowces. 2.03 Requested Items. The Responsible Party will be personally liable for any services . or products specifically requested by the Responsible Party to be supplied to the Residem; unless . such services or products are covered by a governmental program. 2.04 Fa~haustion of Resident's Funds. ffthe Resident's financial resowces change such that the Residem tray be eligible for Medicaid, the Resident and/or Responsible Party must notify the Cemer in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsble Party fails to notify the Center in writing or fails to file for Medicaid in~a timely a Rx Date/Time JUN-14-20D7(THUj 15:40 P. 007 Jun 14 2007 2:35PM HP LRSERJET FRX p.7 `~.. ~..- and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Ceooeration for Financial Assistance. If the Resident is eligible for Medicaid, the . Responsible Party must provide such information about the Resident's finances as Medicaid ~.' representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. If the Resident andlor Responsible , Party fail to provide such information as Medicaid represematives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Residem's care, the ' Resident may be discharged ar transferred upon appropriate and reasonable notice for nonpaymem, as provided in Section 4.06. 2.06 Acceptance Upon Discharee. Upon termination of this Agreement a~s provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the. Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or inunediately make medically appropriate alternative arrangements and to pay promptly all charges. . 2.07 Additional Res~,nsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Residem Handbook, and Attachments. 2.08 Misuse of Resident Funds. in the evem that the Responsible Party misappropriates . the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding ` the Responsible Party's obligation to make payments on behalf of the Resident under Section 2.02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Residem's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. III. RIGHTS AND RESPONSIBILTrIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. Rx Date/Time JUN-14-2007(THU) 15;40 P. 008 Jun 14 2007 2:36PM HP LRSERJET FRK p.8 ~ ~• 3.03 osit. The Center acla~owledges receipt of the D~osit, if any, noted at the; beginning of this Agreement. The Deposit will be appfied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. 'Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the tune frame required by State law. In the case of'_Viedicaid Residents, any such refund will be paid within thirty (30) days . of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 .Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Ceneer personnel, attending physicians and consultants; any person, firm, government entity, third parry payor or managed care organization responsible for _ all or any part of the payment or reimbursement of the Resident's charges, including aay utilisation review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability . insurance earri~, and any person authorized bylaw to review the medical records. 4.02 Consent to Treat. The Resident aadlor Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement, authorizes the appropriate staff of tbe Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician. in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she ha,s the legal authority to make health care decisions on behalf of the Resident, that docurnerns supporting such authority have been delivered to the Cetrter, and that such Responsible Party consents on behalf of the Resident to the Treatmenrt described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center felting a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services, Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Residem and/or Responsible 6 Rx Date/Time JUN-14-20071THU) 15:4D P. 00'9 Jun 14 2007 2:36PM HP LHSERJET FRX p•9 ~ ~ Party acknowledge they have had the opportunity to ask, questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits. See Attachme~ C. b. SNF Medicare Determination Notice. See Attachment D. c. Medicare Secondary Payor Questionnaire. See Attachme~ E. d. At the request of the Resident and/or Responsible Party, the Center will - maintain the Resident's personal funds in compliance v~7th the laws and regulations relating to the Center's management of such funds. A description and/or polices and procedures of protection of resident funds and the Personal - Tcust Fund Agreement, Resident Personal Funds Authorization and arty other related documents. See Attachments F-1 and F-2. e. Center Supplement: 1. Policy and procedure oa bedholds, election of bedhoids and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy goups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5, The name, speaalty'and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of ProP~y• - f. The Resident Handbook. g. ResidentlPatient Rights. h. MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refiuxis for previous payments. 7 Rx Date/Time JUN-14-2007(THU) 15:40 P.O10 Jun 14 2007 2:36PM HP LRSERJET FR}{ p. 10 i.~ ° ~J i. Receipt of information on advance directives including a copy of"Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State surnrnary of its laws governing the Resident's right to direct his/her medical treatment_ See Attachments G-1 and G-2. j. Privacy Act Notification. See Attachment H. k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and I-2. Ancillary Services Management Form. See Attachment J. 4.05 Assi¢nmer-t of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third parry payor benefits as described in Sections 1.05, and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible Party authorise the Center and say holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Te lion. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least sever (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (?) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will_defend, indemnif~- and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by arty person resulting from any damage or injury caused by the Resident to arty person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. s Rx Date/Time JUN-14-2007(THU) 15:40 Jun 14 2007 2:36PM HP LRSERJET FRX ATTACHII'IENT A ROOM AND BOARD RATE The Resident will pay the following monthly rate: SEMI Private 3 Bed $5673.00 SEMI Private 2 Bed $5828.00 pRIVpTE $6758.00 P. 011 p.ll to Rx Date/Time JUN-14-20071THU) 15:40 P. 012 Jun 14 2007 2:37PM HP LRSERJET FRX P•12 ~' ~--` ATTACHMENT B ANCILLARY CHARGES The services and supplies categorically described on this Attachment are not included in the basic Room and Board Rate. Therefore, the Resident will be individually billed for these items in accordance with Section 1.02 of the Adnussion Agreement. A complete list of ancillary items, together with the current price, is on file at the Center's business office. Dry cleaning. Beauty and Barber Shop services Tobacco and smokiag supplies, newspapers and periodicals Stationary, postage, and writing implements Radios, televisions, cable service, room telephone Transportation for non-medical purposes and ambulance charges Photocopies of medical records Personal physicians and specialists Dental services and Dentures Optometrist/Ophthalmologist services and Eyeglasses Podiatry services Special nursing services, care for catheters, decubiti, incontinence, isolation and dressings Therapy services, including physical, speech, occupational, audiology and respiratory therapy Prescription and non-prescription medication Laboratory and x-ray tests Oxygen and related supplies IV Therapy and supplies Peritoneal dialysis Tracheotomy supplies Ventilator rental and related supplies Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes, surgical stockings, and all other supplies necessary for the treatment, nursing care, or well- being of the Reside Incontinence supplies Special equipment (for some items, a rental, rather than purchase fee is charged), such as wheelchairs, wheelchair pad, trapeze, canes, geri-chair, special mattresses, ports-chairs, etc. Special, supplementary, or very low calorie prescription dietary products, including liquid for.gastric and nano-gastric tubes, and any supply necessary to accomplish apeaal feedings. ;~ 11 4. . Rx Date/Time JUN-14-2009(THU) 15:40 Jvn 14 2007 2:37PM HP LHSERJET FfiX ~- ~..~ P. 013 p. 13 ~uu~'1i~~,Q,\~~.r'' 4, 08 Changes in the Law. Auy provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will coirtinue to fiilfill their respective obligations under this Agreement consisteirt with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUE5TIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Residern: Date: Signature of Responsible Party ~ ' Date: 1 I 1 G I U fe Center Representative: Date: ~ ~ /~(o _ EXHIBIT "B" .V '`Q _ O ~ ~ t-~ _~ ~ ~ -n ~ _J ~. ~„ ~ ~ _ -~ t-. a f ~ y f _~ 1 ;_, l..' G.~ '_.4 SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2007-03540 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MANOR HEALTHCARE CORP D/B/A VS WALKER GRADY 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: WALKER' GRADY but was unable to locate Him deputized the sheriff of DAUPHIN serve the within COMPLAINT & NOTICE County, Pennsylvania, to On July 13th 2007 this office was in receipt of the attached return from DAUPHIN Sheriff ' s Costs : So answers : ~~-~ !~ Docketing 18.00 -'" ~ - Out of County 9.00 ~. /`~t%~ Surcharge 10.00 R. Thomas Kline Dep Dauphin County 29.25 Sheriff of Cumberland County Postage 1.14 67.39 / Yl6p'01 07/13/2007 SCHUTJER BOGAR Sworn and subscribe to before me this day of in his bailiwick. He therefore A.D. .I~ 'I'b~ C®~rt ®f Ca~~®~ Peas ~~ C~~~~~la~~ ~~~l~~y, P~~~sy~~a~~a Manor Heatlhcare Corp etc VS. Grady Walker 07-3540 civil No. Now, A 26' X00'7 , I, SHERIFF OF CUMBERLAND COUNTY, FA, do hereby deputize the Sheriff of ~auph'n County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Now, Affidavit of.Servic~ 20 , at o'clock M. served the within upon at by handing to a and made known to 5o answers, Sheriff of copy of the original _ Sworn and subscribed before me this day of , 20 COSTS SERVICE ~ $ MILEAGE AFFIDAVIT County, PA the contents thereof. ('~~£tCE II# ~P ~~Eriff Mary Jane Snyder Real Estate Deputy William T. Tully Solicitor Charles E. Sheaffer Chief Deputy Michael W. Rinehart Assistant Chief Deputy Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 780-6590 fax: (717) 255-2889 Jack Lotwick Sheriff Commonwealth of Pennsylvania MANOR HEALTHCARE CORP D/B/A MANORCARE vs County of Dauphin • WALKER GRADY Sheriff's Return No. 0995-T - - -2007 OTHER COUNTY N0. 07 3540 I, Jack Lotwick, Sheriff of the County of Dauphin, State of Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for WALKER GRADY the DEFENDANT named in the within NOTICE & COMPLAINT and that I am unable to find him/her in the County of Dauphin, and therefore return same NOT FOUND, July 6, 2007 NO SUCH ADDRESS IN HARRISBURG CITY Sworn and subscribed to before me this 9TH day of JULY,. 2007 ' ~i'~ c/ NOTARIAL SEAL MARY JANE SNYDER, Notary Public Highspire, Dauphin County My Commission Expires Sept I, 2010 So Answers, Sheriff of Dauphin County, Pa. fN By Deputy Sheriff Sheriff's Costs: $29.25 PAID BY COUNTY WONG ~~~-i~~ ~~~~ ~3i zt`4~ ,~~~6i0OTAf','~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ~~ ~ ~ ~~' ~ ~ ~' ~~ ~ "~ ~ ~ MANOR HEALTHCARE CORP. d/b/a ~~_i,' ~`~ !--1r~keP"4~^'' MANORCARE HEALTH SERVICES - CARLISLE, . Plaintiff, v. No. 07-3540 GRADY WALKER, Defendant. CIVIL ACTION -LAW PRAECIPE TO WITHDRAW, DISCONTINUE, AND END TO THE PROTHONOTARY: Kindly mark the above-captioned action that was filed with your office on June 18, 2007 as withdrawn, discontinued, and ended, without prejudice. Respectfully submitted, SCHUTJER BOGAR LLC Dated: ~U ~ ~! By: ~ M' ty D. B tel PA Attorney I.D. No. 204190 (214) 523-9024 2911 Turtle Creek Boulevard Suite 300 Dallas, TX 75219 Fax No.: (214) 523-9014 Attorneys for Plaintiff ORIGINAL CERTIFICATE OF NON-SERVICE Service of the Complaint was never effectuated. Date: ~ ~ ') ~ V By: