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HomeMy WebLinkAbout07-7147IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, ; Plaintiff, V. No. M - *7/Y7 Civi( (per" ALMA FERGUSON, Defendant. 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 ORIGINAL EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, ; Plaintiff, V. No. ALMA FERGUSON, Defendant. CIVIL ACTION - EQUITY 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 accion dentro de los proximos veiente (20) dias despues de la notificacion 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 reclamacion 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 Tel6fono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - : WEST SHORE HEALTH AND REHABILITATION, ; Plaintiff, V. No. O Y 7 CtUd- ?u---- ALMA FERGUSON, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Golden Living Center - West Shore Health and Rehabilitation ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following complaint against Alma Ferguson ("Defendant"), and in support thereof, states: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a skilled nursing care provider with its principal offices located at 770 Poplar Church Road, Camp Hill, Pennsylvania 17011. 2. Defendant is an adult individual who currently resides at 66 Ashburg Drive, Mechanicsburg, Pennsylvania 17050. 3. On or about June 15, 2007, Defendant made application for the admission of Ms. Kirk to Plaintiff's skilled nursing facility. 4. On or about June 15, 2007, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Ms. Kirk with skilled nursing care and services in return for Defendant's promise to make timely payment for that skilled nursing care and services from Ms. Kirk's resources, or, upon Ms. Kirk becoming insolvent, to make timely and proper application for Medical Assistance benefits on her behalf and to provide all of the necessary documentation for an eligibility determination to be made with regard to Ms. Kirk's application for Medical Assistance benefits. A true and correct copy of the Admission Agreement is attached as Exhibit "A." 5. Shortly after Ms. Kirk's admission to Plaintiff's skilled nursing facility, she allegedly became insolvent. As a result, an application for Medical Assistance benefits was subsequently filed. 6. The application for Medical Assistance benefits will be denied unless the information needed by the Cumberland County Assistance Office to determine Ms. Kirk's eligibility for Medical Assistance benefits is provided to the Cumberland County Assistance Office. 7. Defendant has not cooperated with the Medical Assistance application process by providing the information and documentation necessary for that process. 8. As of November 9, 2007, an outstanding balance of $22,899.00 (twenty-two thousand, eight hundred, ninety-nine dollars) is owed to Plaintiff for the care and services it has provided to Ms. Kirk. 2 COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 9. Paragraphs 1 through 8 are incorporated by reference as though restated in full. 10. Plaintiff has provided, and continues to provide, skilled nursing care and services to Ms. Kirk in accordance with the Agreement attached as Exhibit "A." 11. Defendant has breached the Agreement attached as Exhibit "A" by not providing the documentation requested by the Cumberland County Assistance Office for a determination to be made as to the eligibility of Ms. Kirk for Medical Assistance benefits. 12. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff and presents an issue of immediate and irreparable harm to Plaintiff, as Ms. Kirk's application for Medical Assistance benefits will be denied absent the necessary documentary evidence to establish her eligibility for benefits. 13. Upon information and belief, at all times material hereto, Ms. Kirk has been financially unable to compensate Plaintiff for the care and services that it has rendered to her and continues to render to her in accordance with the terms and conditions of the Agreement. 14. Accordingly, only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. 3 WHEREFORE, Plaintiff respectfully requests that this Court enter a decree ordering specific performance of the Agreement by the parties. Dated: I 11QV07C04 Respectfully submitted, SCHUTJER BOGAR LLC By. cg W a" Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff 4 VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the bast of my knowledge, information and belief. I understand that any false statements therein are subject to the perWtics contained in 18 Pa. C. S. § 4904, relating to unswom falsification to authorities. Dated: t? n BtGerly Fry, Q Executive Dir, or, Golden Living Center - West Shore EXHIBIT "A" THANK YOU FOR CHOOSING USCFOR YOUR NURSING F_•fC'ILITY CARE RE The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. I• NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. H. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or as health care workers. In the course of this Participation, care may be rendered to the Resident by such trainees under supervision as required by law. 'in addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services, Consent to routine nursing care provided by the Facility shall include consent for care by such trainees and contractors. B. Physician Services - The Resident acknowledges that he or she is under the medical care of a Personal attending physician and that the.Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. [f, however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes not associates or agents of the Facility and that the Facility's liability afor any physician's hact orf omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. III. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time IV. ARBITRATION - The Resident acknowledges that disputes under this Agreement may be submitted to arbitration, if the Resident elects to do so, by signing a separate agreement executed ST/9'd S26S606:01 :WOad L0:60 L002-02-nON 900 *d DU:60 (PI)Z002-02-AON awil/2400 xa between the parties. Agreeing to arbitration is not a condition of admission or continuing care. V. PRIVACY ACT NOTIFICATION S'T'ATEMENT - Skilled nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of Tune 22, 1998, all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the Federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 1819(0, 1919(0, 1819(b)(3)(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care given in those .facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to. (1) a congressional office from the record of an individual in response to an inquiry from the congressional oflrice made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or quality of health care services provided in the State; (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-60-33, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Medicare/Medical Assistance nursing facility the requested Mformation is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided sen/ices. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medical Assistance services. VI, RESIDENT'S PERSONAL PROPERTY A. -,Safety Of Resident's Personal Property - The Facility strongly discourages the keeping of valuable jetk elry, papers, large sums of rnoncy, or other items considered of value in the Facility. 'The Facility shall make reasonable efforts to sat ;guard the Resident's property/valuables, which the Resident choo.es to keep in his or her possession. ;-he Resident agree-, w -Anform the Facility in writing of all personal property r_pon admission. if, at any time dLnng the Residc rat's stay, new items of value are brought to or -emol.l d from the R;m dent's posseb,iors in :he f, ,c lily, the Resident also agrees .0 so 9T/L'd 9269606:01 200 'd cW021d 8b:60 LO02-02-AON U4:60 oni)1002-02-AON awtl/a4o0 xa inform the Facility Executive Director or designee R. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. VII. PERSONAL FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B• Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Resident's funds shall be credited to the Resident's account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. D. Accounting - The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf This system shall also ensure that the Resident's funds are not commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. E- Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($00.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SST resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance or SSI. F- Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the Facility's Business Office, 3 sl/e*d S26S606:01 :W08J Sb:60 LO02-02-AON 900'd VV:60 0%)1002-02-AON awTl/a4e0 xa G. Security of Funds - The Facility shall ensure the security of all personal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance Program Resident's personal funds for any item or service ror which payment can be made under the Programs. VIII. THE RESIDENT'S DUTIES A. Facility's Rules And Regulations , The Resident agrees that the Facility may, to maintain orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. 1t is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. B. Resident Grievances - Residents are urged to bring any grievance concerning the Facility to the attention of the Facility Executive Director or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered anonymously. This number is 1-800-572- 9981. Residents also have the tight to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. C. Diet - The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages brought into the Facility for the Resident's benefit. D. Medications - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. All drugs or medications brought into the Facility shall be immediately delivered to the nurses' station. E. Care Of Facility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as is to be expected from ordinary wear and tear. F. Care Of The Resident's Room - The Facility encourages the Resident to have a home-like environment and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must concur with any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. IBC. PROHIBITION AGAII iST THIRD PARTY GUARANTOR -FEDERAL AND STATE LAWS PROHIBIT A NURSING IIOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAY,MZNT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION OR CONTENUED STAY IN TIRE FACU ITY. HOWEVER, A FACILITY MAY REQUIRE AN INDIVIDUAL NVRO HAS LEGAL .ACCESS TO TIIE RESIDENT'S INCOME OR RESOURCES AV,k.ABLE TO PAY FOR FACILITY CARE TO SIGN A CONTRACT, WITHOUT INCURRING PERSONAL FINANCLkI, LLX8T1 rY FOR 7HF_ RESIDENT'S COSTS OF CARE, TO PROVIDE FACILITY PAYMENT FROM THE :RESIDENT'S iNCONIE OR RESOURCES. ..1 ST/6'd S26S606:01 :W08J 80:60 )-002-02-nON 600"d DU:60 Oni)L002-02-AON 8W11/81p0 xa Y• AGENT AND/OR LEGAL REPRESENTATIVE A. Agent -For the purposes of this funds/assets that may be legally used to pay the esident's char es or„`, person who manages, uses or controls Resident. The Agent's financial obligations are limited to the amount of the,filnds received on behalf by the Agent for the Resident. The Agent assumes no responsibility to pay for the costs of the R or held by the out of the Agent's personal funds. However, as a necessary Egent is care contractually bound by the terms of this Agreement and may become personally li ble for failure t o perform duties under the Agreement. If the Agent has control of or access to the Resident's i ncome and/or assets, the Agent agrees to use these funds for the Resident's welfare. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due an make prompt payment for care and services provided to the Resident as specified in the term d this s of this Agreement. THE AGENT 1S REQUIRED TO SIGN THIS ACRE EMENT AND DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR AGREES TO PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESOURCES, Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include not only the Resident, but also the obligations cement, act on behalf of the Resident, of Agent to B• Legal Representative - For the purposes of this Agreement, Legal Representative a person recognized under State law as having the authority to make health financial defined for the Resident. The Le gat Representati care and/or decisions ve may or may not be court appointed. A Legal Repres may be an attorney-in-fact acting under a Durable Power of Attorney f entative or Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the copies of documents verifying such status must be provided to the facility at the time of admii tent, ssion. XI. PAYMENT INFORMATION A• Obligation To Pay Timely -1'he Facility charges Resident. These charges are due and payable. by the tenth (i Oth da provided be billed monthly to a notice of a rate change, within ten days of y month or, in the case of (10) mailing of the notice. If payment is Mt received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate 1.5% (one and one-half percent) or the maximum amount permitted bylaw. This late charge e of alter any obligations of the Facility or Resident under this Agreement. In addition under Fed does not law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Fed, Resident is required to vacate for failure to pay, the Facility shall provide advance noti Facility. If a under the Transfer and Discharge section of this A ? ce as set forth I,reemt;nt. B• Credit Card Charges - The Facility accepts MasterCard and VISA. If the Resident the convenience of paying amounts due each month through one of these options, the Resident would like provide the needed information and authorization on the Credit Card Authorization form ath must this Agreement. The Resident recognizes that, unless the Resident has authorized the he stele u ar or VISA, the Facility does not offer credit or accept installment The Facility's se of MasterCard partial payment does not limit the Facility's ri > payments, acceptance of a t,hts under this Agrmment C. Fee For Returned Checks - A service fey charged by the bank, whichever is greater, will be charged ror an five dollars) or the actual fit any rc?et turnc,d check ST/01'd S269606:01 :Woad 60:60 LO02-02-nON 010'd w60 oni)1002-02-AON awtl/a4eo Xd D. Potential Personal Liability Of Ageatt - Agent (includes any Legal Representative serving as the Resident's Agent) shall pay ?he facility ftorn the :loent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's :are, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this V, cement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement. X11. PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each 'additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. in this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment -"Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer. Non-covered ch arges may include any coinsurar?.ce andior deductible amounts required by a third party payer. D. Communicating Changes in Assets - It is «;ssential for the Resident to communicate to the Facility any changes in the Resident's assets cr resources within ten (10) days of know!cdge of the changes in financial status. Upon request by the f'aci!i+y, -.he Resident shall provide the required informatics to the Facility within tcn days If the Resident runs out of private monies, it iSim, pertant to locate alternative payment ,,Ounces ro L.ay ''.:r :?s )r ! er ',?a nterntpted stay in the Facility. Generally, when uriy3te funds are depleted, the Rf'.SiA;!)i :r;_l es for Medical Assistance, and application-processing time can ;>e lengthy. The Resident agrees to xfc;r^i the Fa.cil?Y -A hen the value of `tis,'F;et -•emaining assets are within three (3) n:onchs of be`m; , -duced -c an amomit that. then i.ornhin-d w'ih the ST/TT'd S26S606:01 :WONJ 60:60 4002-02-nON 110 'd VV:60 (3noL002-02-AON awtl/a4e0 xa Resident's monthly income, is no longer sufficient to pay for ti:e cost of care and services. If the Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. E Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. XITI. MEDICAL ASSISTANCE PROGRAM RESIDENT - A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional serviceslitems provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance. A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage, s. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. "the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D, Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment E- Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, ;Private .Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis 7 91/2ti'd S26S606:01 :WOHJ 60:60 )-002-02-AON 210 d VV :60 (814002-02-AON awil/24eO xa F. Continuing Payment of Facility Charges Pending Eligibility - When an application for Medical _kssistance has btvn filed, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall he paid to the Facility on or before the tenth (10th) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. G. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by the Program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H- Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a private Pay Resident, In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. 1. Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XIV. MEDICARE RESIDENT - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. B. Limited Coverage -Medicare c verage i5 established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified 1.-.vel of care is covered for a specified number of days (benefit period). If the Resident no linger meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C- Expiration Of Hencilts - When Medicare ;ovrt Se eXpires, the Resident may remain in the Facility if private pay or ether rayment 71"range.ments bave been made. 'f the Resident wishes to be discharged from the Facility upon expiration of 1.1v1et;ic-jre ber,etits, he or -he must so advise the Facility at the time ^f the Resident's admi.."ion or re-dmis6cn. f the Resi&.nt im ndy to recome private pay when a ST/ET'd S26S606:01 :W08J 0S:60 L002-02-AON E10'd VP :60 Oni )1002-02-60N awil/age0 xa Medicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. D. Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance, and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The facility shall give notice to the Resident and, if kno Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. In uses where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. 8. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVL BED-BOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a bed-hold. The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days, if the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program a for a certain number of bed-hold days Otherwise, a Private Pay or Medicare Resident requesting may bed hold must pay the Facility's rat` during the bed-hold period. l prorated private monthly SZ/bZ'd S269606:01 :W021d 0S:60 L002-02-AON Vl0 d VV:60 (3ni)1002-02-60N awij/a4e0 xa XVIL RESIDENT'S RIGHTS AND F-%C11 ITY POLICY UNDER. ME FF,DERAIL SELF- DETERMINATION ACT A. Bight To Make Decisions Regarding Care -The Facility recognizes the right of each Resident to make decisions regarding his or her care, Where a Resident is incompetent, the Facility recognizes the Resident's right to have these decisions made on his/her behalf by a substitute decision maker in accordance Nvith State law. .R• Right To Formulate An Advance Directive. The Facility recognizes the right of each Resident to have an advance directive and will honor advance directives developed in accordance with State law and consistent with the level of care the Facility is licensed to provide. An advance directive is a written document that states choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of advance directives. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician and/or attorney. C. An Advance Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to continue to reside in the Facility. However, if the Resident has an advance directive, he or she must make it known to the Executive Director or designee so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at the time of admission, the advance directive information shall he provided to family members or other Resident representatives. However, if the Resident later regains competency, the Facility will provide such information directly to the Resident. YVIM CHARGES FOR COPIES OFMEDICAL RECORDS -The Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charted in the Facility's community. X.T.K. SOLE AGREEMENT— This Agreement is the only Admission Agreement between the Facility and the parties, Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining tears shalt stand 3s a valid Agreement. XX• ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not assignable The Resident may not transfer his or har rights under this Agreement to any other person. XXI. INTi ECKALTION - The Parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, premises, understandings, and agreements between the parties, ;4.hether written or oral, and th.CM•fore they are of no further force and cffect Because this is a icily integrated 3gtceirent, the only discussions, statements, representations, promises, understandings, or agreements that .are or will be binding on any of the parties to this Agreement or their employees, affiliates, cortracters, regents, or r"presentative 3 are those expressly set forth in Y.witing in This Agreement, or in order tk.ritt-.n agreements G,?tered into at sl!e j:wie t:me ;is; or subsequent to, this Agreement. SI/ST'd S26S606:01 S10'd 1408A 09:60 1002-02-nON DD:60 Oni )Z002-02-AON aw1l/a4o0 xa ',• Legal Representative,Xnd/Or Agent !`game , pAI Hnme _a honc; [71[11[-71171[31[71W[y][f-1[y) 'Mork Ohorw[ 1[ )[ ][ ?[ if 1( 1[ 1[ 1 [ ) Sd Al, 4•m L e a ? Street ? 'JO ,3 City State Zip 9- Other Person To Be Notified Name Koine Phone; [ )[ ][ )[ 1[ 1[ 1[ ][ ][) [ ) Work Phone[ )[ ]( ][ )[ )[ )[ )[ )( ][ ] Street City State Z;p XXV. XU><. - The Facility is authorized only.) to handle the Resident's mail as follows: Check ( ON box [ ) . If mail ogiw;n directly to the Rcsideni [ All mail ead to the Resident Lvd"Ward nll of the Resident's mail to: ( )Give pe onol mail to the Resident; forward business mail to: XXVI. RESIDENT'S PFIYS[CIAM A- NAME: B. SPECIALTY: C. ADDRESS: 0. " 'ELEPHONE: Xtil.:2ESIDEti'T'T';ZZi'?T ?tp ,• ? r+-X `:.ld by a ?? UTHORUUTION - A Re )e Facility cr the Re!F'Cent's personal use. (Example nor^?,r ,,, - rd ac..?rd c.i•_^t " har ' ? ' = ?? , 3 ?'P ?- ges, -igarcttes, postage stamp ?: ti :,:w i?•??s!'?-rt. j y ;;;;.1itr ,xlcw the Resident authcrius the F.aci - Tl'v '?t?,': ,' ' i t'na?c::_l shall be av t h;. , a?lable •hroij jh qui s, _; rear r U,;1 P_ ".e. ident _ t;t1t._ tie., e. T'ie ", o.ACc- ..ITCC el/2'd 926S606:01 200'd dent Trust Fund is an amount of of use: To allow the resident to pay or other similar expenses as desired y to ,et pup a trust fiord in his/her :erly ;.tatements, and on request, to rdcrsvinds that all'Aithdrawals Resident :WOdA ST:4T 4002-60-AON 21:11 UdJ4 002-60-AON awtl/24e0 xa c r a 4 e G ` ). Ji be !uthor,7cd by the Resident or hi0er Agent or Legal persons May iuthrei,e ,;ithdrawals on the Resident's behalf- Name c.t Ikuthorized Person i--? Name of Re, ident's Signature --- Date '.Vitness i; Resident Signed with a Mark Da e G Legal Representative's Signature (if applicable) Date Agent's Signature (if applicable) Date in writing. The following F-P-- zed person %. v XXVILE CRCDIT CARD,%UTHORiIZATION _ Facility acc M would like the convenience of paying amounts due each month th MasterCard and VISA. If Resident n??edtd 'nfcrmation and authorization' ugh one of these 1 p ease provide the Credit Card Account .# Expiration Date ?- I hereby authorize Facility to charge the account listed above for Agrcx n:ert, Resident or Agent's Signature Ir the Resident is unable to consent or sign this provision because c incclTetence or is a frinor and this provision is being the fc"l0`v;n3; signed by an D?t:.'. Relationship to Resident. l it.i?ss Rev {. sT.R•d E00 'd '? ; tCc SZ6S6O6:O1 charges incurred under this Date physical disability or mental uthorized representative, complete Date- I C t ? I 'Tnk - Nircic:,! "c nrd; j ?t6?w - Rrtc?rla.,. :WONJ SZ:LZ L002-60-f1ON 21:L1 (IdA)L002-60-AON awtl/a4e0 xa Authorized Representative Signature; Print Name and Title- AI?S O n Rev. 03/13/03 White - Business Office BT/t, 'CA S26S606:Oi DOO d Pink - Medical Records Ye11Ov - Resident :WO8-? ST :LT L002-60-nDN 2l:Ll (IdA)A02-60-AON awtl/a4e0 xa "DNIISSION AGREENIEn'r SIGN -X-XI X- PARTIES - The parties to this ,%9rCement are: f dame o Facility) (Name (Na,'ne or' Resident's ??gent) ""e Legal Representative signs the Agreement, check the Type [ J Conservator of Person [ J Guardian [ j [ Conservator of Estate urabl° P°`?'er of Att [ ) Other, sp" for Health Care (DP If you are signing My this Agreement on behalf of the Resident, note relationship to the Resident is y On this' day of this Agreement and agree that ? eh -,2000", the above panics a this Facility. -IS-?day of? 2 Re''si ent Address City. State, Zip Witness if Resident Signed with a Mark 'A itft-gs if Resident Signed with a Mark 0 LcSW ROU'presetttative c sentativC's Address Lc*?,L "J?1:?tu 3usinecs ()f- _e 81/S'd S26S606:01 S00 d 'RE PAGE /I 'of Resident's Legal Representative) Legal Representative (below): [ ) Agent Acting Under General POA relationship to the Resident: La to be bound by the provisions of `C .7the Resident shall be admitted to ?? Date Reside 's Social Security, Number Resid 's Telephone Number Date Date Date Le!zal Telephcne Number ?ink - t .!.C,,I-:7w - PLzi,rnt :W06d ST :LT z002-60-MON 21:Zl (I A )I002-60-AON am?1/a3e0 xa five's social Scxunty No. 1 n ?s v Agent Agent's Address G Facility E tive Director or Designee Facility Name Date Agent's Social Security Number Agent's Tel4phone Number Date Facility Ad ress %() Amp 141/ Note; The signatures above refer to the informs/ tiott contained on 1 Agreement. 1 through 16 of the Admission 0 I 4 Rev 03/13/03 White - Business Office 8T/9'd 900 'd Sz6S606:01 Pink - ,\fcdicai Records 1A Yellow - Resident :WObd ST:LT LO02-60-AON 21:11 (IM L002-60-AON aw?1/aleO xa . ? ,,u} °?n .h.; :?•???il: 1:3,.?,??,nt, 1,'a:l';,i(al?•+(1. ..: , ac l c-.. Id,? nt :'hail I% ;orb L.d-ttW tic P. ?•r 1-arrk:ci iFit ,:>ri?a; ??id :;h?,l.lld r.:asona bly h:.we F,e ;n ?lillct ?ttsct Cf 1iEitrcti m i5 :jillolll to the Iht!: >r r'JCl1Vi'•?? !iL lht` F2 +sid rite :rnitrttipn protxediIi.g. - THE PARTIES UNBERSTAND AND AGREE Ti NA7' TMS C( ,t!.RMTRATION PRO( ISICDN `,11IdIlC:Ii MAY BE ENFORCED XINTERMC. INTO TIFFS ARBITRATION AGREEMENT, TI'i WAIVING TUEIR CONST1171TI;ONAL RIGHT T O FIA% E V OF LAW BEFORE A .I[,ME AND A JURY, AS WELL %S A OR AWARD OF DAMAGES. [he Resident understands that (1) heishe has the right to seek legal Agreement, (2) that cx(xution of this Arbitration Agreement is not furnishing of services to the Resident by the facility, and (3) this A by written notice to the Facility from the Resident within thirty day! thirty days, this Arbitration Agreement shall remain in effect for all if the Resident is discharged from and readmitted to the Facility. The ultdersigned certifies that lit-JAe has read this Arbitration Agret explained to him/her, that he; ilie understands its contents, and has r that heJshe is the Resident, or a person duly authorized by the Rc..,id +lgreement and accept its terms. Date: Signature: (Re:sidcnt) Witness; If the resident is unable to consent or sign this provision because of incompetence or is a minor and an authorized re?presvntative is slgni g h y'thissical diprovsaision,bility or mental following; complLtc the Date: -- lzs- G 7 x RelGtionship to Resident: k Slgnatl.tre: l ' "."M - (Authori ed reprvsentati% ? v??tress. 0 3LV 'r?nit: • "+.r.:'t....-• .'•?-_. 8ti?L'd S26S606:01 J :WO8J SI:LS L002-60-OON M 'd 21:L1 (I8d)L002-60-60N awtl/alp0 xa ••t:l:'?;t? (',' 1:' k: i.?t l'.i11':.: t'Y I" \;'I Vf4. 'j '..riVC(l tc; the •4hich :nt :nd :.Ilc:h cluiln is Ort pic`ttlted in (TRACT CONTA INS 1 BUN DING, Y 7'I#E P.%RTIES, .1yD THAT BY r'ARTIES ARE C','I'y M; UP AND CLAI:XI DE00ED IN n COL'R'r Y APPEAL FROM A DECISION :ounsel concerning this Arbitration precondition to admission or to the )itration Agreement may be rescinded of signature. If not rescinded within ibsecluent stays at the Facility, even nt and that It has hcen tinily •.c•d a copy of the pro ision 'ind or othur.?i,%e to I:xi.cute This n 0 v Date: 4e /,/-5- le" Authorized Representative Signature: -? Print Name and Title- -A2AAQ y` r) Z l Rcv. 03/13/03 White - 6usincss OtFice Phil, - Ma ical Records y Yellow- Reident BT/8'd S26S606:01 :WO8J 9I:LT L002-60-AON BOO 'd 21:11 (I8A)1002-60-60N aw11/24e0 xa A'? r?3 `? J - T -TI - ?, 09 r.? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, Plaintiff, V. No. 07-7147 ALMA FERGUSON, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INTUNCTION AND NOW, COMES, Golden Living Center - West Shore Health and Rehabilitation ("Petitioner"), by and through its attorneys, SCHU FJER BOGAR LLC, and pursuant to the provisions of Pa. R.C.P. No. 1531, makes the following petition for a preliminary injunction and, in support thereof, avers: 1. On or about November 29, 2007, Petitioner filed its Complaint against Alma Ferguson ("Respondent") 2. The Complaint sets forth a claim against Respondent relating to her breach of the Admission Agreement ("Agreement") she signed on behalf of Carolyn Kirk ("Ms. Kirk") by failing to cooperate in Ms. Kirk's Medical Assistance application process by providing the necessary financial documentation to the Cumberland County Assistance Office to determine Ms. Kirk's eligibility for benefits. See Complaint filed with the Cumberland County Prothonotary on November 29, 2007. ORIGINAL °a ?' 3. The very nature of the breach of the Agreement presents an issue of immediate and irreparable harm to Petitioner, as Ms. Kirk's application for Medical Assistance benefits was denied due to the lack of necessary documentary evidence to establish her eligibility for Medical Assistance benefits. 4. The requested injunction would restore the parties to the status quo as it existed immediately prior to Respondent's breach of the Agreement, as Respondent has a contractual duty to cooperate with the Medical Assistance application process commenced on behalf of Ms. Kirk. 5. Greater injury would result from the denial of the requested injunction than from the granting of the same, as absent the injunction, without the documentation necessary to establish the eligibility of Ms. Kirk for Medical Assistance benefits, the appeal of the denial of Ms. Kirk's application for Medical Assistance benefits will fail, and further appeal to the Commonwealth Court would be without merit. 6. Petitioners right to relief is clear. See Complaint. 7. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Ms. Kirk has been financially unable to fully compensate Petitioner for the care and services that it has rendered and continues to render to her. 8. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. 2 WHEREFORE, Petitioner respectfully requests that this Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a Decree ordering specific performance of the Agreement between the parties. Respectfully submitted, Dated: ?2 ??J v7 SCHUTJER BOGAR LLC By: .a cJJ ? ?.. Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 417 Walnut Street, 411, Floor Harrisburg, PA 17101 Attorneys for Petitioner V6 1CATION The undersigned hereby verifies that the statements of fact in the foregoing Petition for PreRwAnaryr injunction are true and correct to tine best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: 1 Z t2 p'} ?v Finr_ Executive Dirdktor, Golden Living Center- West Shore CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Petition for Preliminary Injunction was served first-class, United States mail, postage prepaid, upon the following: Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Dated: 0- t ? 0 --k' By. _VJ__ William Keslar, Paralegal x.317 rt rn rte r? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, Plaintiff, V. ALMA FERGUSON, Defendant PRAECIPE FOR CHANGE OF ADDRESS TO THE PROTHONOTARY: Kindly change the address on record for counsel for Plaintiff in the above- captioned matter as follows: No. 07-7147 CIVIL ACTION - EQUITY SCHUTJER BOGAR LLC 417 Walnut Street, 41h Floor Harrisburg, PA 17101 Respectfully submitted, SCHUTJER BOGAR LLC Dated: 0 4 By: Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 417 Walnut Street, 461 Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff ORIGINAL CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Change of Address was served via first-class, United States mail, postage prepaid, upon the following: Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Date: V_/__ William Keslar, Paralegal 2 C -ca tea c? f rn o c GOLDEN LIVING CENTER- WEST SHORE HEALTH AND REHABILITATION, Plaintiff V. ALMA FERGUSON, Defendant CIVIL ACTION - LAW NO. 07-7147 CIVIL TERM ORDER OF COURT AND NOW, this 3rd day of January, 2008, upon consideration of Plaintiff's Petition for Preliminary Injunction, a hearing is scheduled for Tuesday, January 22, 2008, at 3:30 p.m., in Courtroom No. 1, Cumberland County Courthouse, Carlisle, Pennsylvania. Chadwick O. Bogar, Esq. Maria G. Macus-Bryan, Esq. 417 Walnut Street Fourth Floor Harrisburg, PA 17101 Attorneys for Plaintiff Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Defendant, pro Se IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA BY THE COURT, J Con P t tS /)7e7 c CAL :rc 8C :01 WV C- NVr DOOZ AE ViONU -i'Li-O d 3HI JO 301-11:110-031H IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, Plaintiff, V. No. 07-7147 ALMA FERGUSON, Defendant. CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW WITHOUT PREJUDICE PETITION FOR PRELIMINARY INJUNCTION AND BRIEF IN SUPPORT OF PETITION FOR PRELIMINARY INTUNCTION TO THE PROTHONOTARY: Kindly withdraw, without prejudice, the Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction that was filed in the above- captioned matter on December 17, 2007. Respectfully submitted, SCHUTJER BOGAR LLC Dated: V 1 710 6 G By? Chadwick O. Bogar Attorney I.D. 83755 (717) 909-5920 Maria G. Macus-Bryan Attorney I.D. 90947 (717) 909-8640 417 Walnut Street, 41h Floor Harrisburg, PA 17101 Attorneys for Plaintiff ORIGINAL CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw Without Prejudice Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction was served via United Postal Service Overnight Delivery, postage prepaid, upon the following: Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Dated: t t? 0 6 By: V/-- William Keslar, Paralegal C `, r ?J .,.:.. t.. +..:.a r`7 ) L:a:t 1'l { ?? 1 _ ', I'? `i ?? 1 ,? .?,? GOLDEN LIVING CENTER-WEST SHORE HEALTH AND REHABILITATION, Plaintiff V. ALMA FERGUSON, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-7147 CIVIL TERM ORDER OF COURT AND NOW, this 24th day of January, 2008, upon consideration of Plaintiff's Praecipe To Withdraw without Prejudice Petition for Preliminary Injunction, the hearing previously scheduled for January 22, 2008, is cancelled. BY THE COURT, Chadwick O. Bogar, Esq. Maria G. Macus-Bryan, Esq. 417 Walnut Street Fourth Floor Harrisburg, PA 17101 Attorneys for Plaintiff ?Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Defendant, pro Se Co LES ma l le'4 i?a soda : rc 11 +aa+ r }sti ril ?L? Of -.% IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GOLDEN LIVING CENTER - WEST SHORE HEALTH AND REHABILITATION, Plaintiff, V. No. 07-7147 ALMA FERGUSON, Defendant. CIVIL ACTION - EQUITY PRAECIPE TO SETTLE. DISCONTINUE. AND END TO THE PROTHONOTARY: Kindly mark the above-captioned matter as Settled, Discontinued, and Ended without prejudice. Respectfully submitted, SCHUTJER BOGAR LLC Dated: k/ a BY, Chadwick 0. Bogar Attorney I.D. No. 83755 (717) 909-5920 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Settle, Discontinue, and End was served first-class, United States mail, postage prepaid, upon the following: Alma Ferguson 66 Ashburg Drive Mechanicsburg, PA 17050 Dated: 4o0g By: Christy A. Long, Paralegal ?_ N a C~? ?. ?F `°:y fi_.. r' LL'1 T,y ?_: __w ?_ ::`f '^?'' FR.3 .. ?? =y?