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HomeMy WebLinkAbout07-4665IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. No. 0"~-'x(0(05 ~,t~i I ~~ CIVIL ACTION -EQUITY 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 YOU 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. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 (800) 990-9108 EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, : Plaintiff, v. No. LOIS TRAVER, Defendant. CIVIL ACTION -EQUITY AVISO PARA DEFENDER Conforme a PA RCP Niue. 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 accion 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 accion 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. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant COMPLAINT CIVIL ACTION -EQUITY AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services -Camp Hill, ("Plaintiff ManorCare"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant Lois Traver ("Defendant Traver'), 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 1700 Market Street, Camp Hill, Pennsylvania 17011. 2. Defendant Traver is an adult individual who currently resides at Petitioner's skilled nursing facility. 5. On or about January 25, 2006, Defendant Traver made application for No. ~ 7- yG G S C~ ~t.~,W admission to Plaintiff ManorCare's skilled nursing facility. 6. On or about January 25, 2006, Plaintiff ManorCare and Defendant Traver entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Traver with skilled nursing care and services in exchange for her promise to pay a specific monetary fee and to make timely and proper application for Medical Assistance benefits when she became eligible for such assistance and to pursue any subsequent appeals if that application were denied. A true and correct copy of the Agreement is attached hereto as Exhibit "A". 8. After her admission to Plaintiff ManorCare's skilled nursing care facility, Defendant Traver apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff ManorCare notified Defendant Traver of her contractual duty to make application for Medical Assistance benefits. 9. An application for Medical Assistance benefits was filed with the Cumberland County Assistance Office of the Department of Public Welfare. 10. The application for Medical Assistance benefits referenced will be denied unless Defendant Traver provides the information needed by Cumberland County Assistance Office to determine her eligibility for Medical Assistance benefits. 2 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 Traver breached the Agreement with Plaintiff ManorCare when she did not make complete and proper application for Medical Assistance benefits, and Defendant Traver continues to breach the Agreement with Plaintiff ManorCare by not participating in the Medical Assistance application process by producing the documentation necessary to qualify for Medical Assistance benefits. 13. Defendant Traver's breach of the Agreement with Plaintiff ManorCare has caused and continues to cause irreparable harm to Plaintiff ManorCare. 14. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/ or protections promised under the Agreement. 3 WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, Dated: 5~~ ~?11j0~ SCHUTJER BOGAR LLC By ~ ~ Chadwi k O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Mariclare L. Hayes Attorney I.D. No. 201289 (717) 909-5922 305 North Front Street, Suite 401 Harrisburg, PA 17101 Fax No.: (717) 909-5925 4 V~tIFlCA'I~d1V T.he undersigned hereby verifies that the statements of fact in the foregoing Complaint are the and correct to the best of my knowledge, in fa~onation and belief. I understand that any false statements thrrnin are subject to the penalties contained in 18 Pa. C.S.A. §4909:, rnlating to unsworn falsification to authorlt[es. Datcd:_s~ EXHIBIT'~E~~~ Rx Date/Time JUL-27-2007(FRI) 10:34 7177372189 P. 002 0/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 02 .HCR Manor Core Pennsylvania AAMISSION A,GIttEEMENT This Agreement is ezttered into by and among Nightingale Nursing Hvme, Inc., d.b.a. HCR Manor Caze 1'"HCR 1Vlanor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing For. the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: ManorCare Health Services. CamtZHill Resident: ~~S ~~ ~rQ~~~ Responsible Party: Admission Date: ~ cZJ b Deposit: $-~,AA~ Term: This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Reside»t's discharge date. I. )EtIGI[iTS A,1~1D RESPONSIBTirITIES OF TAE RESIDENT 1.01 Room and Board te. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board R,:Ete is subject to change upon: thirty (30) days written notice, The Room and Board Rate set forl:h 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 dischazge. This Section will not apply if the Resident is covered under a governmental program (see Seetio:a 1.05) or by a third party payor or managed care organization (see Section 1.06). 1.02 Aneillar~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 physician, or provided in the Resident's Plan of Care. 'T'he Center reserves the right to charge for personal~care items of the Reside»t if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list i.. maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. Rx Date/Time JUL-27-2007(FRI) 10;34 7177372189 P. 003 0'7/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 03 1.03 Col;_ections/Late Pa ents. Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection. costs, including attorney's fees. 1,04 I ,t,~de;pendent Providers. The Resident. i.s directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 S~ernmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Cerrter particip~ites in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the s~une 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 a»y 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 particip;rtes in the following programs: x N,[edicare, ~ Medicaid and/or VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there its a required co-payment, which Medicare updates yearly. If the Resident also participates in Prledicare Part B, for physical, occupatSonal, 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 Resident 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 agree:; to pay on a timely basis, as set forth in this Agreement, the contribution amount as determirn:d and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the cor.~tribution amount, the Center may take such. legal action as necessary, including requesting a court to order. such payment. 1.06 T ' d Party Payors and Mana[~ed Care Organisations. 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 sirnilar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is resp~~nsible for any co-payments, deductibles or non-covered charges, according to the same terms ~md conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resi.dent's third party payor, the Center 2 Rx Date/Time JUL-27-2007(FRI) 10: 3d 7177372189 P.OOd 0'x/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 04 will bill the Resi.dent's third party payor as a service, but the Resident remains liable for charges not paid or cover~sd by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay 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 Residem has not been, determined to be eligible for any governmental program or covered under any third party payor or managed :are organization plan. ~'he Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for. benefits. The Resident and/or Responsible Party will notify the: Center in writing when application to Medicaid is made. The Resident and/or Responsible Party v~ill 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 notifiied of the Center's intention to discharge the .Resident for non-p~.yment in accordance with this. Agreement, Resident Handbook and state and fader. al laws. 1.08 Admission >rnformation. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Residenrt's stay including copies of insurance cards, identification or verification of eligibility and coverage information, The :Resident acrd/or Responsible Party will provide the Center in writing with notice within fiv~5~ d~a ~s of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premuium(s) or renewal. of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident 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 cysts associatE:d with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Ap~li~;ation for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance prc~gam, The Center has no obligation to bill any third party payor other than th.e Responsible Patty and, when applicable, a governmental progam third party payor or managed care organization with which the Center is under contract. 1.10 Prima., Responsibility for Payment. Except for payments for. services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily lia ale for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Patty aclvaowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for Wort-covered services, supplies, equipment, medications, anal other care and services which may be delivered by th.c Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or ResF onsible Party that services provided at the Center may not be covered by a Rx Date/Time JUL-27-2007(FRI) 1034 7177372184 97/27/2097 11:33 7177372189 MANORCARE,CAMPHILL P. 005 PAGE 05 governmental payer, third party payer or managed care organization. The Resident andlor Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business a~'ice and is available for review during regular business hours_ I..I l Per.~onal 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 1~enter. At the time of adnssion, the Resident must supply the Center with the name of his/her I~ersonal 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.I2 Pharm_ acv. The Resident and/or Responsible Farty has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, pacltages and supplies pharmaceuticals in :accordance with state law, abides by the Center's policies and procedures and has a medication clistri.bution system similar to the Center's ancillary pharmacy's medication distribution system. RIGHTS ,A:~iD RESPONST.1$ILl[TX OF THE RESPONSIBLE PARTY 2.01 Legal Authority. The Responsible Party represents that he/she has legal access to the Resident's in.conie or resources and that the documents supporting such authority, if any, have been delivered to thE: Center. 2,02 A,gre~~nent to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from t:ie 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 Reside~tt should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Reau~;sted Iterzts. The Responsible Party will be personally liable for any services or products specific2.lly requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 lrxhat~tion of Resident' Funds if the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center 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 1V,(edicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreerraent and transfer yr discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely Rx Date/Time JUL-27-2007(FRI) 10:34 7177372189 P. 006 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 06 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 Cooperation 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 arty charges denied the Center due to any lacy of cooperation. If the Resident and/or Responsible Party fail to provide such information as 1Vledicaid representatives require for continued eligibility for 1Vledicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acct;ptance Upon Discharge. Upon termination of this Agreement as 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 cemoved 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 conditio~i. permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements anal to pay promptly all charges. 2.07 Additional Responsibilities. ~'he Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds In the event 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 c~uali.fying the resident fvr 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 Resident's income ar resources. Such misappropriation of the Resident's income or resources may also result in tht: imposition of criminal or civil sanctions against the Responsible Party. III. RIGHTS A,1'iD R)ESPONSIBII,I~S OF ~'19"E CEIITTER 3.01 Roorz: and Standard Services,, As part of the Room and Board Rate, the Center will furnish basic .r~~om, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be rE.quired 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 Ot er ervices. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. Rx Date/Time JUL-27-2007(FRI) 10;34 7177372189 P. 007 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 07 3.03 Die -osit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's reuript of the final Medicaid payment for care of the Resident. l[V. GENERA-I. 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: Center personnel, attez~dinla physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's chazges, including any utilization 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 carrier; az~d any person authoru~ed by law to review the medical records. 4,02 Con,~ent to Treat. The Resident and/or 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 the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limuited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care:, the administration of ntedicatiorts and treatments, and the performance of therapies, as prescrilted 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 Resi~3ent by federal and/or state law, As al-plicable, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of th.e Resident, that documents supporting such authority have been delivered to th.e Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 ConsE.nt to Photograph, The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph. in the Medication Administration Record or other records and for any other similar. uses of the photograph for Center anal staffto identify the Resident. 4.04 Notic_c of er_v_ices. Po,'cies and~A,dditional Information The Resident and/or Responsible Party aclcnowiedge that the items listed below have been explained and have received copiers of the items c+r policies and procedures, if applicable, The Resident andlor Responsible 6 Rx Date/Time JUL-27-2007(FRI) 10;34 7177372189 P. 008 I~7/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 08 Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payme»t of Benefits. See Attachment C. b, SNF Medicare Determination Notice. See Attachment D. c. N~edicare Secondary Payor Questionnaire. See Attachrztent E. d. .A,t the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal, funds in compliance with the laws and regulations relating to the Center's management of such funds. A description ~tind/or policies and procedures of protection of resident funds and the Personal 'Crust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-1 and F-2. e. Center Supplement 1. Policy and procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. Name, address and phone number of Ombudsman. 4, Location ion the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey a»d certification agency, the state licensure office, the state ombudsman progarra, the protection and advocacy network and the Medicaid fraud control u».it. 5. The name, specialty 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 concerting resident abuse, neglect, mistreatment and rtisappropriation of property. f. The Resident ~Iandbook. g. ResidentlP'atient Rights. h. Medicare%Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, anal how to receive refunds for previous payments. 7 Rx Date/Time JUL-27-2007(FRI) 10;34 7177372189 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL P. 009 PAGE 09 Receipt of information on advance directives including a copy of "Refusal of Life Sustaiting Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment, See Attachments G-1. and G-2. Privacy Act Notification. See Attachment ki. 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:~rrnent Q£ Benefits. The Resident and/or Responsible Party request that payment of authori::ed government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf fer any service furnished by or in the Center. The Resident and/or Responsible Party authorize the: Center and any holder of medical or other information to release such information to the t:enters for Medicare and Medicaid Services "C11±1S" and its agents and to third party payors any inf ~rnnation needed to determine these benefits or benefits for related services. 4.06 Terrrination.~ arge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Aischarge". The Resident and/or Responsible Party may terminate this Ageem.ent by providing the Center written. notice of the Resident's desire to leave at Least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for aiI 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 ~'ransitional Care Unit or Subacute Unit may n~uire less than seven ('~ days notice. If discharge or tran,;fer 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 approF~riate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harrnless from any and al! c1:3ims, demands, suit and actions made against the Center by any person resulting from any dF.mage or injury caused by the Resident to any 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. Rx Date/Time JUL-27-2007(FRI) 10:34 7177372189 ' 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL P. OlD PAGE 10 4.08 C~mges in the Law Any provision of this Agreement that is .found to be invalid or unenforceable fps a result of a change in state or i;'ederal 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 contimie to fulfill their respective obligations under this Agreement consistent with the law. THE UN1I~ERSIGNED CEI,tTXF'Y AND ACKNOWUEDGE THAT THEY I{AVE )EACH READ AivD UNDERSTQOD 'I'8E FOREGOING AGREEMENT, AND THAT THEY AA,VE HAD AN OPPOItTUN)(TY TO ASK QUESTIONS A,ND THAT ANY QUESTIONS F1(.A, VE BEEN ANSWERED TO THEIR SATISFACTION. ~p ,v~ Signature of Resident: d~ y `" Date: 0~5 ~f Signature of Respoa~sible Party: Date: Center Representative: ., Date: a- Q ~j ~ o~ ~ ~ (r Q ~ w v W ~ t~ ~==' n - _..., ~ ~ ~ ~~~. rs~ -. ' -c`. t`F'7 Y " 1 . L ~ t 7 ~- `~° ` rya ~ ~ n _, <:~ .. - _-t ~~ `{ ~ . ~ ;~ O IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. No. 07-4665 Civil Term CIVIL ACTION -EQUITY ACCEPTANCE OF SERVICE I accept service of the Complaint on behalf of Defendant, Lois Traver, and certify that I am authorized to do so. Dated: /1 ~~ ~~ Lowel .Gates, Esquire Atto ey I.D. No. 46779 GA ES, HALBRUNER & HATCH PC 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 (717) 731-9600 Fax No. (717) 731-9627 Attorney for Defendant r-- ~ ° ~ . .a ~ ~~ ~ ` ~ ( ""~? . C , ~ ~ ~~. ~; .- ~r t a ,. -' - _~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. No. 07-4665 CIVIL ACTION -LAW PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of the following ScxuTJER BOGAR LLC attorney as counsel of record in the above-captioned matter: Brandon Williams SCHUTJER BOGAR LLC 417 Walnut Street, 4~ Floor Harrisburg, PA 17101 Attorney I.D. No. 200713 (717) 909-5922 Dated: By: r~~a! vi+ v B/randon Williams ~`'~.. 1~ -1 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Entry of Appearance was served via first-class, United States mail, postage prepaid, upon the following: Lowell R. Gates, Esquire GATES, HALBRUNER & HATCH, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Dated: ~ ~ ~ ~' By: ~-- William Keslar, Paralegal } ~`~ -- ~ .~ 4' ~ ~~ t cn ..s -< ~-.. ~. IN THE COURT OF COMMON FLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. 07-4665 LOIS TRAVER, Defendant. CIVIL ACTION -LAW PRAECIPE TO WITHDRAW TO THE PROTHONOTARY: Kindly withdraw, without prejudice, our Complaint filed in the above captioned matter on August 6, 2007. Respectfully submitted, Dated: r' Scxvz7~x Boc~ut LLC By: _ Chadwick O. Bogar Attorney I.D. No. $3755 (717) 909-5920 Brandon Williams Attorney I.D. No. 2(?0713 (717) 909-5922 417 Walnut Street, 4~ Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for the Plaintiff OR16;NAL ~_ .. CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw Complaint was served first-class, United States mail, postage prepaid, upon the following: Lowell R. Gates, Esquire GATES, HALBRUNER & HATCH, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Dated: ~ I d 8 By: William Keslar, Paralegal r' ~' .._.. .. :---~ -..s