HomeMy WebLinkAbout12-10-07
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IN THE COURT OF COMMON PLEAS - CUMBERLAND COUNTY
ORPHANS' COURT DIVISION
IN RE: CAROLYN KIRK,
An Alleged Incapacitated Person
O.C.No. '2\ - O"\-\\Z.I
PETITION UNDER & 5511 OF THE PROBATE,
ESTATES AND FIDUCIARIES CODE TO ADJUDGE
CAROLYN KIRK TO BE TOT ALLY INCAP ACIT A TED AND
APPOINT A PERMANENT PLENARY GUARDIAN
FOR HER PERSON AND ESTATE
AND NOW, COMES, Petitioner, Beverly Fry, Administrator of Golden Living
Center - West Shore Health and Rehabilitation ("Petitioner"), by and through its
attorneys, ScHU1]ER BOGAR LLC, and hereby petitions for the adjudication of incapacity
and the appointment of a permanent plenary guardian of the person and of the estate of
Carolyn Kirk and, in support thereof, represents as follows:
1. The alleged incapacitated person, Carolyn Kirk, is an 82-year old divorced
individual, born on January 25, 1926, who currently resides at Petitioner's skilled
nursing facility, located at 770 Poplar Church Road, Camp Hill, Pennsylvania 17011.
2.
Petitioner, Beverly Fry, is an adult individual and the Administrator of
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3. On June 15,2007, Carolyn Kirk was admitted to Golden Living Center -
West Shore Health and Rehabilitation, and her Power of Attorney, Alma Ferguson,
signed the Admission Agreement. See Admission Agreement, attached as Exhibit" A."
4. Because the alleged incapacitated person resides in Cumberland County,
this Court has Jurisdiction pursuant to 9 711(10) of the Probate, Estates and Fiduciary
Code and 95512(a).
5. Upon information and belief, and to the extent of Petitioner's knowledge,
Carolyn Kirk does not have any next of kin.
6. An application for Medical Assistance benefits was filed for Carolyn Kirk
with the Cumberland County Assistance Office of the Department of Public Welfare of
the Commonwealth of Pennsylvania and is currently pending.
7. Petitioner is unaware of the value, if any, of the alleged incapacitated
person's estate.
8. Golden Living Center - West Shore Health and Rehabilitation is not
currently Representative Payee for the Social Security income of the alleged
incapacitated person, but the facility has completed and submitted the necessary
paperwork to become Representative Payee.
9. The alleged incapacitated person's treating physician is:
Dr. Thomas Kunkle
550 Brandt A venue
New Cumberland, PA 17070
(717) 774-0300
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10. To the extent of Petitioner's knowledge, Carolyn Kirk, the alleged
incapacitated person, has been diagnosed by Dr. Kunkle as suffering from dementia,
and upon information and belief, that condition has caused her incapacity and requires
that she receive 24-hour-a-day care.
11. Upon information and belief and to the extent of Petitioner's knowledge,
because of the condition set forth in paragraph 10, Carolyn Kirk, the alleged
incapacitated person, is totally unable to manage or even appreciate the significance of
her personal and/ or financial affairs and to make and communicate any decisions
relating thereto, including the ability to communicate her need for assistance in these
areas.
12. Presently, Alma Ferguson serves as the Power of Attorney for Carolyn
Kirk, pursuant to the Power of Attorney attached as Exhibit "B," but Petitioner avers
that Alma Ferguson is inadequately representing the interests of the alleged
incapacitated individual and is not a disinterested and/ or capable agent to manage the
alleged incapacitated person's financial affairs by qualifying her for Medical Assistance
benefits.
13. There are no less restrictive alternatives to the appointment of a
permanent plenary guardian of the person and of the estate of the alleged incapacitated
person.
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14. The proposed guardian of the alleged incapacitated person is
Pennsylvania Guardianship Association located at P.O. Box 7295, Lancaster,
Pennsylvania 17604. Pennsylvania Guardianship Association does not have any
adverse interest to the alleged incapacitated person and an acceptance to serve as
guardian of the person and the estate is attached hereto as Exhibit "C."
15. Pennsylvania Guardianship Association has been suggested as guardian
of the person and estate of Carolyn Kirk, because of its vast experience in dealing with
incapacitated persons such as her.
16. No Court within this Commonwealth, of which Petitioner has knowledge,
has appointed a guardian for Carolyn Kirk.
17. Upon information and belief and to the extent of Petitioner's knowledge,
Carolyn Kirk was not a member of the Armed Services of the United States and is not
receiving any benefits from the United States Veterans' Administration.
18. Upon information and belief and to the extent of Petitioner's knowledge,
the alleged incapacitated person has not executed an advance health care directive.
19. Upon information and belief and to the extent of Petitioner's knowledge,
the alleged incapacitated person does not have a Last Will and Testament.
20. Petitioner is not aware of whether the alleged incapacitated person has
funds reserved for funeral and/ or burial expenses.
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WHEREFORE, your Petitioner prays your Honorable Court to award a citation
directed to the alleged incapacitated person, Carolyn Kirk, to show cause, if any there
be, why she should not be adjudged incapacitated and a guardian of her person and her
estate be appointed.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: lQ..j-=r /:JfX)f
By: ~Jd.~(l~
Chadwick O. Bogar
Attorney J. D. No. 83755
(717) 909-5920
Maria G. Macus-Bryan
Attorney J.D. No. 90947
(717) 909-8640
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Attorneys for Petitioner
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I ·
EXHIBIT II A"
WELCOME
THANK YOU FOR l.1I00S1N{; US FOR YOUR NlIRSING FACILITY C4RE
The staff of this Facility will rake 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 STATEME~T - The Facility welcomes all persons in need of its
services and does not discriminate on the basis of age, disability, race, color, national origin. ancestT)'.
religion, or sex. The Facility does not discriminate among persons based On their sources ofpaymem.
ll. 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
cenification as health care workers. In the course of tbis 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. .Physiciaq 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. It:
however, the Resident does not select an aUending 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 and agrees that such physicians are
not associates or agents ofthe Facility and that the Facility's liability for any physician's act or omission is
limited. The Residtmt 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 oflaw. 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.
ID. .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, jf the Resident elects to do so, by signing a separate agreement executed
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bt:twcen the parties Agreeing to arbitration is not a condition of admission or continuing care.
v . PRIVACY ACT NOTlFIC A TION STATEMENT - Skilfed nursing facilities who contract with the
Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or
"Program") are required to conduct comprehcmsivc. accurate, standardized. and reproducible assessments
of each resident's functional capacity and health status. As of June 22, 1998, an skilled nursing and
nursing facilities are required to establish a database of resident assessment infonnation and to
electronically transmit this information to the State. The State is then required to transmit the data to the
Federal C~ntral Office Minimum Data Set (MOS) repository ofthe Centers for Medicare and Medicaid
Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and !\lIDS
Long Term Care Systems of Records. 'fhe Center tor Medicare and Medicaid Services is authorized to
collect these data by Sections J 819(t), J919(t), 1819(bX3)(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
MedicareIMedical 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 ~tem will collect the minimum amount of personal data needed to accomplish its stated
purpose.
The infonnation collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS)
sysrem of records, System No. 09-70-1516. lnfonnation trom rhis 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 office made at the request of that individual; (2) the Bureau of Census; (3)
t he 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 ora 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 XVllI
functions; (9) services for preventing fraud or abuse under specific conditions.
You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988,
permits the government to verify infonnation by way of computer matches.
Collection of the Social Security Number is voluntary; however, failure to provide this infonnation 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 cenified Medicare/Medical Assistance nursing facility the
reque:>ted information is mandatory because of the need to assess the effectiveness and quality of care
given in ccnified facilities and to assess the appropriateness of provided services. If a nursing home does
not submit the required data it cannot be reimbursed for any MedicareIMedical As~istance services.
VI. RESIDENT'S PERSONAL PROPERTY
A. Safety Of Residentts Personal PrQperty - The FaciJiry strongly disco1Jrages the keeping of
valuable je'.., ~lry, papers. large SlJm~ of money, or other items considered of vfiJue in the Facility. The
Facility 'Shall make reasonable efforts to ~a!eguard the RL-sident's property/valuables. which the Resident
t;hoo~es tu keep in his or her possession. rhe Resident agrees tC) inform the Facility in Writing oj all
p~rsonal propeny l~pGn admission. If. at any ~ime dt;nng ttJe R~idcnt's stay, new items of valu~ are
brought to or remo'./ed from ihe R;~.:dentls pt:'s'ic~~i()ns in the !"lcility, the Resident also agrees fo so
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infonn the Facility Executive Director or designee
B. Penonal 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
Residem if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable
State law.
VD. PERSONAL FUNDS
A. Right To Managf 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 shan assist if
requested fO 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. lnterest - The Facility shan 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. AU interest earned on the Resident's funds shall be credited to the Resident's
account. The Facility shall have the option of depositing funds ofJess than Fifty DoJtars ($50.00) in one
of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The
FaciJityshall 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 Facilitys 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 4 The personal fund balances of Residents who receive Medical
Assistance Program benefits must remain within a certain dollar range to satisfY State and Federal Jaws.
The Facility shall notifY a Medical Assistance Program Resident ifhis or her account balance is within
Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (S5J) limit. The Facility
shall also notifY the Resident if the account balance> in addition to the Resident's known non-exempt
assets., reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to Jose
eligibility for Medical Assistance or SS!.
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 fun accounting of these
funds to the individual, probate jurisdiction administering the Resident'g 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.
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G. Security 1)( iiullds - rhe Facility shall ~nsure the security ,)f gil personal funds deposited with the
F;icility and shall not take money from a Medicar~ or Medical Assistanc.e Program Resident's personal
funds tor any item or service [hr ~hich payment can be made under the Programs.
VUJ. 'mE RESIDENT'S DUTIES
.\. Facility's Rules And Regulations - The Resident agrees that the Facility may. to maintain
orderly and economical operations, adopt reasonable rules and reguJations 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. It is understood
that the rules and regulations may be am~nded from time to time as the Facility may require. Any changes
to the rules and regulations :)haU be given to the R~sident 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 toU-free "Hotline"
telephone number through which grievances can be registered anonymously. This number is 1-800-572-
9981. Residents also have the right to contact the Sta.te 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 db'tribution system. All drugs or
medications brought into the Facility shall be immediately delivered to the nurses' station.
[.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 propeny and premises. The Resident
shall be responsible for repair or replacement of the Facility's propeny 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 wi)) attempt to accommodate all reasonable requests to individualize Resident rooms.
For safety reasons, the Facility must concur with any addition or rearrangement offumiture, hanging of
pictures, posters, or other similar activities.
IX. PROHlBITJON AGAINST TIDRD PARTY GUARA"'TOR -FEDERAL AND STATE LAWS
.PROHIBIT A NURSING DOME fROM REQUIRING A THIRD PARTY GUARANTEE OF
PA YMENT TO THE FACnJTY AS A CONDITION OF .~DMISSION, &,XPEDlTED ADMISSION
<;lR CON'I'VfUED STAY iN mE FACU..ITY. HOWEVER., A FACILITY MAY REQUIRE AN
INDIVIDUAL WHO HAS LEGAL ACCESS TO THE RESIDENT'S INCOME OR RESOURCES
AVAQABLE TO PAY FOR FACllJ.TY CARE TO SIGN A CONTRACT, WlmOUT INCURRING
PERSONAL FlNANCl4L LL'\BITJTY FOR THE. RESIDENT'S COSTS OF CAR~ TO PROVIDE
FACILITY PAYMENT FROM THE :U:SIDENrs INCOME OR RESOURCES.
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x. AGENT A~D/OR LEGAL REPRESE~T A TIVE
A. Agtnt - For the purposes of this Agreement, an Agent i. a per.on whn manages, uses or control.
funds/assets that may be legally used to pay the Resident's cbMges or who otherwise act, on bellalf of rhc
Resident. The Agent's linancw obligations are limited to the amount of th. funds received or h.1d by rhc
Agent for th.Resid.... The Agent assum., DO responsibility to pay for tbe COsts of the Resident', care
out ofth. Agenr, personal funds. However, as a necessary party to thi, Agreement, the Agent is
contractually bound by the terms of this Agreement and may become personally liable for failure to
perform duties under the Agreement. lfthe Agent has control of or access to the Resident's income
and/or assets, the Agent agrees to use these funds fur the Resident', welfar.. The Agen, is required to
produce financial documentation as proof of the ReSident's ability to pay for charges when due and to
make prompt payment for care and services provided to the Resident as specified in the terms of this
Agreement. THE AGENT 18 REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO
DISTRIBUTE TO THE FACILITY. 1IR0M TIlE RESIDENT'S INCOME OR RESOURCES,
PAYMENT WlIEN DUE FOR THE ITEMSiSERVICES PROVIDED TO THE RESIDENT.
Wh......er this A_..t ref... to the Resident's Ii....c;,,' obligotion. ..der this ag....m..t,
"Reald..t" 'hall'" constru.d to lnclnd. not only the Residtnt, b.t abotb. obligations or Agent to
act on behalf of the Resident.
B. Lega' Rep......tallv. - For the: PUrposes ofthis Agreement, Legal Representative is defined as a
person recognized under State law as having the authority to make health care andlor financial decisions
fur the Resident Th. Legal Represeotative mayor may not be court appointed. A Legal Representativ.
roay be an attorney-in-fltct acting under- a Durable Power- of Attorney fOT Health Care. guardian,
conservator, next-of-kin, or other person alJowed to act for the Resident under State Law_ If Legal
Representative status has been conferred by a court of la w or through appointment by the Resident,
copies of documents verifying such status must be provided to the Facility at the time of admission,
XI. PAYMENT LNFORMA nON
A. Obligation T. Pay li....y - The Facility charges for services provided shall he: billed monthly to
the Resident. Thes. charges are due and payable by the tenth (10th) day of each month or, in the case of
a notice of a rate change, within ten (10) days of mailing of the notice. If payment is !!Q! received timely,
the aCCOunt balance is considered poot due and the Facility may add alate charg. to the: Residen(s
account. This late charge shaJl be assessed on the montbly balance at the lesser of the monthly rate of
1.5% (one and on...half percent) or the maximuro amount permitter! by law. This late charge does DOt
alter- any obligations of the: Facility or Resident under this Agreement In addition, under Federal law,
failure to pay any amount due the Facility is grounds for discharge ofthe Resident from the Facility. I f a
Resident is required tn vacate fo< failure to pay, the Facility shall prov;d. advance nOlice as set forth
under the Transfer and Discharge section of this Agreement.
B. Credit Card Cbarges - The Facility accepts MasterCard and VISA. If the Resident would like
the convenience nf paying amounts due each month through one of these options, the ReSident must
provide the needed information and authorization on the Credit Card Authorization form at the back of
this Agreement The Resident recognizes that, unless the Resident has au.hori<ed the use of MasterCard
or VISA, the Facility doe, not offer credit or accept installm.nt payments. The F oeility's acceptance of a
partial payment does not limit the Facility's rights under this Agreement
C. Fee Fo, Returned Checks - A service fee of $25.00 (twenty-five dollars) 0' the actual re.
charged by the bank, which~v~r is grc:att:f. will be chargl.:d for any !"cturned check
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.0. Pf)tential Persomtl Liability Of Agent - Agent (includes arty Legal RKpresentative serving as
the Resident's Agent) shall pay the Facility from the :\gent's ov"n re.SQurces as liquidated damages an
amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's
~Cl.re, which the Agtmt withholds, misappropriates for personal use, or otherwise does not turn over to
Facility for payment of Resident's financial obligations under this Agreement, or an amount cquivalt:nt 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.
XII. PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal
program is paying tor 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 <!etermined in pan 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 ofadrrlssion. an amount no less than the first fun
monih's room and board cr.arge 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 adV311ce 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. Tn this easel the Resident shall be
refunded 11 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 priva.te 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 bUlliness hours.
9. Rate Adjustments - Th~ Facility shall provide advance written notice of any monthly rate
adjustment However, if at any time the Resident.~ 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 tails to leave by this date,
the Resident shall be considered to have con'3ented to the increase tor the duration orthe Residenfs stay.
c. Primary Responsibility for Payment - Notwithstanding the source offunds for payment for the
F'lcilil'j'$ charges, the Resident remaing primarily r;;sponsible for paying all Faciiity charges, including any
charges nl)t ~overed by a third party payer, unle')s expressly prohibited by a contractual agreement
between the Facility and payer. Non-covered dllrges may include any coinsurance andior deductible
amounts required by a third party payer.
D. Communicating Chang" in -\ssets - It ;8 ,~ssential tor the Resident to communicate to the
Facility any changes in the Resident's assets cr resources within ten (10) days of knowledge of the
changes in financial status. I;pon request by lie F~.cilj+y, :.ne Resident shall provide the required
~nformaticJl to the Facility \\'itl1in t~n day,; If ;he Re~!jcnt nms cut of priv.'ttc monies, it is important to
locate alternative paym~nt '}OUfces [() jJJ.y :':r his :jr f~r "~i1~JltcrfIJ.pt~d stay in the F'lcility. Generally,
when pri'l3te funds are deple~ed, the ~e!$idcnT 'l;:.:Ees for .\t~dical Assistance, and application-processing
time can ;)e lengthy. The Resident 19ree~ to ,dor:"'1 the F?',dl>j .Allen the vi11l1e tJf~is/her -emaining
lr.,,,~tS are \':irhin three (3) momhs ..,fbe;n~ ..",duc~d iC :iO a:nOIUlt !har, ""hen GOmhin~d w;lh the
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Resident's monthly income, is no longer sufficient tel pay for the co~t 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 shaII not t:'aIlSfer or evict the Resident solely ac; a result of
the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance,
unless the Facility is not cenified for Medical Assistance.
xm. MEDICAL ASSISTANCE PROGRAM RESIDENT _ A Medical Assistance Program
Resident is one who receives benefits from the State MedicaJ Assistance Program for a majority of his or
her Room & Board charges. The Program mayor may nor Cover charges for additional servlceslitems
provided by the Facility. depending on State law. Medicaid eligibility is a requirement for Medical
Assistance.
A. Applying For Medical Assistance - The FaciJity 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.
B. Qualifying For Medical Assistance. The Resident should 'learn it the Medicaid eligibility
requirement is met at the time of admission. If 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: (I) timely completion and submission., ifapplicable. of
Resident's application, and (2) taking any and aU 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 infonnation 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 Infonned . The Resident
agrees to provide all of the intormation 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 infonnation 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 andlor 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 tor a reasonable share of the cost of their care, referred to as Share afCost, Private Portion,
Patient Liability, Patient Resource, or similar designation, Payment of that share is the responsibility of
the Resident. The State can change the Resid~nt' s share of cost at its discretion. Changes in the
Resident's Share of Cost must be communicatoo to the Facility on a timely basis
Sl....21'd
2l0d
7
S26S612l6 :01
:~~ 6b:60 LI2l02-02-~
VP:&O (3nl)L002-02-^ON aWJl/a4PO x~
~-. Continuing Payment of Fadlity Charges Pending Eligibility - W~el1 an 3.pplicat:on for
1\:lcdical ,\ssistance has ~~'en tiled, the Re.lid~t agrees that whitt: the Resident's a.pplication is "pending,"
the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (lOth) day of
each month. Once the Resident is detennincd to be eligible tor M~ical Assistance, the Resident's Share
of Cost shall be paid to the Facility on or before the tenth day of each month. [fthe 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 ofeost may result in the
Resident's discharge from the Facility.
G. Daily Rate Payment - On admission, the Resident shall be provided ..vith a list of supplies and
services generally paid for by the MedicaJ 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 tor review during normal business hours.
Do 'rennination or Coverage - A Resident who remains in the Facility after Medical Assistance
coverage has expired or been retroactively terminated or denied must pay Facility charg,es as a Private
Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in
t:ffect at the time of service.
I. Designation or Facility As Representative Payee - Resident and Agent agree that, in the event
the Resident become delinquem 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 rhis 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. Medi(are 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 progr-am, and those supplies and
services not paid for by the Medicare program for which the Resident wiJI be separately charged. A
detailed list of charges for supplies and servic~s available in the F ~cj}ity but not covered under the
Medicare program, including the daily coulsuran.ce rate, is maintained in the Business Office and is
available for review during normal business hours..
B. Limited Coverage - Medicare coverage is established by Federal guiddines and not by the
Facility. Medicare ~overag~ is limited in that only a specified l,~vel of care is covered tor a specified
number of days (benefit p~riod). Tftht Resident no !()ng~r meets Medicare coverage criteria, coverage
can be ended before the tJ~c or all allotted days in the cmrent benefit period.
C. :E~piratjon Of 8e-ncfits - When Medicare C<.wernge expires, the R~jident may remain in the
Facility if private payor orher vaym~t ~rrangerr'~nt~ hJve neen ?flade. If the Resident wishes to be
,jischarg~d from the Facility upon expiration ofM~rlic;}re benents, he or she must so advise the Facility at
the time ('fthc R~sidC'nt's adm;.;~jcn (',f rc~dnJlS'3i;,:.n. i'fthe Reo;id,;l1t in.t'~nd" to ljeCl)me private pay when
~
Sl/~l'd
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S26S606 : O.l
:wo~~ 0S:60 L002-02-~ON
VV:60 (3nl)L002-02-~ON awrl/a~QO XM
Medicare benefits expire, the Resident agrce~ to pay in advance for one month's room and board at the
prhrate 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 cowred by the Medical A.,sistance Program for dually eligible
residents.
xv. TRANSFERS AND DISCHARGES
A. Notice - The Facility shall give notice to the Resident and. ifknown, a family member or Legal
Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required,
this notice shall be givcn at least thirty (30) days prior to the Resident's transfer or discharge. In cases
where the safety or healtb 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 trans ferl discharge. Notice
will also include information regarding the right to appeal a transfer/discharge.
B. 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 ofindividuafs in the Facility is endangered or because the health ofindividuals 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 tor (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.
XVI. BED.HOLDS - In tbe event that the Resident is temporarily absent from the Facility fo.r
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 Medica! Assistance
Program, the Program may pay for a certain number of bed-hold days. }fthe 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 ratc. Otherwise) the Resident shall be
readmitted upon the first availability of a bed in a non-private room as long as the Resident: I) 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 mayor 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 may pay for a certain number orbed-hold days Otherwise, a
Private Payor Medicare Resident reque~ting a bed-hold must pay tht:: Facility's prorated private monthly
rate during the bcd-hold period.
s"t/!;,t: 'd
UlOd
S26S606:01
:WO~~ 0S:60 L002-02-~ON
UU:60 (3nl)l002-02-~ON aWT1/a~PO x~
XVIL RESIDENT'S RIGHTS -\ND FACILITY POLley tNDER rHE FEDER..\L SELF-
OETERMINA TION ACT
A. Right To Make Decisions Regarding Care -The Facility recogniz~s the right of each Resident
to lnak~ decisions regarding his or her care. Where a Resident is incompetent, the Facility recognizes the
Rt.1sident's right to have these decisions made on his/her h~halfby a substitute decision maker in
accordance with State Jaw.
.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 rhose choices. These
choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney
for HeaJth 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 tlunily, physician andlor .attorney.
C. An Advance Direttive 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 sha.H be provided to family
members or other Resident representatives. However, jfthe Resident later regains competency, the
Facility will provide such information dire<.1ly to the Resident.
XVIII. CHARGES FOR COPlES OF MEDICAL RECORDS -The Facility may charge the Resident
for copies of hisll1er medical record in accordance with either state prescribed rates or the rate commonly
charged in the Facility's community.
XIX. SOLE AGREEMENT- This Agreement is the only Admission Agre~ment between the Facility
and the parties. Changes to this ..l\greement are valid only if made in writing and signed by all parties. If
changes in State or Federal law make any part ofthi!l Agreement invalid, the remaining tenns shall stand
'lS a valid Agreement.
XX. ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not
:1ssignable The Resident may not transfer his or h~r rights under this Agreement to any other person.
XXI. INTEGRc\ nON - The Parties under::tand and expressly agree that this Agreement supersedes aU
other prior discu~'Sions, ~tatements, r~presentations, promises, understandings, and dgrceme:tts between
~he parri~s, '~hether writt~n or oral, and tl1erdbre ~hey are of no tlmher force and effect Be~ause this is a
fully integratt:d 19rcem~nt, rhe only discussions, ~tatements, representations, promis~s, understandings, or
agreements that :'lre a 'Hill be binding .)n any I)f the partics to this Agreement or their employees,
a1liJiates. cor-tractors, 1gents, or repr~~entath;~5 are those ~xpressly set forth in wliring in this Agreement,
or inl)thcr l...ritt-:;n Jgre~J1?eJlts tl1tcred into ,it rhe ~;lI11c l:me as, or :)ubscql.l~nt h). this Agreement.
Sl/Sl"d
510' d
S26S606:01
:WO~j 0S:60 L002-02-~ON
PP:60 (3nl)L002-02-~ON aWJ1/a~go x~
,\. Ltgal Rcpres~nt3ti'Ve And/Or Agent
K1mc . ~J./J1D ,QRjI/S(),-tJ
Hnmc Ph\1n~ [7][1 J[~J[ 7JL3J[71ft;J[f{J~J[1J
Work ~hOli~[ I[ l[ l[ J[ ][ ][ J[ ][ ] [ 1
,s~ AI, ~ sr:. LemuvJJe
Strc~t City ,
;;)
fA..
Stat
17t?p' 3
Zip
B. Other Person To Be Notified
r\ame
Horne Phone [ J[ J[ J[ 1l J( j[ J[ J[ J [ J
Work Phone[ 1[ J[ }[ J[ ][ j[ J[ ][ ][ ]
Street
City
State
Zip
XXV. MAIL - The Facility is authorized to handle the Resident'! mail as follows: (Check ono box
only.)
l J .\11 mail gl'l(.;11 directly to the Resident
~:ard illl otlhc Resident's maillo:
[ ] All mail ead to the Resident
(.
,
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r:..-fJP? tI J" C7 d
[ J Give pet onal mail to the Resident;
forward business mail to:
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XXVI. RESIDENrs PHYSICIAN
A NAME:
-{
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(,
B. SPECIALTY:
C. ADDRESS: _
I). ~:"ELEPHO~E
~._X\ }l. ~SID[i""T T~U5T FU~D .~.lTlIORIZ.\ TlON . A Re idem "T'rust fund is an amount of
r"'cnl'::' ~~dd hy ~ 'le F eciiity ~cr the R<:~ir.:ent' s personal '..;se. (Example of u~c: r 0 allow the resident to pay
,OJ -!~(),r ~r.d bcu':i, cl::::I.1':f ~;-.}P .;harges. ,=igardtes. po~r3ge ~tamp~ or other similar expenses as desired
cy ;:..:. R'':'~:GI~rt.j ~y :;;::;.1i1l2 ;)ckw. (he Resident authcri:~l.:s the Faci! ty [0 :.ct ~p a tru.n fund in his/her
-. -':. :r.c '1Ic~; .." "..;::.i fna::r.:.:.J :._"Co.-.js shall be a\ial~ble .hmfJ~r.. qua:terly ;:.tatemems, and on request, to
' t; .C'::'~1,;11t Gr :':sih.:r '>-:}enr ')r Le:~:,J P_Ll)r'~5t;nr:!t;'.e. TIll;; ,~el'.ident ..:p.d(;r~tz.nds l!tat all ~ithdrawals
.~::v {::, 1.~.1'\]
!~:~c -- ~L~...l~~~ J~ free
8't/2.d
200 'd
S26S606:Dl
r;; .i.; - \. ~(.:(;.l !) .:t;cr~ I ':'.;iI>:\.. _ Resident
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2l:l.l (I~U)L002-EiO-t'lON aWJ!/a:p?o x~
,11,.11 be .uthor.7.<d by the R.esidenl or hislh", Ag""l or Legal R. """""abve in ..riting. The following
j)~r:';()ns r"ay :n./thcllze withdra\\Ials on the Resident's behalf
Date
(lA~uly,u it/IR/C
Name of .\uthoriz~d Person
Rc~ident' s Signature
'.~ itness jf Resident Signed with a Mark
Date
~ LfA,~ J~__
Legal Representative's Signature
(if applicable)
t
Datc
A,gt:nt's S;gnatlJre (it" appJicable)
Date
xx nu. CREDIT CAlU) .\lJmolUZA nON - Facility ace MasterCard and VISA [fJlesjdenl
'. vQuld like Ihe conVenience ~f paying amoUnu due each monlh th. ugh one of these, please provide Ihe
Il~edt:'.d int"crmation and authorization:
~
~
~
,
,
Cn~dit Card
~
Account it
Expiration Date
I hereby aulhorize Facibty 10 charge the account listed above for nthIy chuses illCllm:d under lhis
,\grccment:
R..idenl Or ".genl'. Si/lOSlUre Dale
",he Reside...t is unable 10 tonsenl or ';811 thi. provision because 0 physical disamlity or _
ioccmpL<enee or i, a I1'Jnor ar.d thi, provision i. being signed by an thorized representative, complete
the tcl!owin:r
D~k:
ReJation;ship to Resident
.,.
;~13;"!;1i!_r...::
:l.urhorizcd Rtprl:semative
.\ in ~~s .-
--:-.~r f<~~;:it.-:
.t?.,:v J.:'- ~:.-i,.:
Date:
; 1.)~ - .3uSil!i.:E:, J 1ice
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Authorized Representative Signature:
. ..I, tiVS
Print Name and Title:
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Rev. 03/13/03
White - Business Office
81/i;>"d
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S25S506:01
Pink - Medical Records Yellow _ Resident
fA J :WO~~ Sl:Ll L002-50-nON
21 : Ll (Hl.:l )L002-60-~ON aw !l/a~po ><M
.\OMlssrON AGREEME"'T SIGNA t'RE ~'\G[
XXIX. PARTIES - The parties to this l\gn..'Cm~nt are:
-If:fHIf:..
(Name 0 Facility)
(Name or' Resident's Agent)
'I.M A- RJ.,et';VSt7 AI
e ot Resident's Legal Representative)
rfrhe LCgalltCPrescntativc ';8115 the AgJ"l:ement. chcc~ thc Type " . Legalltcprescntativc (below):
[ J C ,nsetntor of Penon ( J Guardian ('ffl6iib1o Powc.- of Art mey ( J Agcnr Acting
[ ] Conservator of Estate for Health Care Il>P tIC) Undc:I- General
[ ] Other, specifY POA
If you .... signing this Agreement on behalf of lhe Re,ident. note y ur telationship to 'he Residenl:
My relationship to the Resident is
On Ihis J }I/"'^ day of Ik IU e
this AgrCement and agree that on the
this Facility,
,2~ the above Partics a ce to be bound by the provisions of
Ie;- day of ;:j/{ N e ,;. l?j'lhe Rt:sident shaU be admitted to
(l1I,f(/(J';N ~ /!;)~
Rt."Sident / .
Date
Address
Reside's Social Security Number
City. State, Zip
· s Telephone Number
Witness if Resident Signed with a Mark
Date
',,\ itn~>ss if Resident Signed with a Mark
X- /lLMA FP~t}l/roAl
,
legaJ R~'Prcsentatj\le
X 4/A.1~ ~'?--
L~g:~II\.~rcSentative I S Address
Date
Date
Lc:!o.l3,ep.csentative's ~ocial Sccurity No.
'~~'1 '!:/ i:,,;:
".,'!;ai ?.:.c: :-e~;l;.~:,oti, ~-;i Teiephone ''tJ'umber
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Agent
Date
Agent' s Address
Facility ~~-::: Designee
LI.I.5)/~
Agent's Soc at Security Number
Facility Name
Date
77tJ ~k~ (,Af/I'CA Pol,
Facility Ad ress ~H/J1b !I,'LI ~,
, / I-;~//
Note: The signatures above refer to the infonnation contained on ages 1 through 16 of the Admission
Agreement.
~
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Rev 03/13/03
White - Business Office
Pink - Medical Records
I~
YelJow - Resident
8't/9"d
900 "d
~26S606 : Dl
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21 : Ll (HU H002-60-r'lON alii q/a~go x~
ilil':Lill1~. r-'\~\:'.l':l :'I','.I'.~"'r ;::.., '''0 :h~ ::..'1je hl'..io1u,t. i,':l.l~':I(;tin!l, :,' '-.:bkd '...',r.....'..!f'.~i:l(..:nr '~IVI~")
p,'Jvi(:l:d I)}' ~i1~ :::ld~l} iI, . Ill.: Il,.;~ iLkllt :'hr.II 1;0,; hrhir:atr.:d in , "0.: p' .I~o.;l:t!i:~'!.. \ ';;uirn ',hall ,~C '.~divui
and tnr~'1..:r b:lrn.:d irir anl::t: 1nd .;h'Juld r~:iSl)nably h:wc b;t:n di::;e. ........,'j I),j.)r 10 the .\w; I..)l~n '..l,hich
rll:tice cf Jlbirrl:ti.m i:> :~i'l'':lI to the F::;.;ilit,~, ,')r r-ecCiVi:d "'l' dl" R.:sid .,pt ,nd :;lId, daim is .'10 pll:Slt1tcd in
.he ~roitr.llion proG~edillg.
THE P.\RTJES lll\&EaST.\ND .\ND ACREE THAT THIS C NT~.\CT COi'tT. \jNS \ ar:'iDJNG
AR3ITaATIOS t'RO''''SION '."IUCH '\-l.\V BE E~FORCED Y THE P.\RTlEs., .\~D THAT BV
J.:NTERTNG INTO nus ARB1TRATrON i\GREEM[~T. TH .'ARTIES .\R[ (-;.\-dNG UP .\NO
WAIVING THEIR CONST.TLnO~AL RIGHT TO HA \ E.\:' Y CL.\lM DECiDED IN A COt:RT
OF L.\W BEFORE A .JUOCE .\NO A .JlRY, AS WELl. \S NY APPEAL r'~O\f.\ OECISION
o'a A WARD OF OAM.\GES.
The RC::iid~nt Imdcrstands that ( I) he/she has the rizht to s(.,'d; !egal
Agreement, (2) that execution of this Arbitration Agreement is oot
furnishing of services to the Resident by the Facility, and (3) this.
by written notice to the Facility from the R~sidc"t 'Nithin thirty cay
thirty days, this Arbitration Agrcem~nt shall remain in effect tor :lll
if the Resident is discharged from and readmitted to the Facility.
ounse! l:cncerning this Arbitrrstion
precondition to admission or to the
itration Agreement may be rescinded
of signature, [1' not rcscindt.-d ""ithin
ubsequent stays at the facility, even
The IJlldcrsignt.'d ccnities that ht:hhe has read this Arbitr:l.tion Agrc ment and (hat it has ht;cn fully
-.:x:pJained to him/her, (hat he/~;he understands its contents, and has r cd,,~'d a eopy of th~ pnwision 'lnd
I hat h("jshe is the Resident, or a person dilly auth\Jrizcd by th~ R(.~J nt \Jr other.;., ise to 1~l'.I:Cutt: this
,"lift'cmcnt and accept its h::rrns.
Date:
Signature:
I Resident)
Witness:
If the resident is unable to consent or sign this provi:;ion because of hysical disability or mental
incompetence or is a minor and an authorized rcpres..:ntativt: is signi g this provision, compl~tc the
following
Date:
x
V Si2natl.,re: t..-
(' - -
(Au thOrii:t;d n:pn.:scnt:ui\
'I\':rn.::is.
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Date:
~js ;7
Authorized Representative Signature:
Print Name and Title:
Rev. 03/13/03
81...8 "d
900.d
YeUow - Resident
:wo~~ 9!:L! L002-60-nDN
am! lIa=lPO x~
White - Business Office
S26S606 : 01
Pink - Mcdi.caJ Records
21:Ll (U:l.:j)L002-fiO-flON
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EXHIBIT "B"
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..
____.__--L
lAW OfFICES OF
:iTEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE. PA 17013
STEPHEN J. HOGG
ATTORHBY At LAW
19 S. HANOVER STREEt;. SUITE lOt
CARLISLE, PENNSYLVANIA 17013 ..
(717) 245-2691." F~~45-0829
NOTICE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE
THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD
POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR
PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR
APPROVAL BY YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY
ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN
POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE
TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS
POWER OF ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME
INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE
DURATION OF THESE POWERS OR YOU REVOKE THESE
POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES
YOUR AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM
YOUR AGENT'S FUNDS.
A COURT CAN TAKE AWAY THE POWERS OF YOUR
AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A
POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.
C.S. CH. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO
NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR
OWN CHOOSING TO EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE
AND I UNDERSTAND ITS CONTENTS.
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CtU~ Y~J
CAROL~N H. KIRK
/11!rr;
DATe
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I.,\W OfFICES OF
rEPHEN J. HOGG
9 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
POWER OF ATTORNEY
I, Carolyn H. Kirk, of Cumberland County, Lemoyne,
Pennsylvania, do hereby nominate, constitute and appoint Alma J.
Ferguson, as my true and lawful Attorney-In-Fact, to act in my name,
place and stead to do and perform any act that I myself might perform
if I were personally present in regard to the following:
To endorse checks, notes, drafts and any other commercial
papers in my name and to withdraw money from any bank accounts
that I may have for my benefit, and to sign orders or receipts therefore
in my name;
To enter into any safe deposit box I may have in my own name
or jointly with another person to inventory the contents of such box or
to do or perform any. act with respect to the contents that I might legally
perform if I were personally present;
To sell and enter into a contract or contracts for the sale of all or
any part of my personal property, effects and belongings of every kind
and nature wherever situated for my benefit with full power to deliver
possession of said personal property and to execute in my name any
documents necessary to transfer title to said personal property,
including bills of sale or other documents of title, and to take any
security interest for any unpaid balance which my Attorney-In-Fact in
her discretion may deem necessary and proper; and to buy, sell,
assign or transfer stocks, bonds or any other personal property.
To borrow money from such sources and on such terms as my
Attorney may deem fit and proper, and to. execute in conjunction with
any loan of money a security agreement covering any of my real or
personal property and to execute, sign, acknowledge and deliver in
any form that instrument that may be required in conjunction with the
transaction;
To authorize my admission to medical, nursing, residential or
similar facility and to enter into agreements for my care. This power is
to be construed and implemented in accordance with the provisions of
Chapter 56 of Title 20, Consolidated Pennsylvania Statutes, in effect
on the date of execution of this Power of Attorney;
To authorize medical and surgical procedures. This power is to
be construed and implemented in accordance with the provisions of
Chapter 56 of Title 20, Consolidated Pennsylvania Statutes, in effect
on the date of execution of this Power of Attorney.
. .
LAW OFFICES OF
.TEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE. PA 17013
I direct that this Power of Attorney shall be a durable Power of
Attorney and shall become effective immediately.
c~..v:fJ
Caroly . Kirk
I (Lf(n
Date
.~ :t o~
Witness /
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LAW OFFICES OF
,TEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE. PA 17013
Commonwealth of Pennsylvania
ss
County of Cumberland
On this LA day of , 2007 I before
me, the underSiQrled officer ersonallyapp red Carolyn H. Kirk,
known to me or satisfactorily proven to be the, person whose name is
subscribed to the attached Power of Attorney, and acknowledged that
she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official
seal.
,
My Commission expires:
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,/! I .
Notary Public
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I,\W 011 Ins I II'
jTEPHEN J. HOGG
19 S. HANOVER STREET
SVITE 101
CARLISLE. PA J 7013
ACKNOWLEDGEMENT
I, Alma J. Ferguson, have read the attached Power of Attorney
and am the person identified as the agent for the principal. I hereby
acknowledge that in the absence of a specific provision to the contrary
in the Power of Attorney or in 20 Pa. C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
assets.
I shall keep the assets of the principal separate from my
I shall exercise reasonable caution and prudence.
"\
I shall keep a full and accurate record or aU actions.
receipts and disbursements on behalf of the principal.
1M ~
j'!ji;ji t 2; L :t=v'-
Af,';1a J. Fer' on //
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Date
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EXHIBIT IIC"
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ACCEPTANCB OF PROPOSED
PERMANENT PLENARY GUARDIAN
Pennsylvania Guardianship Association, the guardian of the person and the estate
proposed in the foregoing petition for appointment of a permanent plenary guardian of
Carolyn Kirk, the alleged incapacitated person, agrees to accept the appointment as
permanent plenary guardian and avers that:
1. The proposed guardian is Pennsylvania Guardianship Association, who
currently handles numerous guardianship matters similar to the instant.
2 Neither Pennsylvania Guardianship Association nor its agents is a
fiduciary of any estate in which the alleged incapacitated person has an
interest, and the proposed permanent guardian and its agents of Carolyn
Kirk do not have any interests adverse to her.
Dated:
1/6<t/o?
b<2_L/~
rian Brooks, President
Pennsylvania Guardianship Association
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NO'J-27-2007(TUE) 10.12
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P 007/007
VERIFICATION
The undersigned hereby verifies that !:he statements of fact in the foregoing
Petition are true and correct to the 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. 9 4904, relating to unsworn falsification to authorities.
Dated;~
orne Administrator
West Shore Health