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HomeMy WebLinkAbout07-7672ti IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. a^J 7Z7-P,, SUSAN CAVANAGH, 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 'J IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. SUSAN CAVANAGH, 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 medic, 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED : D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Plaintiff"), by and through its attorneys, SCHUT JER BOGAR LLC, and files the following complaint against Caroline Savage ("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 100 W. Park Street, Carlisle, Pennsylvania 17013. 3. On or about December 15, 2004, Defendant made application on behalf of her father, Robert W. Savage ("Mr. Savage"), for admission to Plaintiff's skilled nursing facility. 4. On or about December 15, 2004, Plaintiff and Defendant entered into a written Long Term Care Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Mr. Savage with skilled nursing care and services in return for Defendant's promise to make payment for that skilled nursing and services from Mr. Savage's resources, to "cooperate fully with the Health Center and any third party payer to secure payment," and, in the event that Mr. Savage became insolvent, to apply for Medical Assistance benefits on his behalf and to "pursue MA (Medical Assistance) coverage." A true and correct copy of the Agreement is attached as Exhibit "A." 5. When Mr. Savage became insolvent, an application for Medical Assistance benefits was filed on his behalf and that application is currently pending before the Cumberland County Assistance Office. 6. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant the application for Medical Assistance benefits will ultimately be denied. COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 7. Paragraphs 1 through 6 are incorporated by reference as though restated in full. 8. Plaintiff has provided skilled nursing care and services to Mr. Savage in accordance with the Agreement attached as Exhibit "A." 9. Defendant has breached the Agreement attached as Exhibit "A" by not securing Medical Assistance benefits for her father and not providing the necessary documentation to the Cumberland County Assistance Office to qualify Mr. Savage for Medical Assistance benefits. 2 10. If the documentation needed to determine Mr. Savage's eligibility is not provided, the application will be denied. 11. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff. 12. Upon information and belief and to the extent of Plaintiff's knowledge, at all times material hereto, Mr. Savage has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to him in accordance with the terms and conditions of the Agreement. 13. 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. Dated: Respectfully submitted, SCHUTJER BOGAR LLC By: Ch wick O. Boga Attorney I.D. No. 83755 (717) 909-5920 Mariclare L. Hayes Attorney I.D. No. 201289 (717) 909-5922 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff VERMCATION 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 19 Pa. C. S. j 4904, relatiniz to unsworn falsification to authorities. Dated: EXHIBIT "A" ADMI NT LONG TERM CARE ADMISSION AGREEMENT I. INTRODUCTION . This Agreement is between a V :t Resident, or Cayzp_L,w C es t Representative (referred to as Resident in the Agreement) and SlA?CJI,L?? . Health Center, a licensed Long Term Care Facility (referred to as Health Center in this Agreement), for admission of Resident to the Health Center on OQ -)1 & , 20 :(Date) Resident requests occupancy of Room I0 , a room for occupancy of OZ, residents at a Daily Rate of $aC . Re i Wma-y 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 coming 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 wbo .is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for him/herself. C. Medical 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 -2- Admission Agr./PA/MA 10-08-02 shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf. 7. 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 Services. 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 service. -3- Admission AgrJPA/MA 10-08-02 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. -4- Admission Agr./PA/MA 10-08-02 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 reasonable 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. I. honor Resident's Rights as outlined in the Department of Public Welfare Admissions Notice Packet (MA 401). J. hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. 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. -5- Admission AgrJPA/MA 10-08-02 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 free 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. -6- Admission Agr./PA/MA 10-08-02 C. provide the Health Center with a cppy 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 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 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 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 -7- Admission AgrJPA/MA 10-08-02 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 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. 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 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. -8- Admission AgrJPA/MA 10-05-02 I. understand that Resident will be notjfied 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. J. 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 HI(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. -9- Admission Agr./PA/MA 10-08-02 P. pay for items and services requested, by Resident and not covered by MA within thirty days of receiving the non-covered service. Q. pay for any damages or injuries caused by Resident to other persons, residents or staff, and indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions. 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 termination 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 -10- Admission AgrJPA/MA 10-08-02 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 -11- Admission Agr./PA/MA 10-08-02 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 Manned Care The Health Center participates as a provider of skilled nursing services under some, but not all Medicare MCOs. -12- Admission Agr./PA/MA 10-08-02 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. -13- Admission Agr./PA/MA 10-08-02 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 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 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 -14- Admission A¢rJPA/MA 10-0"2 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 medical 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 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. -15- Admission Agr /PA/MA 10-08-02 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. 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. The Health -16- Admission Agr./PA/MA 10-08-02 Center does not discriminate on the basis of racP,,color, national origin, age, ancestry, sex, handicap 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 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. 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 -17- Admission Agr./PA/MA 10-08-02 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. XIV. 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. -18- Admission Agr./PA/MA 10-08-02 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. Admi istrator or Executive D ector Date Resident Date X ? 15 . Resident Representative Date Witness Date -19- Admission AgrJPA/MA 10-002 cp oa n r i hJ C.? r?=7 C'7 N . N G r T?_t'Y1 -G 9 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED : D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES, Plaintiff, Presbyterian Homes Incorporated, d/b/a Green Ridge Village, ("Plaintiff"), by and through its attorneys, SCHU7UER BOGAR LLC, and pursuant to the provisions of Pa. R.C.P. § 1531, makes the following petition for preliminary injunction and, in support thereof, avers: 1. On December 21, 2008, Petitioner filed a complaint ("Complaint") against Caroline Savage ("Respondent") seeking specific performance of the written Admission Agreement into which Respondent entered upon the admission of her father, Robert W. Savage ("father") to Petitioner's skilled nursing facility. 2. The Complaint sets forth a claim against Respondent relating to her breach of the Admission Agreement ("Agreement") she signed in her individual capacity, by failing to secure Medical Assistance benefits on behalf of her father by providing the necessary financial documentation to the Cumberland County Assistance Office to qualify her father for benefits. See Complaint, Exhibit "A." ORIGINAL 3. The very nature of Respondent's breach of her 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 father's Medical Assistance application will fail due to the lack of necessary evidence to qualify Respondent's father 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 same because absent the injunction, without the information necessary to qualify Respondent's father 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 father has been financially unable to fully compensate Petitioner for the care and services that it rendered to him and continues to render to him in accordance with the Agreement. 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 this Honorable Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a decree ordering the specific performance of the contractual duty of Respondent. Respectfully submitted, SCHUTJER BOGAR LLC Dated: ? g C By: Cha wick 6. Bogar Attorney I. D. No. 83755 (717) 909-5920 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Petitioner • CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petition for Preliminary Injunction was sent to Shinkowsky Investigations to personally serve the following: Caroline Savage 100 W. Park Street Carlisle, PA 17013 Dated:. ? / t 1 /w- By:LA2UA Catherine Klobucar, Paralegal E IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. 01 - 740 %k SUSAN CAVANAGH, Defendant. C ('- N - t 0 _ -- C'7 fTl i"- V ?r7l =- -71 _ (D O -c Ot. c-. 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 COPY IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. SUSAN CAVANAGH, 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 Ias 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 TTENE UN ABOGADO, LLAME O VAYA A LA SIGLIIFNTE 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Plaintiff"), by and through its attorneys, SCHUT JER BOGAR LLC, and files the following complaint against Caroline Savage ("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 100 W. Park Street, Carlisle, Pennsylvania 17013. 3. On or about December 15, 2004, Defendant made application on behalf of her father, Robert W. Savage ("Mr. Savage"), for admission to Plaintiff's skilled nursing facility. 4. On or about December 15, 2004, Plaintiff and Defendant entered into a written Long Term Care Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Mr. Savage with skilled nursing care and services in return for Defendant's promise to make payment for that skilled nursing and services from Mr. Savage's resources, to "cooperate fully with the Health Center and any third party payer to secure payment," and, in the event that Mr. Savage became insolvent, to apply for Medical Assistance benefits on his behalf and to "pursue MA (Medical Assistance) coverage." A true and correct copy of the Agreement is attached as Exhibit "A.- 5. When Mr. Savage became insolvent, an applicatio;1 for Medical Assistance benefits was filed on his behalf and that application ?, currently pending before the Cumberland County Assistance Office. 6. If the documents r equested by the Cumberland County Assistance Office are not provided by D2fendant the application for Medical Assistance benefits will ultimately be denied. COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 7. Paragraphs 1 through 6 are incorporated by reference as though restated in full. 8. Plaintiff has provided skilled nursing care and services to Mr. Savage in accordance with the Agreement attached as Exhibit "A." 9. Defendant has breached the Agreement attached as Exhibit "A" by not securing Medical Assistance benefits for her father and not providing the necessary documentation to the Cumberland County Assistance Office to qualify Mr. Savage for Medical Assistance benefits- 2 10. If the documentation needed to determine Mr. Savage's eligibility is not provided, the application will be denied. 11. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff. 12. Upon information and belief and to the extent of Plaintiff's knowledge, at all times material hereto, Mr. Savage has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to him in accordance with the terms and conditions of the Agreement. 13. Accordingly, only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefit; 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. Dated: 111 It I.W Respectfully submitted, SCHUTJER BOGAR LLC By: Ch wick O. Boga Attorney I.D. No. 83755 (717) 909-5920 Mariclare L. Hayes Attorney I.D. No. 201289 (717) 909-5922 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff VERIECATfON 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 arc smbject to the penalties contained in 19 Pa. C. S §49t14,relatimg tv unsworn falsification to authorities. Dated: J EXHIBIT "A" ,NT ADM LONG TERM CARE ADMISSION AGREEMENT 1. INTRODUCTION This Agreement is between n V 1 Resident, or CCJ?YtpQ.;,rr•?D? 3?,1VUlA es;t s Representative (referred to as Resident in the Agreement) and ',SINN CL, AA . Health Center, a licensed Long Term Care Facility (referred to as Health Center in this Agreement), for admission of Resident to the Health Center on CQCJ 1 L , 20 O: (Date) Resident requests occupancy of Room 110 a room for occupancy of 0, residents at a Daily Rate of $oZCG Reid W 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 coming 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 wbo is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for him/herself. C. Medical 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 -2- Admission AgrJPA/MA 10-08-02 shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf. J. 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 Services. 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. 111. 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 service. -3- Admission AgrJPA/MA 10-05-02 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. -4- Admission Agr./PA/MA 10-05-02 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 reasonable 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. hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. 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. -5- Admission AgrJPA/MA I0-08-02 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 free 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. -6- Admission Agr./PA/MA 10-0"2 C. provide the Health Center with a cppy 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 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 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 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 -7- Admission Agr.JPAJMA 10-08-02 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 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. 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 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. -8- Admission AgrJPA/MA 10-08-02 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. J. 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 III(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. Admission AgrJPA/MA 10-08-02 -9- P. pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. Q. pay for any damages or injuries caused by Resident to other persons, residents or staff, and indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions. - 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 termination 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 -10- Admission AgrJPA/MA 10-08-02 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 Admission Agr./PA/MA 10-08-02 -11- • by the Facility. (Note: onlythe 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. Admission Agr./PA/MA 10-08-02 -12- 1. Requirements for eligibility NT 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. -13- Admission AgrJPA/MA 10-08-02 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 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 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 Admission A¢rJPA/MA 10-08-02 -14- 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 medical 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 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. Admission AgrJPA/MA 10-08-02 -15- ,r _ f 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 tam 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. 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. The Health Admission AgrJPAlMA 10-OM2 -16- r - • Center does not discriminate on the basis of racg,_color, national origin, age, ancestry, sex, handicap 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 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. M. 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 Admission Agr./PA/MA 10-08-02 -17- 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. XIV. 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. -18- Admission AgrJPAlMA 10-08-02 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. Admi 'strator or Executive D ctor Date Resident Date l5#?- Resident Representative Date' Witness Date -19- Admission Agr./PA/MA 10-08-02 rr r3 0 a ? ''a IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED : D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, 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: 1 /it I g Respectfully submitted, SCHUTJER BOGAR LLC^ By: &- Alf , Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Allison O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Petitioner f-5 ? Q .. ? r ?S JAN 16 2008 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY ORDER AND NOW, this day of 2008, a hearing in the above-captioned matter on Plaintiff's petition for the issuance of a .A3 preliminary injunction is scheduled for 2008, at '8: &a _E.m. in Court Room No. S Courthouse. Cumberland County BY THE COURT: 10 ;? '` d L 6 NF OOOZ s3 ripo Svf u? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d /b / a GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY BRIEF IN SUPPORT OF PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Petitioner, Presbyterian Homes Incorporated d/b/a Green Ridge Village ("Petitioner'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following Brief in Support of Petition for Preliminary Injunction against Respondent, Caroline Savage ("Respondent"), pursuant to Pa. R.C.P. § 1531. I. SUMMARY OF ARGUMENT Respondent applied for the admission of her father, Robert W. Savage ("father"), to Petitioner's skilled nursing facility. Petitioner and Respondent entered into a written Long Term Care Admission Agreement ("Agreement"), which provided that Petitioner would care for Respondent's father in return for Respondent's promise to make payment for that skilled nursing care and services from her father's resources, to "cooperate fully with the Health Center and any third party payer to secure payment," and, in the event that her father became insolvent, to apply for Medical Assistance benefits for her father and to "pursue MA [Medical Assistance] coverage." See Exhibit "A" to Complaint. ORIGINAL Shortly after his admission to Petitioner's facility, Respondent's father allegedly became insolvent, and Petitioner requested that Respondent file an application for Medical Assistance benefits for her father. An application for Medical Assistance benefits was subsequently filed; however, said application was denied on December 21, 2007, because Respondent failed to provide the Cumberland County Assistance Office with the information needed to qualify her father for Medical Assistance benefits. While an appeal of that denial has been filed and is currently pending before the Bureau of Hearings and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania, if the aforementioned information is not provided to the Cumberland County Assistance Office prior to or at the time of the hearing, the appeal will be denied and any request for review by Commonwealth Court would be without merit. In breach of the Agreement, Respondent has not cooperated with the Medical Assistance application and appeal process by providing the necessary information to the Cumberland County Assistance Office to qualify her father for Medical Assistance benefits. If Respondent is not compelled to fulfill her contractual duties and secure Medical Assistance benefits for her father, Petitioner will be left without a reasonable remedy to obtain complete payment for the care and services that Petitioner provided to Respondent's father, and the appeal of the denial of the application for benefits will be denied. Consequently, an injunction is necessary to compel Respondent to cooperate with the pending appeal that has been filed of the denial of her father's Medical Assistance application and to produce the requisite records needed to qualify her father for Medical Assistance benefits. 2 II. QUESTION PRESENTED Is Petitioner entitled to a Preliminary Injunction? Suggested Answer: Yes. III. FACTUAL BACKGROUND Respondent made application for her father's admission to Petitioner's skilled nursing facility on December 15, 2004. Petitioner and Respondent entered into a written Admission Agreement ("Agreement"), pursuant to which Petitioner agreed to provide Respondent's father with skilled nursing care and services in exchange for the payment of a specific monthly fee from her father's income or resources. In addition, if her father became insolvent, Respondent further agreed to make application for Medical Assistance benefits and to cooperate fully in that application process and to pursue Medical Assistance benefits on behalf of her father. After Respondent's father's admission to Petitioner's skilled nursing facility, he apparently became insolvent. As a result, an application for Medical Assistance benefits was filed on behalf of Respondent's father. Subsequently, Respondent failed to turn over to the Cumberland County Assistance Office the requisite information for an eligibility determination to be made with regard to that application. The application for Medical Assistance benefits was denied on December 21, 2007, and although the denial has been appealed, if Respondent does not produce the requisite information to qualify her father for Medical Assistance benefits prior to or at the forthcoming hearing on the appeal, the appeal will fail and any subsequent appeal to the Commonwealth Court would be without merit. 3 IV. ARGUMENT An injunction is an extraordinary remedy, the issuance of which is solely within the trial court's discretion. Soja v. Factoryville Sportman's Club, 522 A.2d 1129,1131 (Pa. Super. 1987). The burden is on the party seeking the injunction to establish the following elements: (1) [T]he injunction is necessary to prevent immediate and irreparable harm that cannot be adequately compensated by damages; (2) [G]reater injury would result from refusing an injunction than from granting it, and concomitantly, that issuance of an injunction will not substantially harm other interested parties in the proceedings; (3) [A] preliminary injunction will properly restore the parties to their status as it existed immediately prior to the alleged wrongful conduct; (4) [T]he activity it seeks to restrain is actionable [and] ... its right to relief is clear...; (5) [T]he injunction it seeks is reasonably suited to abate the existing activity; and (6) [A] preliminary injunction will not adversely affect the public interest. Warehime v. Warehime, 860 A.2d 41, 46-47 (Pa. 2004) (internal citations and quotations omitted). In addition, in order for Petitioner to comply with Pa. R.C.P. 1531(b), Petitioner avers that a bond in the amount of $100.00 should be adequate to protect Respondent in the event that it is later determined that the issuance of the instant petition was in error. 4 A. Sufficient Legal Basis Exists for This Court to Issue an Injunction, As Respondent Has Breached the Agreement with Petitioner. Respondent breached the Agreement into which she entered with Petitioner, the appropriate remedy for which, on the facts of this case, is an injunction requiring the specific performance of that Agreement between the parties. Petitioner provided, and continues to provide, care and services to Respondent's father in accordance with the terms of the Agreement. However, Respondent has not abided by her promise to cooperate to secure Medical Assistance benefits for her father by providing the information that the Cumberland County Assistance Office requires to qualify Respondent's father for benefits. As will be shown, based on the application of the aforementioned legal factors to the facts before this Court, it is clear that Petitioner is entitled to the relief requested, and an injunction should be granted to ensure that Respondent abides by the terms and conditions of the Agreement into which she entered with Petitioner. B. Petitioner is Entitled to a Preliminary Injunction. 1. The breach of the Agreement by Respondent has caused immediate and irreparable harm to the interests of Petitioner for which a legal remedy is inadequate in this case. Respondent's breach of the Agreement with Petitioner, by failing to provide the necessary information as requested by the Cumberland County Assistance Office to make an eligibility determination with regard to her father's application for Medical Assistance benefits, presents an issue of immediate and irreparable harm to Petitioner. 5 Absent a decree ordering specific performance of the Agreement, Petitioner will be left with a claim against Respondent's father to secure repayment of the costs incurred and services rendered. Upon information and belief and to the extent of Petitioner's knowledge, Respondent's father does not possess adequate assets to fully satisfy the significant outstanding balance owed to Petitioner and to continue to pay for the care and services he is receiving. Accordingly, to file suit against Respondent's father would be of no avail to Petitioner. It is unlikely that any judgment would ever be paid, and such judgment would, therefore, be worthless. Therefore, any legal remedy against Respondent's father is inadequate. Conversely, if the Cumberland County Assistance Office determines that Respondent's father is eligible for Medical Assistance benefits, Petitioner would receive payment for the care that it provided to Respondent's father and that it continues to provide to him. If the requisite information is not produced, the appeal will be denied, and the ability to secure repayment from Medical Assistance for the services provided will be lost. In short, there is no remedy if Petitioner loses the appeal of the denial of Respondent's father's Medical Assistance application. 2. Greater injury will result if the injunction is not granted. The issuance of an injunction under the circumstances of this case is further appropriate because significant harm would result from the denial of the requested injunction than from the granting of the same. By denying the injunction, the Court would be allowing the appeal of the denial of the application for Medical Assistance benefits for Respondent's father to be denied. All chance at reimbursement for the months of care Petitioner rendered to Respondent's father would be lost. 6 Conversely, what harm would result to Respondent from the issuance of the injunction? Respondent contractually agreed to cooperate fully with Petitioner and any third party payer to secure payment and to pursue Medical Assistance coverage for her father. She has not abided by her contractual duties. The injunction would in fact benefit Respondent by properly allowing her father to qualify for Medical Assistance benefits retroactively and as well as prospectively, particularly because, to the extent of Petitioner's knowledge, there are inadequate assets to continue to compensate Petitioner for the care and services that it will continue to render to Respondent's father, in accordance with the terms and conditions of his admission. 3. The requested injunction would restore the parties to the status . -UO• The issuance of the injunction will put the parties back into the position in which they were at the time of the admission of Respondent's father to Petitioner's skilled nursing facility. Simply put, Respondent is contractually obligated to secure Medical Assistance benefits and to cooperate in the application and appeal process for her father by providing the requisite information necessary to qualify him for benefits. Petitioner provided Respondent's father with skilled nursing care and services, but Respondent failed to fulfill her respective contractual duties. In short, the injunction would require Respondent to perform her respective contractual duties and restore the parties to the status quo. 7 4. Petitioner's right to relief is clear. As set forth in the Complaint against Respondent, Petitioner's right to relief could not be clearer. The activity that this injunction seeks to abate is the ongoing breach of the Agreement effectuated by Respondent's failure to cooperate fully in securing Medical Assistance benefits for her father. The Agreement is clear that Respondent would pursue Medical Assistance benefits. Respondent has no excuse for failing to cooperate with the Medical Assistance application and appeal process. 5. The injunction is suited to abate the harm to Petitioner's interests. An injunction that simply requires Respondent to provide verification is reasonably limited and abates any harm to Petitioner. Determining Respondent's compliance with an injunction of such limited scope will not be a significant burden to this Court because it is merely a question of whether Respondent takes those steps as directed by the Cumberland County Assistance Office to obtain Medical Assistance benefits for her father and whether she turns over the verification necessary for an eligibility determination to be made with regard to her father's Medical Assistance application, or whether she continues to not perform her contractual obligations, thereby perpetuating an ongoing harm to Petitioner's interests. 8 6. Granting this injunction is in the public interest. Petitioner requests this injunction to hold Respondent to her contractual obligations. It is in the public interest to both encourage a party to fulfill his duties under a contract into which he has entered willingly and voluntarily and to ensure that those institutions that provide skilled nursing care for its residents are fully compensated. Accordingly, it is unlikely that Respondent would be able to articulate a valid reason why the injunction should not be granted, for such a remedy clearly is not only within Petitioner's and Respondent's interests, but also in the interests of the public. V. CONCLUSION Based on the above, Petitioner respectfully requests that this Court issue a decree ordering Respondent to fully complete the Medical Assistance application process by taking any and all steps necessary to qualify her father for the receipt of Medical Assistance benefits, including providing the verification requested by the Cumberland County Assistance Office to qualify him for benefits. Respectfully submitted, Dated: 1116[6 K SCHUTJER BOGA LC By: Chadwick O. ogar Attorney I.D. No. 83755 (717) 909-5920 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Petitioner 9 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Brief in Support of Petition for Preliminary Injunction was sent to Shinkowsky Investigations to personally serve the following: Caroline Savage 100 W. Park Street Carlisle, PA 17013 Dated: 1h 103 By. NWIIU? -?A" / A,* 1---) Catherine Klobucar, Paralegal 4 A. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. CAROLINE SAVAGE, Defendant. No. 07-7672 Civil Term CIVIL ACTION - EQUITY PRAECIPE TO AMEND NOTICE TO DEFEND Kindly amend the attached Notice to Defend which was originally filed with your office on December 21, 2007. Respectfully Submitted, SCHUTJER BOGAR LLC Dated: Le g By: Cha ick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Mariclare L. Hayes Attorney I.D. No. 201289 (717) 909-5922 417 Walnut Street, 41h Floor Harrisburg, PA 17101 Attorneys for Plaintiff i • 4 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d /b / a GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 .. , . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 Civil Term CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY AVISO USTED HA SIDO DEMANDADO/A EN COUTE. 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 n ? r R 7 ; r=- ? ?d r .4 r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED d/b/a GREEN RIDGE VILLAGE, Plaintiff V. CAROLINE SAVAGE, Defendant No. 07-7672 CV CIVIL ACTION - EQUITY PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Please enter the appearance of Terry S. Hyman, Esquire of SCHMIDT KRAMER PC as attorney of record for the Defendant in the above-captioned action. Respectfully submitted, DATE: SCHMIDT KRAMER PC T ry S' Hyman, Esquire orney I.D. 36807 209 State Street Harrisburg, PA 17101 717/232-6300 I CERTIFICATE OF SERVICE AND NOW, this Q ? day of January 2008, I, Janice S. Harmon, an employee of SCHMIDT KRAMER PC, do hereby certify that I have served a true and correct copy of the PRAECIPE FOR ENTRY APPEARANCE in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Mariclare L. Hayes SCHUTJER BOGAR LLC 305 North Front Street, Suite 401 Harrisburg, PA 17101 t ?t r--a Tr -. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 07-7672 Civil Term AFFIDAVIT OF SERVICE Presbyterian Homes Incorproated d/b/a Green Ridge Village VS. Caroline Savage Commonwealth of Pennsylvania County of Dauphin as. I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 7:29 PM on 01/18/2008, I served Caroline Savage at 100 West Park Street, Carlisle, PA 17013 in the manner described below: ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is ? 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. 11 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: 45 - Skin: White - Hair: Brown - Height: 5' 0 " - ight: 75 X Sw to and sub ribed before me on this Jo Shinkowsky day of 2011 S nkowsky Inve i ions 3 6 Fawn Ridge tht Harrisburg, PA 17110 (800) 276-0202 PUBLIC COr__? _MONVEAITH OF PFNtucvjv..,,,, Atty File#: 07-7672 - Our File# 2836 DONNA NO M. WIERMM ?'S+ Public Susquehanna Twp., Dauphin County My Commisslor, Expires July 28, 2009 Law Firm: Schutjer ogar Address: 417 Walnut Street, 4th Floor, Harrisburg, P , 17102 Telephone: (717) 909-5925 co IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff. V. No_ 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY STIPULATED ORDER AND NOW this day of __ A 2008, in consideration of the parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that: Within fifteen (15) days of the date of this Order, Caroline Savage shall take any and all actions needed and provide any and all records within his possession that are required by the Cumberland County Assistance Office for the pending application to determine Robert'A!_ Savage's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits on Robert W. Savage's behalf. BY THE COURT Xc6d _ Sn/fir/F ?t.ii\?{ j? r` Tyl V I =!r'VI ?i4/ 60:Z W Zt NVWoc0Z A8VIONO,ii _0 d 3Hi 30 33Ed-"C?gly + S + IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY STIPULATED AGREEMENT Presbyterian Homes, Inc. d/b/a Green Ridge Village ("Petitioner") and Caroline Savage ("Respondent") stipulate and agree to the following: 1. On or about December 21, 2007, Petitioner filed a Complaint against Respondent, the daughter of Petitioner's resident, Robert Savage ("father") 2. The Complaint sets forth a single claim against Respondent based on her failure to specifically perform the terms of the Long Term Care Admission Agreement ("Agreement") entered into with Petitioner. See Complaint Exhibit "A." Specifically, the Complaint alleges that Respondent failed to assist her father in the application for Medical Assistance by failing to provide documentation needed by the Cumberland County Assistance Office to make an eligibility determination with regard to that application. 3. An application for Medical Assistance benefits was filed on behalf of Respondent's father and the Cumberland County Assistance Office denied that application on December 21, 2007. 4. An appeal of the aforementioned denial is currently pending before the Cumberland County Assistance Office of the Department of Public Welfare. ORIGINAL Jan 21 08 09:16p Crystal Gurin 215-629-0627 p.1 5. The parties agree to the entry of an Order directing Respondent to sign and/or provide any and all records which she has in her possession which are currently required by the Cumberland County Assistance Office to determine the eligibility of Respondent's father for Medical Assistance benefits within fifteen (15) days of the date of the Order and to sign and/or make reasonable efforts to obtain any other documents necessary to obtain benefits for Respondent's father as required under the Long'Term Agreement. 'That Order is attached as Exhibit "A." 6. Petitioner agrees to withdraw, vvdthout prejudice; its Petition for a Preliminary Injunction. 7. The parties may mutually agree, sometime in the future, to substitute Susan Cavenagh for Caroline Savage, as Robert Savage's representative and may, at that time, mutually agree to apply this order to Ms. Cavenagh. Respectfully submitted, Dated: 1162-15lds Dated:= 0 By: Allison M. al loro Attornev far Petitioner By: Savage Dated: - ,!?i, ?02? By: Caroline Savage EXHIBIT "A° IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D / B / A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY STIPULATED ORDER AND NOW, this day of 2008, in consideration of the parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that: 1. Within fifteen (15) days of the date of this Order, Caroline Savage shall take any and all actions needed and provide any and all records within his possession that are required by the Cumberland County Assistance Office for the pending application to determine Robert W. Savage's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits on Robert W. Savage's behalf. BY THE COURT J? CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Stipulation for Entry of Injunction was personally served via regular, United States mail, postage prepaid, upon the following: Susan Cavenaugh 100 W. Park Street Carlisle, PA 17013 Caroline Savage 100 W. Park Street Carlisle, PA 17013 Dated: 3(310 -8 By: (az Catherine Klobucar, Paralegal IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW PETITION FOR PRELIMINARY INJUNCTION TO THE PROTHONOTARY: Kindly mark the Petition for Preliminary Injunction, filed in the above- captioned matter on January 14, 2008, as withdrawn without prejudice. Respectfully submitted, SCHUTJER BOGAR LLC Dated: g By: Chadwick O. Bogar Attorney I.D. 83755 (717) 909-5920 Allison E. O'Horo Attorney I.D. 200568 (717) 909-5924 417 Walnut Street, 411, 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 first-class, United States mail, postage prepaid, upon the following: Terry S. Hyman, Esquire SCHMIDT KRAMER 209 State Street Harrisburg, PA 17101 (Attorney for Caroline Savage) Susan Cavanaugh 100 W. Park Street Carlisle, PA 17013 Dated: 3?il IOT By: OA±&Ula "Catherine Klobucar, Paralegal r- f =d• n i i.d7' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. No. 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY RETURN OF SERVICE I HEREBY CERTIFY THAT: I, Catherine Klobucar, served the annexed Stipulated Order upon the following: Terry s. Hyman, Esquire SCHMIDT KRAMER 209 State Street Harrisburg, PA 17101 Service was made via first-class, United States mail, certified, return receipt requested, on March 18, 2008. A copy of the receipt evidencing service is attached hereto. I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service is true and correct. Dated: N ?? Im By: IQ Catherine Klobucar SCHUTJER BOGAR LLC 417 Walnut Street, 4th Floor Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, No_ 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY STIPULATED ORDER .f I AND NOW, this _1.24 _ day of it _ 2008, in consideration of the parties` Stipulated Agreement, it is hereby ORDERED AND DECREED that: Within fifteen (15) days of the date of this Order, Caroline Savage shall take any and all actions needed and provide any and all records within his possession that are required by the Cumberland County Assistance Office for the pending application to d eterr i, e Robert W_ Savage's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits on Robert W. Savage's behalf- BY THE COURT t is T?• ?•?i J.; ¦ Complete items 1, 2, and 3. Also complete Item 4 If Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we canIreturn the card to you. ¦ Attach this card to the back of the maiipiece, or on the front if space permits. 1. Article Addressed to: ??Sf yS. \A \?4wk-An,C--skwx LSbuc?, VIA 2. Article Number 7007 0220 (rmnster from service kaw A. by ("Printed Name) I C. 0 Agent Is delivery address different from item 4? / U/Ye: If YES, enter delivery address below: 0 No 3 Service Type Certl led Mail 0 Express Mail Istered 0 Rehm Rees" for Merchandise 0 Insured Mail 0 C.O.D. 4. Restricted Delivery? (Extra r=ee) 0 Yes 0000 2164 5185 Ps Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 ir'O : f a'. I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff, V. CAROLINE SAVAGE, Defendant. RETURN OF SERVICE I HEREBY CERTIFY THAT: No. 07-7672 CIVIL ACTION - EQUITY I, Catherine Klobucar, served the annexed Stipulated Order upon the following: Susan Cavanaugh 100 W. Park Street Carlisle, PA 17013 Service was made via first-class, United States mail, certified, return receipt requested, on March 15, 2008. A copy of the receipt evidencing service is attached hereto. I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service is true and correct. Dated: 'NaL41o? By: 0A LL4 ,? ? bCatherine Klobucar SCHUTJER BOGAR LLC 417 Walnut Street, 4th Floor Harrisburg, PA 17101 ,. s IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN HOMES INCORPORATED D/B/A GREEN RIDGE VILLAGE, Plaintiff. v No. 07-7672 CAROLINE SAVAGE, Defendant. CIVIL ACTION - EQUITY STIPULATED ORDER AND NOW, this f2i??_ day oftA&k-.---, 2008, in consideration of the parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that- I- Within fifteen (15) days of the date of this Order, Caroline Savage shall take any and all aciions needed and provide any and all records within his possession that are required by the Cumberland County Assistance Office for the pending application to determine Robert W - Savage's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits on Robert W- Savage's behalf. BY THE COURT x Cot, Wrir?1 \ - N'S% t Complete Items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ¦ Print your name and address on the reverse $o that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. t. Article Addressed to; 1 ? 2. Article Number wr,..r..r?.Q 0 7 4 220 (ran%W fiam service . •, •, A. Signature x ??k I B. ReceI (Printed Name) C. Da7WDWery 5i L ir?A 3 111-5 ffS D. Is delivery address different from item t ? Y ff YES, enter delivery address below: o 3. Type Mail ? Express Mail ? Registered ? Return Receipt for Merchandise ? Insured Mail ? C.O.D. 4. Restricted Delivery? (Extra Fee) ? Yes 00011 2164 5178 PS Form 3811, February 2004 Domestic Return Receipt W2595-02-WW AI ..?; co