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HomeMy WebLinkAbout07-7540IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. : No. bl- 1541) civil -Prm DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, : Plaintiff, V. No. DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY AVISO 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. DARYL HURLEY, Defendant. No. O 7- ?S?/U u?.f ?? -r CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following complaint against Daryl Hurley ("Defendant"), and in support thereof, states: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 210 Big Spring Road, Newville, Pennsylvania 17241. 2. Defendant is an adult individual who currently resides at 9 Fox Hollow Lane, Carlisle, Pennsylvania 17015. 3. On or about April 24, 2007, Defendant made application on behalf of his mother, Goldie Hurley ("Ms. Hurley"), for admission to Plaintiff's skilled nursing facility. 4. On or about April 24, 2007, Plaintiff and Defendant entered into a written Long Term Care Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Ms. Hurley with skilled nursing care and services in return for Defendant's promise to make payment for that skilled nursing and services from Ms. Hurley's resources, to "cooperate fully with the Health Center and any third party payer to secure payment," and, in the event that Ms. Hurley became insolvent, to apply for Medical Assistance benefits on her behalf and to "pursue MA [Medical Assistance] coverage." A true and correct copy of the Agreement is attached as Exhibit "A." 5. Subsequent to Ms. Hurley"s admission to Plaintiff's skilled nursing facility, no payment was made for services rendered to her, because she allegedly became insolvent. As a result, an application for Medical Assistance benefits was subsequently filed. 6. The Cumberland County Assistance Office denied the application for Medical Assistance benefits because Defendant failed to provide the information needed by the Cumberland County Assistance Office to determine Ms. Hurley's eligibility for Medical Assistance benefits. 7. As of November 30, 2007, an outstanding balance of $32,265.98 is owed to Plaintiff for the care and services that it has provided to Defendant's mother, and this balance increases monthly, as Ms. Hurley is a current resident. 2 8. An appeal of the denial of the application for Medical Assistance benefits is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant prior to or at the time of the hearing on the appeal, the application for Medical Assistance benefits will ultimately be denied, and any further appeal to the Commonwealth Court would be without merit. COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 10. Paragraphs 1 through 9 are incorporated by reference as though restated in full. 11. Plaintiff has provided skilled nursing care and services to Ms. Hurley in accordance with the Agreement attached as Exhibit "A." 12. Defendant has breached the Agreement attached as Exhibit "A" by not securing Medical Assistance benefits for his mother by providing the necessary documentation to the Cumberland County Assistance Office to qualify Ms. Hurley for Medical Assistance benefits. 13. As a result of the failure of Defendant to abide by the terms and conditions of the Agreement, the application for Medical Assistance benefits filed for Ms. Hurley has been denied. 14. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff. 3 15. Upon information and belief and to the extent of Plaintiff's knowledge, at all times material hereto, Ms. Hurley has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to her in accordance with the terms and conditions of the Agreement. 16. 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. WHEREFORE, Plaintiff respectfully requests that this Court enter a decree ordering specific performance of the Agreement by the parties. Respectfully submitted, SCHUTJER BOGAR LLC Dated 4(3 &4 10 Ad 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, 4th Floor 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 best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. G S. § 4904, relating to unswom falsification to authorities. Dated: IA O o'-0 Jeff Davis Chief Financi 1 Officer E ADMI NT LONG TERM CARE ADMISSION AGREEMENT 1. INTRODUCTION i L old This A cement is between Resident, or U , Resident's Representative (referred to as Resident in the Agreement) and Health Center, a licensed Long Tenn Care Facility (referred to as Health Center in this Agreement), for admission of Resident to the Health Center on Wja/ , 20 .Date) Resident requests occupancy of Room a room for occupancy of residents at a Daily Rate of $ Resident may request a room change and the Health Center will snake every effort to honor such requests as soon as possible. However, a room change may result in a change in the Daily Rate upon occupancy of the new room. In the event of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any change, thereby giving Resident sufficient time to request a room change (for example from a private to a semi-private room) or to transfer to another nursing facility. The Health Center agrees to accept payments from Medicare and other contracted third party payers for Resident's stay if Resident meets all qualifications required by Medicare or other third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by Medicare or other third party payers. If Resident qualifies for Medical Assistance ("MA"), the Health Center agrees to accept the Patient Pay Liability (as defined below) as determined by the County Assistance Office with the balance of the payment for covered services conung from the MA Program. II. DEFINITIONS A. Daily Rate. The rate the Health Center charges a private pay resident for room and board, general nursing care, housekeeping services, linen services, nutrition management, limited ui-room storage of Resident's personal belongs, and recreational programs for each day a Resident is at the Health Center. Physician services are not included in the Daily Rate. B. Healthcare Surrogate. An adult who is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for him/herself C. Alfedical Director. The physician designated by the Health Center to be responsible for resident care policies and the coordination of medical care in the Health Center. D. Clinical Records. All records (excluding financial records) pertaining to a particular Resident that are prepared and maintained by Health Center. E. Patient Pay Liability. The amount of personal funds, as determined by the Commonwealth County Assistance Office, that a Resident who is receiving MA must pay monthly to the Health Center in addition to the payment from the MA program. F. Personal Needs Services. Personal services such as telephone service, laundry, beauty and hair care (exclusive of routine assistance with grooming), and newspaper delivery provided by the Health Center to Residents for their convenience at Residents' expense. G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of the Health Center from his/her own resources (including private insurance and Medicare Part B) and who is not covered by or has exhausted Medicare Part A and MA coverage. H. Resident Funds. Personal funds of a Resident that the Resident has authorized in writing that the Health Center shall manage for the Resident. I. Resident's Representative. A person who is responsible for making decisions on behalf of the Resident and has been so designated in writing by the Resident or a court of competent jurisdiction. If a Guarantor Agreement is attached to this Agreement, the Resident's Representative is only obligated to make payment from the Resident's personal funds. Reference in this Agreement to Resident shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf. J. Skilled Ntersing Care. Professionally supervised nursing care and related medical and other health services provided to an individual not in need of hospitalization, but whose needs are above the level of room and board and can only be met in a long-tern care nursing facility on an inpatient basis because of age, illness, disease, injury, convalescence or physical or mental infirmity. K. Specialty Care Scn)ices. Medical services ordered by a physician for a Resident that are not included in the Daily Rate. Medicare and Medicaid each include certain Specialty Care Services in the per diem rates, but neither include all such services. L. Transfer and discharge. Movement of a resident to a bed outside of the certified facility or unit whether that bed is in the same physical plant or not. Transfer and discharge do not refer to movement of a resident within the same certified facility. III. HEALTH CENTER OBLIGATIONS: The Health Center will: A. provide, as part of the Daily Rate, room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongings, and recreational programs. General nursing care does not include private duty nursing. B. provide Specialty Care Services ordered by Resident's treating or attending physician. Although additional fees for specialty services may be covered by third party payers, the Specialty Care Services identified on Exhibit A are not included in the daily rate, and are billed at the rates set forth in Exhibit A. Any items ordered by a physician, which are not identified on the Exhibit A will be provided at charges identified by the Health Center prior to the delivery of the ser-Vrce. C. Provide Personal Needs Services, at Resident's expense (at the rates set forth on the Fee Schedule attached as Exhibit A) and at Resident's request, including but not limited to: 1. Beauty/Barber Services 2. Newspaper delivery and personal reading materials 3. Local and Long Distance Telephone Services 4. Cable Services, depending on cable provider 5. Personal laundry, dry cleaning and mending 6. Personal clothing. D. provide safekeeping of Resident Funds, if authorized in writing by the Resident, and make those funds available, at Resident's request, during normal business hours. 1. Resident may manage his/her financial resources if (s)he wishes. 2. Residents may keep a limited amount of funds at the Health Center, the maximum amount, which is specified from time to time by the Health Center. 3. Requests for withdrawals in excess of $50.00 require advance notice to assure availability of cash at the Health Center. Resident Funds shall be retained in compliance with State and Federal regulations. Resident Funds exceeding $50.00 shall be placed in an interest bearing account. A written quarterly statement of these funds shall be provided to Resident. Resident agrees to return signed copy to facility if required. E. provide refunds of unused advance payments and Resident Funds within thirty (30) days after deductions for payment of any outstanding bills or other amounts due the Health Center after Resident's discharge or death. In the event of Resident's death, refunds will be made to the authorized representative of Resident's estate. F. assist Resident in applying for and obtaining private insurance and/or public benefits to cover the cost of the Resident's care. G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of the Health Center only for medical reasons, for Resident's welfare, because the safety or health of individuals in the Health Center is endangered, because the Resident has failed, after Veasonable notice, to pay for a stay at the Health Center, or. with the voluntary consent of Resident. Except in emergency situations, 'at, least thirty (30) days' notice will be provided to Resident and Resident's Representative to assure that the transfer is safe and orderly. The Health Center reserves the right and discretion to move Resident to another room or bed within certified parts of the Health Center consistent with the safety, care and welfare needs of the Resident. H. arrange for Resident's transfer or discharge upon the order of Resident's personal physician when he/she deems it necessary to receive services the Health Center is: not qualified to provide or at Resident's request. 1. honor Resident's Rights as outlined in the Department of Public Welfare Admissions Notice Packet (MA 401). J. to the extent permitted by law, hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. To the extent pennitted by law, Resident shall indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions or oinissions. Health Center will be responsible for loss of or damage to Resident's personal property by Health Center staff. , K. provide Resident with a locked drawer or box for Resident's valuables or for . medications retained for self-administration. Resident may self-administer medications only in certain circumstances and may not have medications in his/her room without physician authorization. I. provide Resident with a choice of pharmacy if Resident does not wish to utilize the pharmacy provider designated by the Health Center. With this choice, pharmacy must provide medications in compliance with all applicable laws and under a delivery system that is consistent with the one used by the Health Center, must provide a monthly written profile of all drugs provided to the Health Center's consultant pharmacist, and must be delivered from the provider pharmacy in tamper-proof containers, directly to the Health Center's licensed nursing staff. M. provide Resident with a choice of attending physician who will provide medical care during the Resident's stay at the Health Center and who shall comply with the Health Center's rules, regulations, policies and procedures and all applicable laws and credentialling standards. Resident may also designate an alternate attending physician in the event that the primary attending physician is unavailable. In the event that Resident's attending physician(s) are unavailable, the Resident authorizes Health Center's Medical Director or other physician designated by the Health Center to issue appropriate orders. IV. RESIDENT OBLIGATIONS The Resident agrees to: A. by signing this Agreement, Resident certifies that (s)he is competent, and has never been adjudged incompetent, and is entering into this Agreement of his/her own fi ee will. 1. In the event Resident has been adjudged incompetent, Resident's healthcare surrogate will attest, in a separate document that (s)he has the legal authority to act on behalf of the Resident. B. provide the Health Center with all information about Resident's health status and financial resources. Failure to accurately identify resources and income, or the submission of false information may amount to a violation of law and may result in the termination of this Agreement by and at the option of the Health Center. C. provide the Health Center with a copy of all current insurance cards. Resident will provide the Health Center with changes in insurance coverage or financial status in a timely manner, and will update the information provided to the Health Center from time to tune, as requested. Resident understands that making incomplete or inaccurate disclosures will be considered a breach of this Agreement. D. authorize the Health Center to provide care and treatment to Resident consistent with the terms of this Agreement and to carry out the orders of the Resident's treating or attending physician or of the physician designated by the Health Center. Resident also authorizes the Health Center to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident may be transferring. E. authorize the Health Center to make Resident's Clinical Records available to Health Center staff and agents. Resident also authorizes the release of the Resident's Clinical Records to any other health care provider from whom Resident receives treatment, to third-party payors of health services, and to any managed care organization (MCO) in which Resident may be enrolled. Resident also authorizes the release to the Health Center of records prepared and maintained by any third-party payor of health care services pertaining to health care services rendered to the Resident by the Health Center. Resident also acknowledges receipt of the "Release for Electronic Transmission of Minimum Data Set" ("MDS"), which explains the NMS system of records using Resident data. Resident's Clinical Records will remain otherwise confidential, and shall not be made available to anyone other than Resident or authorized agents of the state or federal governments without the express written authorization of Resident or without a subpoena or other judicial order. F. cooperate fully with the Health Center and any third party payer to secure payment. Resident authorizes the Health Center to collect any payments made by third parties on Resident's behalf directly from the third party payer. Resident also authorizes the Health Center to make claims, file appeals or grievances, and take other actions necessary and appropriate to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident to the fullest extent permitted by law. Provided that Resident may, but shall not be required to authorize the Health Center to pursue grievances or appeals on Resident's behalf under Penrisylvania's Quality Health Care Accountability and Protection Act, to the fullest extent permitted by law and as security for payment of the Health Center's charges, Resident hereby assigns to the Health Center all of Resident's rights to any third-party payments now or subsequently payable for services rendered by or provided under arrangement through the Health Center. G. pay the Daily Rate established for the accommodation requested. Payment is due 30 days in advance, and Resident agrees to make full payment by the first of each month. Collection procedures are initiated after thirty (30) days of unpaid balances. Interest shall be charged on unpaid balances. 1. If the Health Center initiates any legal actions to collect payments due from Resident under this Agreement, Resident shall be responsible to pay all attorney's fees and costs incurred by the Health Center in enforcing Resident's financial obligations under the.Agreement. 2. This Agreement shall serve as an assignment to the Health Center of as much of Resident's property as equals the amount of any unpaid obligations under this Agreement, and this assignment shall be an obligation of Resident's estate that may be enforced against Resident's estate. Resident's estate shall be liable to and shall pay to the Health Center an amomit equivalent to any unpaid obligations of Resident under this Agreement. This liability shall apply whether or not Resident is occupying the Health Center at the time of Resident's death. H. pay for additional items, services and equipment not included in the Daily Rate as identified by the Fee Schedules, attached as Exhibit A. I, understand that Resident will be notified thirty (30) days in advance of changes in the Daily Rate except when Resident requests room change, changes in charges for Specialty Care Services or Personal Needs Services, or changes in billing procedures, and agree that the changes will be effective upon the date designated by the Health Center. 7. understand that the Resident may continue to live at the Health Center as long as Resident continues to pay the Daily Rate. Resident may be discharged for non- payment of incurred charges or transferred for the benefit of the Resident or others, as set forth in Section IH(H) of this Agreement. K. acknowledge that non-payment of the Daily Rate for a private room will result in a room change. L. acknowledge that the Health Center has the discretion, with thirty (30) days' notice, to transfer Resident to another room or bed within the Health Center consistent with the safety, care and welfare needs of Resident. The Health Center also has the discretion, upon thirty (30) days' advance notice, to transfer or change Resident's roommate, if any, at any time consistent with the needs of the Health Center. M. tenninate this Agreement upon written notice to the Health Center, but if Resident leaves for any reason other than a medical emergency or death, Resident must give reasonable advance written notice to the Health Center. N. notify the Health Center at least two months before the Resident has insufficient resources, funds or income to meet his/her financial obligations and to apply for MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not eligible for MA, Resident agrees to vacate the Health Center. 0. pay co-payments and/or deductibles for services covered by the Medicare Program or other third party payer, and pay the Health Center within thirty (30) days of receipt of services for those services not covered by the Medicare Program or other third party payer. P, pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. Q to the extent otherwise permitted by law, assume responsibility for any damages or injuries caused by acts or omissions of the Resident to other persons, residents or staff' . R. comply with reasonable rules, regulations, policies and procedures that the Health Center establishes from time to time and makes available to Residents, subject to reasonable accommodation of Resident's individual needs and preferences. The Health Center's rules, regulations, policies and procedures are for purposes of internal management and shall not be construed as imposing contractual obligations on the Health Center and are subject to change from time to time. S. acknowledge receipt of the Resident Handbook, a document that provides Residents with Health Center rules, regulations, policies and procedures. T. acknowledge receipt of information on Advance Directives in the absence of providing the Health Center with an existing Advance Directive or Living Will. U. provide the Health Center with a copy of any and all Durable Powers of Attorney, Guardianships, and/or Advance Directives pertaining to the Resident. V_ acknowledge that (s)he has read and understands the terms of this Agreement, that the terms have been explained to them by a representative of the Health Center, and that (s)he has had an opportunity to ask questions about the Agreement. V. MEDICARE AND MEDICAID The Health Center is certified to participate in the Medicare and Medicaid Programs. The Health Center's participation in these programs is subject to tennination by either the Health Center or the responsible government entity. The Pennsylvania Department of Public Welfare (DPW) is responsible for administering benefits under the Medicaid Program and the Centers for Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program through an intermediary. The Resident acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of DPW, CMS or the Medicare intermediary in administering these programs. A. Medicare If Resident is eligible for benefits under the Medicare Program, Resident understands that certain skilled nursing and related health care services may be covered by Medicare. The Health Center will bill Medicare Part A on behalf of the Resident for skilled nursing services and payment will be made by Medicare Part A directly to the Health Center for services received by Resident. When the Health Center notifies Resident that the nursing services being provided to the Resident no longer qualify as a skilled service, the Resident may request that the Health Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for the charges incurred on the Medicare Part A non-covered days. The following describes coverage under the Medicare Part A Program: 1. Medicare Part A covers from one (1) to one hundred (100) days at the Health Center. Coverage is not guaranteed and is limited to the unused days in the Resident's benefit period. Conditions stipulated by Medicare must be met for coverage to begin and remain in force. 2. The Medicare Part A Program pays for all covered charges from day one (1) through day twenty (20) if the criteria for skilled service is met. 3. The Medicare Part A Program pays a portion but not all of the charges from day twenty-one (21) through day one hundred (100). The Resident is responsible for and shall pay any co-u7surance or deductible amounts as determined by the Medicare Part A program. Depending on the circumstances, this payment may be made by personal health insurance, MA, or personal fluids. 4. The Medicare Part A Program covers the following services: room and board, linens, meals, most prescription medications, therapy services, most medical supplies, non-private duty nursing services, most recreational services, most social services, and most personal hygiene items provided by the Facility. (Note: only the type and brand of personal hygiene items provided by the Health Center are included.) 5. Some items and services not covered by the Medicare Part A Program include, but are not limited to: personal clothing, eyeglasses, hearing aids, services of a beautician or barber, guest meals, special or alternative meals not required for therapeutic purposes or as a nutritional substitute, services not deemed medically necessary, and personal telephone service. The Fee Schedule for items and services provided to Medicare Part A eligible Residents that are not covered by Medicare Part A is attached as Exhibit A. 6. Bed hold days are not covered by the Medicare Part A Program. (See Section VII.) 7. Residents covered by Medicare Part A should not go out on overnight leave as this may disqualify them from further coverage by Medicare Part A. 8. Residents may be covered for therapy and other ancillary services under the Medicare Part B Program. The Health Center or provider approved by Health Center will bill Medicare Part B directly for these services. The Residents are responsible for the annual deductible and the co-insurance payment for Medicare Part B covered services. 9. Resident is responsible to pay the Health Center for services and supplies not covered by the Medicare Program. 10. In the event that Medicare coverage is changed by law, those changes will control and take precedence over any contrary provision in this Agreement. B. Medicare Managed Care The Health Center participates as a provider of skilled nursing services under some, but not all Medicare MCOs. 1. Requirements for eligibility for Medicare payments, deductibles and co- insurance may be different from those discussed in Section V(A). Pre- authorization of services is required 'by Medicare MCOs, and if the.,, Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Health Center for those services. If the MCO refuses coverage on the grounds that it does not consider an item or service to be medically necessary, Health Center or MCO will provide an Advance Beneficiary Notice of that determination. The Health Center will communicate directly with .Resident's Medicare MCO to obtain authorization for continued Medicare managed care coverage. 2. The Health Center will accept payment from the Medicare MCO as payment in full only for those services and supplies covered by the Medicare MCO. Resident is responsible for any copayments or other costs assigned to Resident or not covered by the MCO under the specific terms of the managed care plan. 3. Resident acknowledges that an MCO for which the Health Center is not an authorized provider may not approve payment for services provided by the Health Center, so that Resident may be required to pay the Health Center directly. Resident also acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of any MCO for which the Health Center is an authorized provider, including decisions relating to a denial of coverage or refusal to pay on behalf of the Resident. 4. The Health Center reserves the right to stop its participation in any MCO at any time and in its sole discretion. To the extent practicable, the Health Center will provide advance notice to Residents enrolled in a particular managed care plan or insurance program of its decision to stop participation in that managed care plan or insurance program. C. Medical Assistance Program 1. Residents who qualify for coverage under the MA Program must apply for and be approved for these services at the County Assistance Office. It is Resident's responsibility to pursue MA coverage. Until approval of MA coverage is obtained, the Health Center will consider Resident to be a Private Pay Resident. 2. Resident will be required to use the Patient Pay Liability to pay the Health Center for the Resident's stay in conjunction with the MA Program. Periodic adjustments in the Patient Pay Liability are made by the County Assistance Office and when issued, will supersede all previous determinations. Resident shall arrange, if possible, for the designation of the Health Center for direct deposit of any Social Security or related benefits or any other income sources of the Resident in an amount not to exceed the Patient Pay Liability. 3. MA program coverage includes the following: room and board, prescription and non-prescription medications, meals, linen service, nursing services, incontinence care, social services, recreational activities, personal laundry, a hair cut every six (6) weeks, a shampoo and set every two (2) weeks, one permanent per year, and personal hygiene items provided by the Health Center. (Note that only the type and brand of personal hygiene items provided by the Health Center are included.) The MA Program limits the fi equency of coverage for the purchase of eyeglasses, hearing aids, and dentures. 4. The Health Center will not charge, solicit, accept or receive monies from or on behalf of Resident for bed hold days covered by MA Program, except for the Patient Pay Liability, to cover the cost of Resident's stay or as a condition of admitting a Resident under the MA Program. 5. Some items and services not covered by the MA Program include, but are not limited to: personal telephone service, personal clothing, guest meals, brand name personal hygiene items, and additional services provided by a beautician other than those listed above. Resident is responsible for charges incurred for these services at the rates listed on the Fee Schedule attached as Exhibit A in addition to the patient pay liability amount. 6. Residents receiving MA coverage are permitted to keep the amount that has been designated as the Resident's personal needs allowance for personal spending. Personal funds may be given to the Health Center for safekeeping (see Health Center Obligations in Section III). 7. The MA Program provides for bed hold days for limited periods of time during Resident's stay. a) Up to fifteen days bed hold days are allowed when Resident is transferred to a hospital. b) Up to thirty days bed hold days are allowed annually for intermittent therapeutic leave from the Health Center. c) The bed hold days referenced above are based upon the law in effect at this time, and may be subject to change if the governing state law is changed. 8. The Health Center provides equal access to its services to all individuals, regardless of payor source. VI. THIRD-PARTY PAYMENTS A. If Resident is or becomes eligible to receive financial assistance or reimbursement from any third parties (such as private insurance, employee benefit plans, MA, Medicare, managed care coverage, supplemental inedical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance), the Health Center reserves the right to collect such payments directly from the third-party. Resident shall cooperate frilly with the Health Center and each third-party payor to secure payment, and Resident shall designate the Health Center, to the extent permitted by law, as the recipient of direct deposit for receipt of Federal Social Security benefits or any other Federal or State . government assistance, reimbursement, or benefits to the extent of all amounts due the Health Center. B. Resident authorizes the Health Center to make claims and to take necessary actions to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident. To the firllest extent permitted by law, as security for payment _ of the Health Center's charges, Resident agrees to assign to the Health Center Resident's rights to any third-party payments now or subsequently payable to satisfy all charges due under this Agreement. Resident shall endorse and turn over to the Health Center any payments received from third-party payor to the extent necessary to satisfy the charges under this Agreement. C. In the event of any denial of coverage by the Resident's insurance company, Resident shall pay the facility for all non-covered services retroactive to the date of the initial delivery of services. VII. READMISSION - BED HOLD POLICY A. A Health Center representative shall cormnunicate with Resident regarding his/her desire to continue to occupy the Health Center bed during hospitalization or therapeutic leave. Verbal- consent shall be given to the Health Center representative who shall document this consent in the clinical record. Written consent shall be obtained following the verbal consent. See Fee Schedule (Exhibit A) for bed-hold rates. B. Bed holds- for Residents enrolled in the MA Program are subject to the provisions of Section 5(C)(7). C. Resident's belongings shall be removed from the Health Center within 24 hours if Resident does not execute a bed hold authorization. Belongings not removed in a timely fashion may be packed and stored. VIII. CIVIL RIGHTS COMPLIANCE All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in need of services and are not'restricted to members of the Presbyterian Church. It is the policy of PHI facilities to a&iiit and to treat all residents without regard to race, color, national origin, age, ancestry, sex, religious creed, handicap, limited English proficiency, or disability. The same requirements for admission are applied to all; and residents are assigned without regard to race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. There is no distinction in eligibility for, or in the manner of providing, any service provided by or through the facility. All facilities 'are available without distinction to all residents and visitors, regardless of race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. Roommate preference requests, staff assignment to residents and resident ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency or disability. All persolis and organizations that have occasion either to make referrals for admission or recommend a PHI facility are advised to do so without regard to race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. IX. REGULATION The Health Center and Resident recognize that Health Center is licensed by the Pennsylvania Department of Health and is regulated by the DPW. The Health Center and Resident recognize that Health Center is also regulated by CMS of the United States Department of Health and Human Services. Both parties recognize that regulatory changes may alter the conditions of this agreement. X. GRIEVANCE PROCEDURE If Resident believes that Resident is being mistreated in any way or Resident's lights have been or are being violated by staff or another resident, on in any other way, Resident may submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow the Health Center's grievance procedure as described in the Resident Handbook. The Health Center's grievance procedure does not preclude Residents from pursuing grievances with appropriate regulatory agencies. XI. ARBITRATION Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or concerning any rights arising thereunder or the breach thereof shall be settled exclusively by arbitration, which shall be conducted at the Health Center in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties and may be entered in any court having jurisdiction thereof. Provided, however, that this arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a resident under the Medicare or MA programs or an applicable state law. XII. GOVERNING LAW This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XIII. SEVERABILITY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. ,xqV. ENTIRE AGREEMENT This Agreement represents the entire understanding between the parties, and supersedes all previous representations, understandings or agreements, oral or written, between the parties. XV. MODIFICATIONS The Health Center has the right to modify unilaterally the terms of this Agreement to the extent necessary to conform to subsequent changes in law or regulation. To the extent practicable, the Health Center will give Resident and Resident's Representative thirty (30) days advance written notice of any such modifications. XVI. WAIVER OF PROVISIONS The Health Center Executive Director reserves the right to waive any obligation of Resident under the provisions of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Health Center unless and except to the extent that such waiver is in writing by the Health Center. Any waiver by the Health Center shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. r Signatures This Agreement and any addenda to this Agreement constitute the entire Agreement and understanding between the Health Center and the Resident with respect to the subject matter of this Agreement and supersede all prior Agreements and understandings. There are no Agreements, understandings, restrictions, warranties, or representations between the Health Center and the Resident other than those set forth in this Agreement, or incorporated in this Agreement by reference. This Agreement may be amended only by a document in writing signed by the Resident and the Administrator or Executive Director, and no act or omission of any employee or agent of the Health Center shall alter, change or modify any of the provisions of this Agreement. A - istrator or Executive Director Date Resident Date Resideilt Repre tative Date .l ? " 0 Witness Dat 1:'.1:06 ''-f I? Oo W 00 W 0 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7540 Civil Term DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Petitioner, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Petitioner"), by and through its attorneys, SCHIMER BOGAR LLC, and files the following Petition against Respondent, Daryl Hurley ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. On or about December 17, 2007, Petitioner filed its Complaint against Respondent. 2. The Complaint sets forth a claim against Respondent relating to Respondent's breach of his contractual duties owed to Petitioner by failing to cooperate in the appeal of the denial of the Medical Assistance application of Goldie Hurley, his mother ("mother"), by providing the necessary financial documentation to the Cumberland County Assistance Office to determine his mother's eligibility for benefits. See Exhibit "A" to Complaint. 3. The very nature of Respondent's breach of his contractual duties presents an issue of immediate and irreparable harm to Petitioner, as the appeal of the Cumberland County Assistance Office's denial of Respondent's mother's Medical Assistance application will fail due to the lack of necessary evidence to qualify Respondent's mother for Medical Assistance benefits. 4. If Respondent does not provide the information requested by the Cumberland County Assistance Office prior to or at the time of a hearing on that appeal, the appeal will be finally denied and any further appeal to the Commonwealth Court would be without merit. 5. The requested injunction would restore the parties to the status quo as it existed immediately prior to the breach of Respondent's contractual duty. 6. Greater injury would result from the denial of the requested injunction than from the granting of the same because absent the injunction, without the information necessary to qualify Respondent's mother for Medical Assistance benefits, the appeal of the denial of the Medical Assistance application will fail. 7. Petitioner's right to relief is clear. See Complaint attached hereto as Exhibit "A." 8. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent's mother has been financially unable to fully compensate Petitioner for the care and services that it rendered to her and continues to render to her in accordance with the Agreement. 2 9. 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. WHEREFORE, Petitioner respectfully requests that the Court schedule an immediate hearing on its request for injunctive relief and thereafter issue a decree ordering specific performance of the contractual duty of Respondent. Dated:/ 21 04 Respectfully submitted, SCHUTJER BOGAR LLC gy:?}1?Gla7v? Chadwick O. BogaF 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 Plaintiff 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Petition for Preliminary Injunction was sent to Shinkowsky Investigations to serve upon the following: Daryl Hurley 9 Fox Hollow Lane Carlisle, PA 17015 /?' Dated: a L) By: Catherine Klobucar, Paralegal E ? t n' 4 rin rri IN THE COURT OF COMMON PLEAS = CUMBERLAND COUNTY, PENNSYLVANIA ` 7 PRESBYTERIAN HOMES INCORPORATED y z `' d /b / a GREEN RIDGE VILLAGE, co mic Plaintiff, V. No. b7- 15qD Civil Tim DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 COPY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following complaint against Daryl Hurley ("Defendant"), and in support thereof, states: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 210 Big Spring Road, Newville, Pennsylvania 17241. 2. Defendant is an adult individual who currently resides at 9 Fox Hollow Lane, Carlisle, Pennsylvania 17015. 3. On or about April 24, 2007, Defendant made application on behalf of his mother, Goldie Hurley ("Ms. Hurley"), for admission to Plaintiff's skilled nursing facility. 4. On or about April 24, 2007, Plaintiff and Defendant entered into a written Long Term Care Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Ms. Hurley with skilled nursing care and services in return for Defendant's promise to make payment for that skilled nursing and services from Ms. Hurley's resources, to "cooperate fully with the Health Center and any third party payer to secure payment," and, in the event that Ms. Hurley became insolvent, to apply for Medical Assistance benefits on her behalf and to "pursue MA [Medical Assistance] coverage." A true and correct copy of the Agreement is attached as Exhibit "A." 5. Subsequent to Ms. Hurley's admission to Plaintiff's skilled nursing facility, no payment was made for services rendered to her, because she allegedly became insolvent. As a result, an application for Medical Assistance benefits was subsequently filed. 6. The Cumberland County Assistance Office denied the application for Medical Assistance benefits because Defendant failed to provide the information needed by the Cumberland County Assistance Office to determine Ms. Hurley's eligibility for Medical Assistance benefits. 7. As of November 30, 2007, an outstanding balance of $32,265.98 is owed to Plaintiff for the care and services that it has provided to Defendant's mother, and this balance increases monthly, as Ms. Hurley is a current resident. 2 8. An appeal of the denial of the application for Medical Assistance benefits is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant prior to or at the time of the hearing on the appeal, the application for Medical Assistance benefits will ultimately be denied, and any further appeal to the Commonwealth Court would be without merit. COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 10. Paragraphs 1 through 9 are incorporated by reference as though restated in full. 11. Plaintiff has provided skilled nursing care and services to Ms. Hurley in accordance with the Agreement attached as Exhibit "A." 12. Defendant has breached the Agreement attached as Exhibit "A" by not securing Medical Assistance benefits for his mother by providing the necessary documentation to the Cumberland County Assistance Office to qualify Ms. Hurley for Medical Assistance benefits. 13. As a result of the failure of Defendant to abide by the terms and conditions of the Agreement, the application for Medical Assistance benefits filed for Ms. Hurley has been denied. 14. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff. 3 15. Upon information and belief and to the extent of Plaintiff's knowledge, at all times material hereto, Ms. Hurley has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to her in accordance with the terms and conditions of the Agreement. 16. 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. WHEREFORE, Plaintiff respectfully requests that this Court enter a decree ordering specific performance of the Agreement by the parties. Respectfully submitted, SCHU IJER BOGAR LLC Dated 43 &? 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, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff 4 VERiFICATIQN _ The undersigned Hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief- I understand that any false statemetnb therein are abject to the penalties contained in 18 Pa_ C S_ § 4904, rekting to unswom falsification to authorities. Dated: j IG?C Jeff D Chief EXHIBIT "A" ADMI NT LONG TERM CARE ADMISSION AGREEMENT I. INTRODUCTION This A eement is between old Resident, or U Resident's Representative (referred to as Resident in the Agreement) and Health Center, a licensed Long Tenn Care Facility (referred to as Health Center in this Agreement), for admission of Resident to the Health Center on *_1 20 ('_l Date) Resident requests occupancy of Room /0 / ff , a room for occupancy of residents at a Daily Rate of $ Resident may request a room change and the Health Center will make every effort to honor such requests as soon as possible. However, a room change may result in a change in the Daily Rate upon occupancy of the new room. In the event of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any change, thereby giving Resident sufficient time to request a room change (for example from a private to a semi-private room) or to transfer to another nursing facility. The Health Center agrees to accept payments from Medicare and other contracted third party payers for Resident's stay if Resident meets all qualifications required by Medicare or other third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by Medicare or other third party payers. If Resident qualifies for Medical Assistance ("MA"), the Health Center agrees to accept the Patient Pay Liability (as defined below) as determined by the County Assistance Office with the balance of the payment for covered services comiing from the MA Program. II. DEFINITIONS A. Daily Rate. The rate the Health Center charges a private pay resident for room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongs, and recreational programs for each day a Resident is at the Health Center. Physician services are not included in the Daily Rate. B. Healthcare Surrogate. An adult who is appointed to make Healthcare decisions for Resident when Resident becomes unable to make them for him/herself. C. Alfedical Director. The physician designated by the Health Center to be responsible for resident care policies and the coordination of medical care in the Health Center. D. Clinical Records. All records (excluding financial records) pertaining to a particular Resident that are prepared and maintained by Health Center. E. Patient Pay Liability. The amount of personal funds, as determined by the Commonwealth County Assistance Office, that a Resident who is receiving MA must pay monthly to the Health Center in addition to the payment from the MA program. F. Personal Needs Services. Personal services such as telephone service, laundry, beauty and hair care (exclusive of routine assistance with grooming), and newspaper delivery provided by the Health Center to Residents for their convenience at Residents' expense. G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of the Health Center from his/her own resources (including private insurance and Medicare Part B) and who is not covered by or has exhausted Medicare Part A and MA coverage. H. Resident Funds. Personal funds of a Resident that the Resident has authorized in writing that the Health Center shall manage for the Resident. 1. Resident's Representative. A person who is responsible for making decisions on behalf of the Resident and has been so designated in w iting by the Resident or a court of competent jurisdiction. If a Guarantor Agreement is attached to this Agreement, the Resident's Representative is only obligated to make payment from the Resident's personal funds. Reference in this Agreement to Resident shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf 1. Skilled Nursing Care. Professionally supervised nursing care and related medical and other health services provided to an individual not in need of hospitalization, but whose needs are above the level of room and board and can only be met in a long-term care nursing facility on an inpatient basis because of age, illness, disease, injury, convalescence or physical or mental infirmity. K. Specialty Care Serv4ces. Medical services ordered by a physician for a Resident that are not included in the Daily Rate. Medicare and Medicaid each include certain Specialty Care Services in the per diem rates, but neither include all such services. L. Transfer and discharge. Movement of a resident to a bed outside of the certified facility or unit whether that bed is in the same physical plant or not Transfer and discharge do not refer to movement of a resident within the same certified facility. III. HEALTH CENTER OBLIGATIONS: The Health Center will: A. provide, as part of the Daily Rate, room and board, general nursing care, houselceeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongings, and recreational programs. General nursing care does not include private duty nursing. B. provide Specialty Care Services ordered by Resident's treating or attending physician. Although additional fees for specialty services may be covered by third party payers, the Specialty Care Services identified on Exhibit A are not included in the daily rate, and are billed at the rates set forth in Exhibit A. Any items ordered by a physician, which are not identified on the Exhibit A will be provided at charges identified by the Health Center prior to the delivery of the service. C. provide Personal Needs Services, at Resident's expense (at the rates set forth on the Fee Schedule attached as Exhibit A) and at Resident's request, including but not limited to: 1. Beauty/Barber Services 2. Newspaper delivery and personal reading materials 3. Local and Long Distance Telephone Services 4. Cable Services, depending on cable provider 5. Personal laundry, dry cleaning and mending 6. Personal clothing. D. provide safekeeping of Resident Funds, if authorized in writing by the Resident, and make those funds available, at Resident's request, during normal business hours. 1. Resident may manage his/her financial resources if (s)he wishes. 2. Residents may keep a limited amount of funds at the Health Center, the maximum amount, which is specified from time to time by the Health Center. 3. Requests for withdrawals in excess of $50.00 require advance notice to assure availability of cash at the Health Center. Resident Funds shall be retained in compliance with State and Federal regulations. Resident Funds exceeding $50.00 shall be placed in an interest bearing account. A written quarterly statement of these funds shall be provided to Resident. Resident agrees to return signed copy to facility if required. E. provide refunds of unused advance payments and Resident Funds within thirty (30) days after deductions for payment of any outstanding bills or other amounts due the Health Center after Resident's discharge or death. In the event of Resident's death, refunds will be made to the authorized representative of Resident's estate. F. assist Resident in applying for and obtaining private insurance and/or public 0 =1 benefits to cover the cost of the Resident's care. G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of the Health Center only for medical reasons, for Resident's welfare, because the safety or health of individuals in the Health Center is endangered, because the Resident has failed, after teasonable notice, to pay for a stay at the Health Center, or. with the voluntary consent of Resident. Except in emergency situations, at least thirty (30) days' notice will be provided to Resident and Resident's Representative to assure that the transfer is safe and orderly. The Health Center reserves the right and discretion to move Resident to another room or bed within certified parts of the Health Center consistent with the safety, care and welfare needs of the Resident. H. arrange for Resident's transfer or discharge upon the order of Resident's personal physician when he/she deems it necessary to receive services the Health Center is- not qualified to provide or at Resident's request. 1. honor Resident's Rights as outlined in the Department of Public Welfare Admissions Notice Packet (MA 401). J. to the extent permitted by law, hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. To the extent permitted by law, Resident shall indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions or omissions. Health Center will be responsible for loss of or damage to Resident's personal property by Health Center staff. , K. provide Resident with a locked drawer or box for Resident's valuables or for. medications retained for self-administration. Resident may self-administer medications only in certain circumstances and may not have medications in his/her room without physician authorization. L. provide Resident with a choice of pharmacy if Resident does not wish to utilize the pharmacy provider designated by the Health Center. With this choice, pharmacy must provide medications in compliance with all applicable laws and under a delivery system that is consistent with the one used by the Health Center, must provide a monthly written profile of all drugs provided to the Health Center's consultant pharmacist, and must be delivered from the provider pharmacy in tamper-proof containers, directly to the Health Center's licensed nursing staff. M. provide Resident with a choice of attending physician who will provide medical care during the Resident's stay at the Health Center and who shall comply with the Health Center's rules, regulations, policies and procedures and all applicable laws and credentialling standards. Resident may also designate an alternate attending physician in the event that the primary attending physician is unavailable. In the event that Resident's attending physician(s) are unavailable, the Resident authorizes Health Center's Medical Director or other physician designated by the Health Center to issue appropriate orders. IV. RESIDENT OBLIGATIONS The Resident agrees to: A. by signing this Agreement, Resident certifies that (s)he is competent, and has never been adjudged incompetent, and is entering into this Agreement of his/her own fi ee will. 1. In the event Resident has been adjudged incompetent, Resident's healthcare surrogate will attest, in a separate document that (s)he has the legal authority to act on behalf of the Resident. B. provide the Health Center with all information about Resident's health status and financial resources. Failure to accurately identify resources and income, or the submission of false information may amount to a violation of law and may result in the termination of this Agreement by and at the option of the Health Center. C. provide the Health Center with a copy of all current insurance cards. Resident will provide the Health Center with changes in insurance coverage or financial status in a timely manner, and will update the information provided to the Health Center from time to time, as requested. Resident understands that making incomplete or inaccurate disclosures will be considered a breach of this Agreement. D. authorize the Health Center to provide care and treatment to Resident consistent with the terms of this Agreement and to carry out the orders of the Resident's treating or attending physician or of the physician designated by the Health Center. Resident also authorizes the Health Center to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident maybe transferring. E. authorize the Health Center to make Resident's Clinical Records available to Health Center staff and agents. Resident also authorizes the release of the Resident's Clinical Records to any other health care provider from whom Resident receives treatment, to third-parry payors of health services, and to any managed care organization (MCO) in which Resident may be enrolled. Resident also authorizes the release to the Health Center of records prepared and maintained by any third-party payor of health care services pertaining to health care services rendered to the Resident by the Health Center. Resident also acknowledges receipt of the "Release for Electronic Transmission of Minimum Data Set" (' MDS"), which explains the MDS system of records using Resident data. Resident's Clinical Records will remain otherwise confidential, and shall not be made available to anyone other than Resident or authorized agents of the state or federal governments urithout the express written authorization of Resident or without a subpoena or other judicial order. F. cooperate fully with the Health Center and any third party payer to secure payment. Resident authorizes the Health Center to collect any payments made by third parties on Resident's behalf directly from the third party payer. Resident also authorizes the Health Center to snake claims, file appeals or grievances, and take other actions necessary and appropriate to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident to the fullest extent permitted by law. Provided that Resident may, but shall not be required to authorize the Health Center to pursue grievances or appeals on Resident's behalf under Pennsylvania's Quality Health Care Accountability and Protection Act, to the fullest extent permitted by law and as security for payment of the Health Center's charges, Resident hereby assigns to the Health Center all of Resident's rights to any third-party payments now or subsequently payable for services rendered by or provided under arrangement through the Health Center. G. pay the Daily Rate established for the accommodation requested. Payment is due 30 days in advance, and Resident agrees to make full payment by the first of each month. Collection procedures are initiated after thirty (30) days of unpaid balances. Interest shall be charged on unpaid balances. I. If the Health Center initiates any legal actions to collect payments due from Resident under this Agreement, Resident shall be responsible to pay all attorney's fees and costs incurred by the Health Center in enforcing Resident's financial obligations under the.Agreement. 2. This Agreement shall serve as an assignment to the Health Center of as much of Resident's property as equals the amount of any unpaid obligations under this Agreement, and this assignment shall be an obligation of Resident's estate that may be enforced against Resident's estate. Resident's estate shall be liable to and shall pay to the Health Center an amount equivalent to any unpaid obligations of Resident under this Agreement. This liability shall apply whether or not Resident is occupying the Health Center at the time of Resident's death. H. pay for additional items, services and equipment not included in the Daily Rate as identified by the Fee Schedules, attached as Exhibit A. I. understand that Resident will be notified-thirty (30) days in advance of changes in the Daily Rate except when Resident requests room change, changes in charges for Specialty Care Services or Personal Needs Services, or changes in billing procedures, and agree that the changes will be effective upon the date designated by the Health Center. I understand that the Resident may continue to live at the Health Center as long as Resident continues to pay the Daily Rate. Resident may be discharged for non- payment of incurred charges or transferred for the benefit of the Resident or others, as set forth in Section M(H) of this Agreement. K. acknowledge that non-payment of the Daily Rate for a private room will result in a room change. L. acknowledge that the Health Center has the discretion, with thirty (30) days' notice, to transfer Resident to another room or bed within the Health Center consistent with the safety, care and welfare needs of Resident. The Health Center also has the discretion, upon thirty (30) days' advance notice, to transfer or change Resident's roommate, if any, at any time consistent with the needs of the Health Center. M. terminate this Agreement upon written notice to the Health Center, but if Resident leaves for any reason other than a medical emergency or death, Resident must give reasonable advance written notice to the Health Center. N. notify the Health Center at least two months before the Resident has insufficient resources, funds or income to meet his/her financial obligations and to apply for MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not eligible for MA, Resident agrees to vacate the Health Center. 0. pay co-payments and/or deductibles for services covered by the Medicare Program or other third party payer, and pay the Health Center within thirty (30) days of receipt of services for those services not covered by the Medicare Program or other third party payer. P.. pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. Q. to the extent otherwise permitted by law, assume responsibility for any damages or injuries caused by acts or omissions of the Resident to other persons, residents or staff'. R. comply with reasonable rules, regulations, policies and procedures that the Health Center establishes from time to time and makes available to Residents, subject to reasonable accommodation of Resident's individual needs and preferences. The Health Center's rules, regulations, policies and procedures are for purposes of internal management and shall not be construed as imposing contractual obligations on the Health Center and are subject to change from time to time. S. acknowledge receipt of the Resident Handbook, a document that provides Residents with Health Center rules, regulations, policies and procedures. T. acknowledge receipt of information on Advance Directives in the absence of providing the Health Center with an existing Advance Directive or Living Will. U. provide the Health Center with a copy of any and all Durable Powers of Attorney, Guardianships, and/or Advance Directives pertaining to the Resident. V. acknowledge that (s)he has read and understands the teens of this Agreement, that the terns have been explained to them by a representative of the Health Center, and that (s)he has had an opportunity to ask questions about the Agreement. V. MEDICARE AND MEDICAID The Health Center is certified to participate in the Medicare and Medicaid Programs. The Health Center's participation uz these programs is subject to termination by either the Health Center or the responsible goverrnnent entity. The Pennsylvania Department of Public Welfare (DPW) is responsible for administering benefits under the Medicaid Program and the Centers for Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program through an intermediary. The Resident acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of DPW, CMS or the Medicare 'intermediary in administering these programs. A. Medicare If Resident is eligible for benefits under the Medicare Program, Resident understands that certain skilled nursing and related health care services may be covered by Medicare. The Health Center will bill Medicare Part A on behalf of the Resident for skilled nursing services and payment will be made by Medicare Part A directly to the Health Center for services received by Resident. When the Health Center notifies Resident that the nursing services being provided to the Resident no longer qualify as a skilled service, the Resident may request that the Health Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for the charges incurred on the Medicare Part A non-covered days. The following describes coverage under the Medicare Part A Program: 1. Medicare Part A covers from one (1) to one hundred (100) days at the Health Center. Coverage is not guaranteed and is limited to the unused days in the Resident's benefit period Conditions stipulated by Medicare must be met for coverage to begin and remain in force. 2. The Medicare Part A Program pays for all covered charges from day one (1) through day twenty (20) if the criteria for skilled service is met. 3. The Medicare Part A Program pays a portion but not all of the charges from day twenty-one (21) through day one hundred (100). The Resident is responsible for and shall pay any co-insurance or deductible amounts as determined by the Medicare Part A program. Depending on the circumstances, this payment may be made by personal health insurance, MA, or personal funds. 4. The Medicare Part A Program covers the following services: room and board, linens, meals, most prescription medications, therapy services, most medical supplies, non-private duty nursing services, most recreational services, most social services, and most personal hygiene items provided by the Facility. (Note: only the type and brand of personal hygiene items provided by the Health Center are included) 5. Some items and services not covered by the Medicare Part A Program include, but are not limited to: personal clothing, eyeglasses, hearing aids, services of a beautician or barber, guest meals, special or alternative meals not required for therapeutic purposes or as a nutritional substitute, services not deemed medically necessary, and personal telephone service. The Fee Schedule for items and services provided to Medicare Part A eligible Residents that are not covered by Medicare Part A is attached as Exhibit A. 6. Bed hold days are not covered by the Medicare Part A Program. (See Section VII) 7. Residents covered by Medicare Part A should not go out on overnight leave as this may disqualify them from further coverage by Medicare Part A. 8. Residents may be covered for therapy and other ancillary services under the Medicare Part B Program. The Health Center or provider approved by Health Center will bill Medicare Part B directly for these services. The Residents are responsible for the annual deductible and the co-insurance payment for Medicare Part B covered services. 9. Resident is responsible to pay the Health Center for services and supplies not covered by the Medicare Pro grain. 10. In the event that Medicare-coverage is changed by law, those changes will control and take precedence over any contrary provision in this Agreement. B. Medicare Manaced Care The Health Center participates as a provider of skilled nursing services under some, but not all Medicare MCOs. 1. Requirements for eligibility for Medicare payments, deductibles and co- insurance may be different from those discussed in Section V(A). Pre- authorization of services is required by Medicare MCOs, and if the.,, . Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Health Center for those services. If the MCO refuses coverage on the grounds that it does not consider an item or service to be medically necessary, Health Center or MCO will provide an Advance Beneficiary Notice of that determination. The Health Center will communicate directly with Residents Medicare MCO to obtain authorization for continued Medicare managed case coverage. 2. The Health Center will accept payment from the ' Medicare MCO as payment in full only for those services and supplies covered by the Medicare MCO. Resident is responsible for any copayments or other costs assigned to Resident or not covered by the MCO under the specific terms of the managed care plan. 3. Resident acknowledges that an MCO for which the Health Center is not an authorized provider may not approve payment for services provided by the Health Center, so that Resident may be required to pay the Health Center directly. Resident also acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of any MCO for which the Health Center is an authorized provider, including decisions relating to a denial of coverage or refusal to pay on behalf of the Resident. 4. The Health Center reserves the right to stop its participation in any MCO at any time and in its sole discretion. To the extent practicable, the Health Center will provide advance notice to Residents enrolled in a particular managed care plan or insurance program of its decision to stop participation in that managed care plan or insurance program. C. Medical Assistance Program l . Residents who qualify for coverage under the MA Program must apply for and be approved for these services at the County Assistance Office. It is Resident's responsibility to pursue MA coverage. Until approval of MA coverage is obtained, the Health Center will consider Resident to be a Private Pay Resident. 2. Resident will be required to use the Patient Pay Liability to pay the Health Center for the Resident's stay in conjunction with the MA Program. Periodic adjustments in the Patient Pay Liability are made by the County Assistance Office and when issued, will supersede all previous determinations. Resident shall arrange, if possible, for the designation of the Health Center for direct deposit of any Social Security or related benefits or any other income sources of the Resident in an amount not to exceed the Patient Pay Liability. 3. MA program coverage includes the following: room and board, prescription and non-prescription medications, meals, linen service, nursing services, incontinence care, social services, recreational activities, personal laundry, a hair cut every six (6) weeks, a shampoo and set every two (2) weeks, one pennanent per year, and personal hygiene items provided by the Health Center. (Note that only the type and brand of personal hygiene items provided by the Health Center are included.) The MA Program limits the frequency of coverage for the purchase of eyeglasses, hearing aids, and dentures. 4. The Health Center will not charge, solicit, accept or receive monies from or on b6half of Resident for bed hold days covered by MA Program, except for the Patient Pay Liability, to cover the cost of Resident's stay or as a condition of admitting a Resident under the MA Program. 5. Some items and services not covered by the MA Program include, but are not limited to: personal telephone service, personal clothing, guest meals, brand name personal hygiene iterns, and additional services provided by a beautician other than those listed above. Resident is responsible for charges incurred for these sen?ices at the rates listed on the Fee Schedule attached as Exhibit A in addition to the patient pay liability amount. 6. Residents receiving MA coverage are permitted to keep the amount that has been designated as the Resident's personal needs allowance for personal spending. Personal funds may be given to the Health Center for safekeeping (see Health Center Obligations in Section Ill). 7. The MA Program provides for bed hold days for limited periods of time during Resident's stay. a) Up to fifteen days bed hold days are allowed when Resident is transferred to a hospital. b) Up to thirty days bed hold days are allowed annually for intermittent therapeutic leave from the Health Center. c) The bed hold days referenced above are based upon the law in effect at this time, and may be subject to change if the governing state law is changed. 8. The Health Center provides equal access to its services to all individuals, regardless of payor source. VI. THIRD-PARTY PAYMENTS A. If Resident is or becomes eligible to receive financial assistance or reimbursement from any third parties (such as private insurance, employee benefit plans, Na, Medicare, managed care coverage, supplemental imedical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance), the Health Center reserves the right to collect such payments directly from the thud party. Resident shall cooperate fully with the Health Center and each third-party payor to secure payment, and Resident shall designate the Health Center, to the extent permitted by law, as the recipient of direct deposit for receipt of Federal Social Security benefits or any other Federal or State . government assistance, reimbursement, or benefits to the extent of all amounts due the Health Center. B. Resident authorizes the Health Center to make claims and to take necessary actions to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment _ of the Health Center's charges, Resident agrees to assign to the Health Center Resident's rights to any third-party payments now or subsequently payable to satisfy all charges, due under this Agreement. Resident shall endorse and turn over to the Health Center any payments received from third-party payor to the extent necessary to satisfy the charges under this Agreement. C. In the event of any denial of coverage by the Resident's insurance company, Resident shall pay the facility for all non-covered services retroactive to the date of the initial delivery of services. VII. READMISSION - BED HOLD POLICY A. A Health Center representative shall communicate with Resident regarding his/her desire to continue to occupy the Health Center bed during hospitalization or therapeutic leave. Verbal- consent shall be given to the Health Center representative who shall document this consent in the clinical record. Written consent shall be obtained following the verbal consent. See Fee Schedule (Exhibit A) for bed-hold rates. B. Bed holds for Residents enrolled in the MA Program are subject to the provisions of Section 5(C)(7), C. Resident's belongings shall be removed from the Health Center within 24 hours if Resident does not execute a bed hold authorization. Belongings not removed in a timely fashion may be packed and stored. VIII. CI 11L RIGHTS COMPLIANCE All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in need of services and are not'restricted to members of the Presbyterian Church. It is the policy of PHI facilities to admit and to treat all residents without regard to race, color, national origin; age, ancestry, sex, religious creed, handicap, liinited English proficiency, or disability. The same requirements for admission are applied to all; and residents are assigned without regard to race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. There is no distinction in eligibility for, or in the manner of providing, any service provided by or through the facility. All facilities -are available without distinction to all residents and visitors, regardless of race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. Roommate preference requests, staff assignment to residents and resident ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency or disability. All persons and organizations that have occasion either to make referrals for admission or recommend a PHI facility are advised to do so without regard to race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited English proficiency, or disability. IX. REGULATION The Health Center and Resident recognize, that Health Center is licensed by the Peimsylvania Department of Health and is regulated by the DPW. The Health Center and Resident recognize that Health Center is also regulated by CMS of the United States Departnient of Health and Hurnan Services. Both parties recognize that regulatory changes may alter the conditions of this agreement. X. GRIEVANCE PROCEDURE If Resident believes that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, on in any other way, Resident may submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow the Health Center's grievance procedure as described in the Resident Handbook. The Health Center's grievance procedure does not preclude Residents from pursuing grievances with appropriate regulatory agencies. XI. ARBITRATION Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or concerning any rights arising thereunder or the breach thereof shall be settled exclusively by arbitration, which shall be conducted at the Health Center in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties and may be entered in any court having jurisdiction thereof. Provided, however, that this arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a resident under the Medicare or MA programs or an applicable state law. XH. GOVERNING LAW This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XIII. SEVER" MITY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. XCIV. ENTIRE AGREEMENT This Agreement represents the entire understanding between the parties, and supersedes all previous representations, understandings or agreements, oral or written, between the parties. XV. MODIFICATIONS The Health Center has the right to modify unilaterally the terms of this Agreement to the extent necessary to conform to subsequent changes in law or regulation. To the extent practicable, the Health Center will give Resident and Resident's Representative thirty (30) days adwnice written notice of any such modifications. A'VI. WAIVER OF PROVISIONS The Health Center Executive Director reserves the right to waive any obligation of Resident under the provisions of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Health Center unless and except to the extent that such waiver is in writing by the Health Center. Any waiver by the Health Center shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. Signatures This Agreement and any addenda to this Agreement constitute the entire Agreement and understanding between the Health Center and the Resident with respect to the subject matter of this Agreement and supersede all prior Agreements and understandings. There are no Agreements, understandings, restrictions, warranties, or representations between the Health Center and the Resident other than those set forth in this Agreement, or incorporated in this Agreement by reference. This Agreement may be amended only by a document in writing signed by the Resident and the Administrator or Executive Director, and no act or omission of any employee or agent of the Health Center shall alter, change or modify any of the provisions of this Agreement. A s&ator or Executive Director Date Resident Date 441 ?< L4- - / /07 Resident Repr tative Date .l ? Witness Dat N c- {- ha CJ s r•y :J c- Q Tj E°F1 - -ri :?s7 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED : D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7540 Civil Term DARYL HURLEY, Defendant. CIVIL ACTION - EQUITY CERTIFICATION 1. Pursuant to Local Rule 208.3(a)(2), a judge has not ruled upon any other issue in the same or related matter. 2 In accordance with Cumberland County Local Rule 208.3(a)(9), Petitioner is unaware of whether Respondent has retained counsel of record, and to date, Petitioner has not received a Entry/Notice of Appearance of counsel of record for Respondent. Dated:/Z Zv o:? Respectfully submitted, SCxvz7ER BoGAR LLC By: ? Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Petitioner C') rbl) iU C -? C Yy J rn IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. DARYL HURLEY, Defendant. DEC 8 7 2W7 lOOZL3X30 ey No. 07-7540 Civil Term CIVIL ACTION - EQUITY ORDER AND NOW, this ?k 5A day of L " 2011 a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for 20? at o'clock -6.m. in Court Room No. , Cumberland County Courthouse. j 4S > Al 0011 F CkYJ BY THE COURT: >- - u i 1 L ?? ta C2.? ,. y l+ ? j- ? LLJ LS I Cy m1 r-, N gt u1 t C \ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 07-7540 AFFIDAVIT OF SERVICE Presbyterian Homes incorporated d/b/a Green Ridge Village vs. Daryl Hurley Commonwealth of Pennsylvania County of Dauphin sa. I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 4:09 PM on 01/03/2008, I served Daryl Hurley at 9 Fox Hollow Lane, Carlisle, PA 17015 in the manner described below: ? Defendant(s) personally served. ® Adult family member with whom said Defendant(s) reside(s). Relationship is Jennifer Hurley,, Spouse. ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. ? Other: a true and correct copy of Notice, Complaint, Verification, Petition for Preliminary Injunction, Certificate of Service, Brief in Support of Petition for Preliminary Injunction, Certificate of Service issued in the above captioned matter. Description: Sex: Female - Age: 35 - Skin: White - Hair: Blonde -Height: 5' 081 ?J W Swor to and su cribed before me on this ifqhn Shinkowsk day of 20,p? inkowsky I e igations 316 Fawn Ri e orth Harrisburg, 17110 (800) 276-0202 NOT Y PUBLIC COMMONWEALTH OF PENNSYLVANI tty File#: 07-7540 - Our File# 2704 NOTARIAL SEAL DONNA M. WTERMAN, Notary Pubric Susquehanna Twp., Dauphin County My Commission Expires July 28, 2009 Law Firm: Schutjer Bogar LLC Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102 Telephone: (717) 909-5925 c7 ? D CID cn -si , `, i IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D / B / A GREEN RIDGE VILLAGE, Plaintiff, V. DARYL HURLEY, Defendant. No. 07-7540 Civil Term CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW PETITION FOR PRELIMINARY INJUNCTION TO THE CLERK OF COURTS: Kindly mark the Petition for Preliminary Injunction, filed in the above- captioned matter on December 26, 2007, as withdrawn. Consequently, the Preliminary Injunction hearing scheduled for January 25, 2008 at 11:00 a.m. is no longer necessary. Respectfully submitted, SCHUTJER BOGAR LLC Dated: O BY iq - Chadwick O. Bogar Attorney I.D. 83755 (717) 909-5920 Maria Macus-Bryan Attorney I.D. 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 Withdraw Petition for Preliminary Injunction was served via overnight delivery, upon the following: Thomas E. Flower, Esquire SAIDIS, FLOWER & LINDSAY 2109 Market Street Camp Hill, PA 17011 (Attorney for Defendant) Dated:l Iaa 1d? By: CA:k?? kgf" Catherine Klobucar, Paralegal t ,. r--. ? ' ? '7 C7 C.aJ a i .. - CO .:.? ---d "L PRESBYTERIAN HOMES IN THE COURT OF COMMON PLEAS OF INCORPORATED, D/B/A CUMBERLAND COUNTY, PENNSYLVANIA GREEN RIDGE VILLAGE, Plaintiff V. DARYL HURLEY, Defendant CIVIL ACTION - LAW NO. 07-7540 CIVIL TERM ORDER OF COURT AND NOW, this 23rd day of January, 2008, upon consideration of the Praecipe To Withdraw Petition for Preliminary Injunction filed in the above matter, the hearing previously scheduled for January 25, 2008, is cancelled. BY THE COURT, Chadwick O. Bogar, Esq. Maria Macus-Bryan, Esq. 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff Thomas E. Flower, Esq. 2109 Market Street Camp Hill, PA 17011 Attorney for Defendant r Wesley Oler, r., J. t 06F,,2s triadecL rc -- ? ,_,_ -?, u ,`, ?. (: `? : ? 1 r it ? ? ???'?? C ??`???U ?i i , _.. . I • IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. DARYL HURLEY, Defendant. No. 07-7540 Civil Term 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: By: Maria G. Macus-Bryan Attorney I.D. No.: 90947 (717) 909-8640 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax - (717)909-5925 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Settle, Discontinue, and End was served via first-class, Untied States mail, postage prepaid upon the following: Thomas E. Flower, Esquire SAIDIS, FLOWER & LINDSAY 2109 Market Street Camp Hill, PA 17011 Attorney for Defendant J Dated: ' I16 k By: Christy A. Long, Paralegal _? ? ? ?? .. ? ...., _ _- ? ? ?_ r ?. " ? , ?<