HomeMy WebLinkAbout01-4092
HCR MANOR CARE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 01 -/..;CH~ Gu'cl /~
vs.
CIVIL ACTION - LAW
AMELIA B. SOBOTOR, IndivIdually,
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
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 is served, by
entering a written appearance, personally of by attorney, and filing in waiting 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 document, or for any other claim or relief requested
by he Plaintiff. You may lose money or property or other right Important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la corte. SI used quaere defensas de esas demandas expuestas en
las paginas, siguientes, used tiene vlente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una aparlencia escrita 0 en persona 0 por abogado y archivar en la
corte en forma escrlta sus defensas 0 sus objeciones a last demandas en contra de SU persona, Sea
avlsado que sl used no se defienda, la corte tomara medidas y psedido entrar una orden contra used sin
prevlo avlso 0 notlficacion y por cualqulerqueja 0 alivlo que es pedldo en la peticion de demanda. Used
puede perder dlnero 0 sus propledades 0 otros derechos Importantes para used,
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VA Y A
EN PERSONA 0 LLAME POR TELEFONO A LA OFlClNA CUY A DIRECCION SE
ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSIT ANClA LEGAL.
Lawyer Referral Service
Cumberland CountY Bar Assocladon
2 Liberty Avenue
Carlisle, Pennsylvania 1 7013
(717) 249-3166
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO. 01- '10 C;.J.. c;;;.J I ~
Plaintiff
vs.
CIVIL ACTION - LAW
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
COMPLAINT
AND NOW, this ~ day o(Ju..ne-
, 200 I, comes the Plaintiff,
HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the
law firm of Wolfson & Associates, P.c., and files the within Complaint and in support
avers as follows:
1. Plaintiff, HCR Manor Care (hereinafter referred to as Plaintiff), Is a
health care provider qualified to conduct business in the Commonwealth of
Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom
Road, Carlisle, Cumberland County, Pennsylvania 17013.
2. Defendant, Amelia B. Sobotor, (hereinafter referred to as "Defendant
Amelia"), Is an adult individual with a last known address of 940 Walnut Bottom
Road, Carlisle, Cumberland CduntY, Pennsylvania 17013.
3. Defendant, Michael Sobotor, (hereinafter referred to as "Defendant
Michael"), is an adult individual with a last known address of 19 Holly Estate Drive,
1
Gardners, Adams County, Pennsylvania 17324. Defendant Michael is the son of
Defendant Amelia.
4. That Defendant Michael represented himself to be Power of Attorney
for Defendant Amelia. A true and correct copy of the General Durable Power of
Attorney dated October 22, 1996 whereby Defendant Amelia designated Defendant
Michael as her lawful Power of Attorney is attached hereto, incorporated herein, and
collectively marked as Exhibit "A".
5. That on or about July 16, 2000, through the present, Defendant
Amelia is a health care residelitof Plaintiff, where she did receive and where she
continues to receive various necessary residential health care services and health care
treatment by Plaintiff. An itemization of said services is attached hereto, incorporated
herein, and collectively marked as Exhibit "B".
6. That on or about July 16, 2000, Defendant Amelia executed an
Admission Agreement which Agreement outlined various terms of residential health
care services to be provided by Plaintiff and the Responsible Party therefor. A true
and correct copy of the Admission Agreement is attached hereto, incorporated
herein, and collectively marked as Exhibit "C".
7. That Part I of the Admission Agreement, titled "Rights and
Responsibilities of the Resident", did describe the various responsibilities of Defendant
Amelia, which responsibilities did include payment for the daily rate and charges for
supplemental services, supplies not paid by any third party, as well as applicable co-
2
insurance and deductibles and all expenses of discharge or transfer. See Exhibit "C"
previously identified and Incorporated herein.
8. That Plaintiff submitted to Defendants a copy of the Itemization of
services accurately showing all debits and credits for transactions with Plaintiff. Said
Statement of Account has been previously identified as Exhibit "B" and incorporated
herein by reference.
9. That Defendants did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendants.
1 O. As of the date of filing of this Complaint, the balance due, owing, and
unpaid on Defendant Amelia's account as a result of said charges is the sum of Eleven
Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See
Exhibit "B" previously Identified and incorporated herein.
11 . Despite Plaintiff's reasonable and repeated demands for payment,
Defendants have failed, refused, and continue to refuse to pay all sums due and owing
on the outstanding account balance, which accrued due to residential health care
services provided to Defendant Amelia, all to the damage and detriment of the
Plaintiff.
12. Plaintiff has made numerous requests to Defendant Michael, as Power
of Attorney and Responsible PartY for Defendant Amelia, demanding that the sums
due and owing to Plaintiff be paid, and Defendant Michael has ignored his fiduciary
obligation to pay necessary and appropriate bills and obligations for Defendant Amelia.
3
13. Pursuant to Section I, Paragraph 1.03 of the Admission Agreement,
Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of
eighteen percent (18%) per year on past due balances. See Exhibit "C" previously
identified and incorporated herein.
1 4. As of the date of the within Complaint, the amount of interest that has
accrued on the past due balance is the sum of Four Hundred Eighteen and 50/100
Dollars ($418.50).
1 5. Plaintiff has retained the services of the law firm of Wolfson &
Associates, P.c., in the collection of the amounts due from Defendants.
16. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement,
Plaintiff Is entitled to receive and Defendilnts have agreed to pay reasonable attorney's
fees and all court costs if the account Is referred to an attorney for collection. See
Exhibit "C" previously identified and incorporated herein.
1 7. As of the filing of this Complaint, Plaintiff has incurred reasonable
attorney's fees from the law office of Wolfson & Associates, P.c., in the collection of
the amounts due and owing by Defendants, incident to the within action, and Plaintiff
shall continue to incur such attorney's fees throughout the conclusion of the
proceedings In the amount of thirty percent (30%) of the principal balance due and
owing to the Plaintiff by the Deferidants.
4
18. That the amount of attorney's fees which represents thirty percent
(30%) of the principal amount due and owing is the sum of Three Thousand Three
Hundred Ninety-Five and 06/100 Dollars ($3,395.06).
1 9. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
20. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment in favor of Plaintiff and against Defendants,
Amelia B. Sobotor, IndivIdually, Michael Sobotor, Individually and on Behalf of
Amelia B. Sobotor, in the amount of Eleven Thousand Three Hundred Sixteen and
87/100 Dollars ($11,316.87), contractual interest in the amount of Four
Hundred Eighteen and 50/100 Dollars ($418.50), reasonable attorney's fees in
5
the amount of Three Thousand Three Hundred Ninety-Five and 06/100 Dollars
($3,395.06), the costs of this action, and such other relief as the Court deems
proper and just.
Respectfully Submitted,
~~~?~
WOLFSON & ASSOCIATES, .c.
267 East Market Street
York, PA 17403
(717) 846-1252
I.D.No.20617
Attorney for Plaintiff
6
EXHIBIT "A"
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GENERAL DURABLE POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, That I, AMELIA B. SOBOTOR,
Manor Care, 940 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania 17013, do hereby appoint my son, MICHAEL P. SOBOTOR,
19 Holly Estates Drive, Gardners, Cumberland County, Pennsylvania
17324, as my agent ("my agent"), for me and on my behalf, in my
name or in his own name, to take a~l actions and to perform all
acts concerning my affairs as he may deem necessary or advisable,
in his absolute discretion, as fully as I could do if personally
present, including, without limiting the generality of the
foregoing, for me and in my name and on my behalf, as follows:
1. Inclusiveness. To receive and receipt for all sums of
money or payments due or becoming due to me from any source; to
enter my safe deposit boxes in any and all banking institutions,
and to add to and to remove any of the contents thereof; to
endorse all checks and other instruments payable to me and
deposit and withdraw any and all moneys, checks and other
instruments to which I may be at any time entitled in my name in
any financial institutions; to pay any and all claims and demands
now or hereafter payable by me; to draw and sign checks, drafts
and other orders for the payment of money upon my checking
account or upon any other bank accounts or deposits now or
hereafter belonging to me; to borrow money and to mortgage,
pledge Or hypothecate any property, real or personal, now or
hereafter owned by me as security therefor; to sell, possess,
insure, manage, maintain, improve, lease, mortgage, pledge,
encumber, convey, and otherwise dispose of, or take any other
action with respect to any property, real Or personal, now or
hereafter owned by me, on such terms and conditions as my agent
considers appropriate, and in the event of any sale of my real
estate to execute the sales agreement and the deed in my name and
to make settlement and receive the proceeds; to purchase, rent or
ot~erwise acquire any property! real or personal, for me and to
pay for the same; to contract with and arrange for my entrance to
any hospital, nursing home, health center, convalescent home, or
similar institution and to pay all bills in connection therewith;
to arrange for and consent to or to withhold medical,
therapeutical and surgical procedures for me, including the
administration of drugs; to institute and to engage in and
compromise any litigation on my behalf; for me and in my name and
as my act to execute, endorse, acknowledge and deliver all
documents; to prepare, execute and file any tax returns,
governmental reports and other instruments of w~atever kind; to
engage and dismiss agents; and to manage, make a~d transact all
and every kind of business of every nature.
'.~~~'"?'~.'.'-~' .
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2. General Autho=itv. To co all other ~hings which my
agent shall deem necessary and proper in order to carry out t~e
foregoing powers which shall be construed as broadly as possible,
giving and granting unto my said agent full power and authority
to do and perform all and every act, deed, matter, and thing
whatsoever i~ and about my estate, property, and affairs as fully
and effectually to a~l intents and purposes as I might or could
do in my own proper person if personally present, the above
specially enumerated powers being :itn aid:: and exemplification 0::
the full, complete, and general power herein granted, and not in
limitation or definition thereof; and hereby ratifying and
conrirming all that my said agent shall lawfully do or cause to
be done by virtue or these presents.
3. Durability. This power of attorney shall not be
arrected by my subsequent disability or incapacity. All acts
done by my agent pursuant to this power during any period of my
disability or incapacity shall have the same effect and enure to
my benefit and bind me and my successors in interest as ir I were
competent and not disabled.
4. Reliance on Power. This power may be accepted and
relied upon by anyone to whom it is presented until such person
either receives written notice of revocation by me or a guardian
or similar riduciary of my estate or has actual knowledge of my
death.
5. Hold Harmless. All actions of my agent shall bind me
and my heirs, distributees, legal representatives, successors and
assigns, and for the purpose or inducing anyone to act in
accordance with the powers I have granted herein, I hereby
represent, warrant and agree that if this power of attorney is
terminated or amended ror any reason, I and my heirs,
distributees, legal representatives, successors and assigns will
hold such party or parties harmless rrom any loss surrered or
liability incurred by s~ch party or parties while acting in
accordance with this po~er prior to that party's receipt of
written notice or any such termination or amendment.
The following is the specimen signature or the person to
whom this power of attorney is given:
~~~{!!s!o#
?age 2 of 3 pages
r:I
I have signed this power of attorney this 22- day of
O~hr-
, 1996.
witnesses:
,'r--. .. J,~ j I _-t-
/ ~~2jf~
AMELIA B. SOBOTOR
'1fIl<kVl/! a h1.1L4 7!f.
/87-(/6- 5)/'7
Social Security No.
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
.L
On this ;2..2-- day of O~~ , 1996, personally appeared
before me, a Notary Public in and for the said county and state,
the above-named AMELIA B. SOBOTOR, who acknowledged the foregoing
power of attorney to be her act and deed and desires the power of
attorney might be recorded according to law.
I have signed my name
and~~~
Notary Public
\ NOTARIAL SEAL.. \
WilliAM S. DANIELS. Notary pubrlC
Carlisle Bora. Cumberlend County
My Commission Expire. Oc\. , 9. 2000
Page 3 of 3 pages
EXHIBIT "B"
HCR-ManorCare
Statement
MANOR CARE CARLISLE 372
9~0 WALNUT BOTTOM ROAD
CARLISLE. PA 17013
(717)-2~9-00B5
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 1732~
t1EDlCAID
PRIVATE
ROOt.1 109 -A
Please Return This Portion
With Your Payment
SOBOTOR. AMELIA B
I'
96129
11/01/00
01/31/01
i~ODE I --~---
I -'---_
BALANCE FOR~JARO
11900 MCB PREMIUM
AOV PVT PORTION
---------r
CHARGES I -
10,366.52
CA TE OF
SERVICE
01/01/01
01/01/01
02/01/01
SERVICE RENDERED
CREDITS
(QTY 1-)
50.00
1,000.35
PAYMENT ~UE BY THE
10TH OF THE MONTH
11,316.87
AMOUNT DUE
\
'\,.
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/2001
10/31/96 TV CABLE $5.00
11/30/96 TV CABLE $5.00
11/30/96 INTEREST UNPAID 1.50% ON 5.00 $0.08
12/18/96 PAYMENT-THANKYOU ($5.00)
12/18/96 PAYMENT-THANKYOU ($5.00)
12/31/1996 RESIDENT PORTION $784.45
1/1-1/31/97 RESIDENT PORTION $806.45
01/21/97 PAYMENT-THANKYOU ($220.00)
02/28/97 TV CABLE $5.00
2/1-2/28/97 RESIDENT PORTION $806.45
02/28/97 INTEREST UNPAID 1.50% ON 1326.98 $19.90
03/04/97 PAYMENT-THANKYOU ($784.53)
03/04/97 PAYMENT-THANKYOU ($564.45)
03/04/97 PAYMENT-THANKYOU ($784.45)
03/12/97 PAYMENT-THANKYOU ($5.00)
03/12/97 PAYMENT-THANKYOU ($806.45)
03/14/97 PAYMENT-THANKYOU ($5.00)
3/1-3/31/97 RESIDENT PORTION $804.35
$56.80
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
03/31/1997 BEGINNING BALANCE $56.80
03/31/97 TV CABLE $5.00
03/31/97 REVERSE INTEREST 2/28/97 ($19.90)
04/1/97 TRANSFER MISAPPLIED PAYMENT ($100.00)
04/10/97 PAYMENT-THANKYOU ($811 .45)
4/1-4/30/97 RESIDENT PORTION $804.35
05/12/97 PAYMENT. THANK YOU ($701.53)
05/31/97 TV CABLE $5.00
5/1-5/31/97 RESIDENT PORTION $804.35
06/10/97 PAYMENT-THANKYOU ($4.92)
06/10/97 PAYMENT-THANKYOU ($806.53)
06/30/97 TV CABLE $5.00
6/1-6/30/97 RESIDENT PORTION $804.35
07/30/97 PAYMENT-THANKYOU ($4.92)
07/30/97 PAYMENT-THANKYOU ($806.53)
07/31/97 TV CABLE $5.00
7/1-7/31/97 RESIDENT PORTION $804.35
08/13/97 PAYMENT-THANKYOU ($601 .45)
06/30/97 MISAPPLIED PAYMENT ($210.00)
($773.03)
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/2001
08/31/97 ADJ BEGINNING BALANCE ($773.03)
08/31/97 TV CABLE $5.00
08/31/97 RESIDENT PORTION $804.35
09/16/97 PAYMENT-THANKYOU ($4.92)
09/16/97 PAYMENT-THANKYOU ($806.45)
09/16/97 PAYMENT-THANKYOU ($0.08)
09/30/97 TV CABLE $5.00
9/1-9/30/97 RESIDENT PORTION $804.35
10/31/97 TV CABLE $5.00
10/1-10/31/97 RESIDENT PORTION $804.35
11/07/97 PAYMENT-THANKYOU ($5.00)
11/07/97 PAYMENT-THANKYOU ($806.45)
11/30/97 TV CABLE $5.00
11/1-11/30/97 RESIDENT PORTION $804.35
12/19/97 PAYMENT-THANKYOU ($4.92)
12/19/97 PAYMENT. THANK YOU ($811.53)
12/19/97 PAYMENT-THANKYOU ($806.45)
12/31/97 TV CABLE $5.00
12/31/97 RESIDENT PORTION $804.35
$27.92
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
12/31/97 ADJ BEGINNING BALANCE $27.92
01/12/98 PAYMENT-THANKYOU ($4.92)
01/12/98 PAYMENT-THANKYOU ($806.53)
01/06/98 BEAUTY CHARGES $32.00
1/1-1/31/98 RESIDENT PORTION $914.50
01/31/1998 INTEREST 0.08
02/09/98 PAYMENT-THANKYOU ($32.00)
02/09/98 PAYMENT-THANKYOU ($806.53)
02/28/98 TV CABLE $5.00
2/1-2/28/98 RESIDENT PORTION $914.50
03/12/98 PAYMENT-THANKYOU ($4.92)
03/12/98 PAYMENT-THANKYOU ($806.53)
03/31/98 TV CABLE $5.00
3/1-3/31/98 RESIDENT PORTION $914.50
04/30/98 TV CABLE $5.00
4/1-4/30/98 RESIDENT PORTION $914.50
05/15/98 PAYMENT-THANKYOU ($4.92)
05/15/98 PAYMENT-THANKYOU ($806.61)
05/31/98 TV CABLE $5.00
$465.04
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/2001
5/3198 ADJ BEGINNING BALANCE $465.04
5/1-5/31/98 RESIDENT PORTION $914.50
05/31/1998 INTEREST $0.Q7
06/29/98 PAYMENT-THANKYOU ($4.92)
06/29/98 PAYMENT-THANKYOU ($806.61)
06/30/98 TV CABLE $5.00
6/1-6/30/98 RESIDENT PORTION $914.50
07/31/98 TV CABLE $5.00
7/1-7/31/98 RESIDENT PORTION $914.50
07/31/1998 INTEREST $12.25
08/17/98 PAYMENT-THANKYOU ($4.91)
08/17/98 PAYMENT-THANKYOU ($811.45)
08/1 7/98 PAYMENT-THANKYOU ($183.64)
08/31/98 TV CABLE $5.00
8/1-8/31/98 RESIDENT PORTION $914.50
08/31/1998 INTEREST $9.60
09/18/98 PAYMENT-THANKYOU ($640.06)
09/18/98 PAYMENT - THANK YOU ($171.47)
09/30/98 TV CABLE $5.00
9/1-9/30/98 RESIDENT PORTION $914.50
09/30/98 INTEREST $9.74
$2,466.14
MANOR CARE HELA TH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE. PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/01
09/30/98 ADJ BEGINNING BALANCE $2,466.14
10/27/98 PAYMENT - THANK YOU ($611.53)
10/31/98 TV CABLE $5.00
1 0/29/98 BEAUTY CHARGES $32.00
10/1-10/31/98 RESIDENT PORTION $914.50
10/31/1998 INTEREST $12.89
11/30/98 TV CABLE $5.00
11/1-11/30/98 RESIDENT PORTION $914.50
11/30/1998 INTEREST $25.73
12/08/98 PAYMENT-THANKYOU ($38.05)
12/08/98 PAYMENT-THANKYOU ($511.95)
12/31/98 TV CABLE $5.00
12/1-12/31/98 RESIDENT PORTION $914.50
12/31/1998 INTEREST 30.04
01/07/99 PAYMENT-THANKYOU ($309.24)
01/07/99 PAYMENT-THANKYOU ($590.76)
01/31/99 TV CABLE $5.00
01/01-01/31/99 RESIDENT PORTION $933.76
01/31/99 INTEREST $29.16
$4,231.69
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
01/31/99 ADJ BEGINNING BALANCE $4,231.69
02/24/99 PAYMENT-THANKYOU ($265.58)
02/24/99 PAYMENT-THANKYOU ($554.42)
02/28/99 TV CABLE $5.00
02/01-02/28/99 RESIDENT PORTION $933.76
02/28/99 INTEREST $27.56
03/31/99 PAYMENT-THANKYOU ($282.76)
03/31/99 PAYMENT-THANKYOU ($547.24)
03/31/99 TV CABLE $5.00
03/01-03/31/99 RESIDENT PORTION $933.76
03/31/99 INTEREST $33.43
04/30/99 TV CABLE $5.00
04/13/99 BEAUTY CHARGES $32.00
04/01-04/30/99 RESIDENT PORTION $933.76
04/30/99 INTEREST $48.01
05/31/99 TV CABLE $5.00
05/01-05/31/99 RESIDENT PORTION $933.76
05/31/99 INTEREST $63.29
$6,541.02
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
05/31/99 ADJ BEGINNING BALANCE $6,541.02
06/02/99 PAYMENT-THANKYOU ($294.25)
06/02/99 PAYMENT-THANKYOU ($755.75)
06/21/99 PAYMENT-THANKYOU ($880.00)
06/30/99 TV CABLE $5.00
06/01-06/30/99 RESIDENT PORTION $933.76
07/31/99 TV CABLE $5.00
07/01-07/31/99 RESIDENT PORTION $933.76
08/09/99 PAYMENT-THANKYOU ($966.32)
08/09/99 PAYMENT-THANKYOU ($433.68)
08/31/99 TV CABLE $5.00
08/01-08/31/99 RESIDENT PORTION $933.76
09/20/99 PAYMENT-THANKYOU ($889.45)
09/20/99 PAYMENT-THANKYOU ($10.55)
09/30/99 TV CABLE $5.00
09/30/99 BEAUTY CHARGES $32.00
09/01-09/30/99 RESIDENT PORTION $933.76
$6,098.06
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0065
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
09/30/99 ADJ BEGINNING BALANCE $6,096.06
10/31/99 TV CABLE $5.00
10/01-10/31/99 RESIDENT PORTION $933.76
11/30/99 TV CABLE $5.00
11/01-11/30/99 RESIDENT PORTION $933.76
12/31/99 TV CABLE $5.00
12/01-12/31/99 RESIDENT PORTION $933.76
01/06/00 PAYMENT-THANKYOU ($1,930.26)
01/06/00 PAYMENT-THANKYOU ($269.74)
01/31/00 TV CABLE $5.00
01/01-01/31/00 RESIDENT PORTION $1,000.35
01/31/00 MCB PREMIUM ($45.50)
02/29/00 TV CABLE $5.00
02/01-02/29/00 RESIDENT PORTION $1,000.35
02/29/00 MCB PREMIUM ($45.50)
03/03/00 PAYMENT-THANKYOU ($750.00)
03/31/00 TV CABLE $5.00
03/01-03/31/00 RESIDENT PORTION $1,000.35
$6,669.39
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
03/31/00 ADJ BEGINNING BALANCE $8,889.39
03/31/00 MCB PREMIUM ($45.50)
04/17/00 PAYMENT-THANKYOU ($1,450.00)
04/30/00 TV CABLE $5.00
04/01-04/30/00 RESIDENT PORTION $1 ,000.35
04/30/00 MCB PREMIUM ($45.50)
04/30/00 BEAUTY CHARGES $36.00
05/31/00 TV CABLE $5.00
05/11/00 BEAUTY CHARGES $9.00
OS/25/00 BEAUTY CHARGES $9.00
05/01-05/31/00 RESIDENT PORTION $1,000.35
05/31/00 MCB PREMIUM ($45.50)
06/30/00 TV CABLE $5.00
06/01-06/30/00 RESIDENT PORTION $1,000.35
06/30/00 MCB PREMIUM ($45.50)
07/03/00 PAYMENT-THANKYOU ($1,300.00)
07/31/00 TV CABLE $5.00
07/01-07/31/00 RESIDENT PORTION $1,000.35
$10,032.79
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/01
07/31/00 ADJ BEGINNING BALANCE $10,032.79
07/31/2000 MCB PREMIUM ($45.50)
08/16/00 PAYMENT-THANKYOU ($1,000.00)
08/31/00 TV CABLE $5.00
08/01-08/31/00 RESIDENT PORTION $1,000.35
08/31/00 MCB PREMIUM ($45.50)
09/30/00 TV CABLE $5.00
09/01-09/30/00 RESIDENT PORTION $1,000.35
09/30/00 MCB PREMIUM ($45.50)
1 0/18/00 PAYMENT-THANKYOU ($1,200.00)
10/31/00 TV CABLE $5.00
11/30/00 TV CABLE $5.00
11/17/00 BEAUTY CHARGES $36.00
11/01-11/30/00 RESIDENT PORTION $1,000.35
11/30/00 MCB PREMIUM ($45.50)
12/22/00 PAYMENT-THANKYOU ($1,000.00)
12/31/00 TV CABLE $5.00
12/06/00 BEAUTY CHARGES $9.00
$9,721.84
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
12/31/00 ADJ BEGINNING BALANCE $9,721.84
12/20/2000 BEAUTY CHARGES $9.00
12/01-12/31/00 RESIDENT PORTION 1000.35
12/31/00 MCB PREMIUM ($45.50)
01/31/01 TV CABLE $5.00
01/01-01/31/01 RESIDENT PORTION $1,031.85
01/31/01 MCB PREMIUM ($50.00)
02/28/01 TV CABLE $5.00
02/01-02/28/01 RESIDENT PORTION $1,031.85
02/28/01 MCB PREMIUM ($50.00)
03/19/01 PAYMENT-THANKYOU ($1,000.00)
03/31/01 TV CABLE $5.00
03/01-03/31/01 RESIDENT PORTION $1,031.85
03/31/01 MCB PREMIUM ($50.00)
05/31/01 TV CABLE $5.00
05/01-05/31/01 RESIDENT PORTION 1,031.85
05/31/01 MCB PREMIUM ($50.00)
04/01/97 REVERSE TX MISAPPLIED PMT $100.00
06/01/97 REVERSE TX MISAPPLIED PMT $210.00
$13,943.09
EXHIBIT "("
... "-.. -"... .-
HCR Manor Care
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Care, the Resident, and the
Legal Representative, for the purpose of providing for the rights and responsibilities of the parties
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
(_, Center~ .:1 ~ S. ~~-^-
~~ORA~~~ .. n -
Resident: > '--fY) o.--v~ ~ ~ l j'~~J2 .
Legal Representative: . &_~
Admission Date: I ~ f La - 0 0 Deposit: $ ~
Term: This Agreement shall begin on the day the Resident enters the Center and end on
the day the Resident is discharged.
I. RIGHTS AND RESPONSmILITIES OF THE RESIDENT
-1-
1.01 Room and, Board Rate./ For the basic services provided for in Section 3.01, the 1-
Resident agrees to pay the applicable Room and Board Rate set forth on Attaclunent A hereto.
The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room
and Board Rate set forth in Attaclunent A is payable in advance and is due by the tenth (10~ day
of each month. The Resident shall be responsible for the Room and Board Rate for the day of
admission as well as the day of discharge. This Section shall not apply if the Resident is covered
under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care
Organization (see Section 1.06).
1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for
additional medical, therapeutic; or personal care services or supplies that may be requested by the
Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The
Center reserves the right to charge for personal care items of the Resident if necessary for the
well-being of the Resident. Such "Ancillary Charges" are described on Attaclunent B hereto, and
a current ancillary charge list is maintained at the Center's business office for review during
regular business hours. Ancillary Charges shall be included in the Resident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(lOth) day of the month. .
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be
subject to a service charge equal to the highest legal rate of interest pennitted by State law as set
forth in Attachment A on the past due balance each month until such time as the balance due is
paid in full. Should the Resident's account for any reason be turned over for collection, the
Resident agrees to pay the Center's collection costs, including attorney's fees.
1. 04 Independent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Resident's attending physician for any health or
personal program in accordance with the terms of the program.
1.05 Governmental Programs. If the Resident is eligible for coverage under any
governmental program, such as Medicare, Medill'aid, or through the Veterans Administration, and
the Center participates in such program, the Center shall accept payments under such program in
accordance with the terms of the program on the contract the Center has with the program. The
Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according
to the same terms and conditions applicable to private pay residents. The Resident must comply
with all program requirements. In the event the Resident's coverage under the governmental
program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay
residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: .1LMedicare, ~Medicaid and/or _VA.
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the
_1_ Resident's care, there is a required co-payment, which-Medicare updates yearly. If the Resident
also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable
charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative
agree to pay any required deductible, any required co-insurance, and any non-covered services
according to the same terms and conditions applicable to private pay residents. For Medicaid, see
Attachment L for additional information. The Resident and/or Legal Representative. are
responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of the Room and Board Rate from their monthly income.
The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this
Agreement, the contribution amount as determined and periodically adjusted by the State and/or
local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the
contribution amount, the Center may take such legal action as necessary, including requesting a
court to order such payment.
__L
1.06 Third Partv Payors and Managed Care Organizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which.the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident shall be responsible for any co-payments, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents. If the Center has
not executed a provider agreement with the Resident's third party payor, the Center
2
will bil! the Resident's third party payor as a service, but the Resident remains liable for charges
not paid or covered by that third party payor including charges not paid within a reasonable
period of time.
1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident has not been determined to be eligible for Medicaid.
The Resident and/or Legal Representative agree to notify the Center promptly if there is
insufficient income or assets to meet the financial obligations to the Center or to make prompt
application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify
the Center in writing when application to Medicaid is made. The Resident and/or Legal
Representative agree to cooperate fully in applying for Medicaid and in the eligibility
determination process. If the Resident is no longer able to pay for care at the Center and the
Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to
discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook
and State and federal laws.
1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal
Representative to notifY the Center and to provide any needed information regarding all third
party payors or governmental coverages on admission and throughout the stay including copies of
insurance cards, identification or verification of eligibility and coverage information. .
_ J _ The Resident and/or Legal Repfesentative agree to provide the Center}v,ith notice
within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage,
failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as
the Center relies on the information supplied regarding such coverage. The Resident and/or Legal
Representative acknowledge that if they fail to provide such information, they may be responsible
for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs
associated with the failure to provide such notice in accordance with the terms and conditions of
this Agreement.
1.09 Application for Benefits. It shall be the responsibility of the Resident and/or Legal
Representative to apply for coverage and to establish eligibility under any governmental, third
party payor, managed care or private insurance program. The Center shall be under no
obligation to bill any third party payor other than the Legal Representative and, when applicable, a
governmental program third party payor or managed care organization with which the Center is
under contract.
1.10 Primary Responsibility for Payment. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall remain primarily Ii!lble
for any and all charges for which the Center may agree to bill a third party. The Resident and/or
Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or
managed care provider may not pay for non-covered services, supplies, equipment, medication;"
and other care and services which may be delivered by the Center or its subcontractors. This
3
Agreement selVes as a written notice that the Center has notified the Resident and/or legal
R:presentative that services provided at ,the,Center may not be covered by a governmental payor,
third party payor or managed care orgaruzatlon. The Resident and/or Legal Representative agrees
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
I. I I Personal Physician. The Resident has the right to choose a personal physician,
provided that the physician selected is properly licensed and agrees to abide by applicable law and
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name of hislher personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notify the Center of
the new physician's name. If the physician chosen by the Resident fails to provide needed
coverage and attendance or fails to abide by applicable I~ws and regulations, the Center shall have
the right to call another physician to attend the Resident and the fees charged by such physician
shall be borne by the Resident.
1.12 Pharmacv. The Resident and/or Legal Representative acknowledge the right to
choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and
supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies
and procedures and the pharmacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distribution system.
II.
RIGHTS AND RESPONSmILITY OF THE LEGAL REPRESENTATIVE
I ,
-.-
_1_
2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal
access to the Resident's income or resources and that the documents supporting such authority, if
any, have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative
agrees to pay promptly from the Resident's income or resources all fees and charges for which the
Resident is liable under this Agreement. The Legal Representative shall not incur personal
liability on behalf of the Resident except for a breach of the duty to provide payment from the
Resident's income or resources for the fees and charges provided for in this Agreement.
2.03 Requested Items. The Legal Representative shall be personally liable for any
services or products specifically requested by the Legal Representative to be supplied to the
Resident, unless such services or products are covered by a governmental program.
2.04 ExhausJion of Resident's Funds. If the Resident's financial resources change such
that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must
notify the Center in writing when the application for Medicaid is made. If the ~
Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and
proper manner, the Legal Representative shall be personally liable for all charges and fees ,not
covered by Medicaid which otherwise would have been covered had application been made m a
timely and proper manner.
4
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid. the
Legal Representative shall provide such infonnation about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally responsible
for any charges denied the Center due to any lack of cooperation.
2.06 Acceptance Upon Di~charge. Upon termination of this Agreement as provided in
the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of
the Resident from the Center. If after notice the Resident is not removed as requested, then the
Center is authorized and empowered to remove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Representative, if
the Resident's condition permits, who shall uncpnditionally be obligated to accept the Resident
and to pay promptly all charges.
2.07 Additional Responsibilities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement and
Attachments.
m. RIGHTS AND RESPONSmILITIES OF mE CENTER
-,-
3.01 Room and Standard Services. As part of the Room and Board Rate, the Center
shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and
bedding, I general nursing care, personal assessment, social services,_IlI1-d such other personal _,_
services as may be required pursuant to the plan of care prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general well-being of the
Resident.
3.02 Other Services. The Center shall act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, ifany, noted at
the beginning of this Agreement. The Deposit shall be applied to the charges for the first month
of the Resident's stay at the Center.
3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by
the Center within thirty (30) days after discharge or transfer or within the time frame required by
Slale law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days
of the Center's receipt of the final Medicaid payment for care of the Resident.
IV. GENERAL PROVISIONS
4.01 Consent to Release of Information. The Resident and/or Legal Represent~tive
hereby consents to the release of hislher medical records to the following persons: Center
personnel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organWltion responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
s
,
reviews or payment audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Trt:at. The Resident and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perfonn such functions, care
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily
activities; and general nursing care, the administration of medications and treatments, and the
performance of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in"the exercise of good nursing judgment, subject to
any rights provided to the Resident by federal and/or state law.
As applicable, the undersigned Legal Representative hereby represents that he/she
has the legal authority to make health care decisions on behalf of the Resident, that documents
supporting such authority have been delivered to the Center, and that such Legal Representative
hereby consents on behalf of the Resident to the Treatment described above.
4.03 Consent to Photograph. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifYing the Resident; for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to identify the Resident.
-1-
4.04 Notice of Services. Policies and Additional Information. The Resident and/or
Legal Representative acknowledge that the items listed below have been explained and have
received copies of the items or policies and procedures, if applicable. The Resident and/or Legal
Representative acknowledge they have had the opportunity to ask questions and questions have
been answered satisfactorily.
a. Authorization for Release or Review of Medical Information. See
Attachment C.
b. Authorization for Payment of Benefits. See Attachment D.
c. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Determination Notice. See Attachment F.
e. Medicare Secondary Payor Questionnaire. See Attachment G.
f. At the request of the Resident and/or Legal Representative, the Cel)ter
shall maintain the Resident's personal funds in compliance with the laws
and regulations relating to the Center's management of such funds. A
description and/or policies and procedures of protection of resident funds
and the Personal Trust Fund Agreement, Resident Personal Funds
6
Authorization and any other related documents. See Attachment H-l and
H-2.
g. The Center's policy and procedure on bedholds, election ofbedholds and
readmission. See Attachment I (Center Supplement).
h, Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
i. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
I'
i- The location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state survey and certification
agency, the state licensure office, the state ombudsman program, the
protection and advocacy network and the Medicaid fraud control unit. See
Attachment I (Center Supplement).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phonVlUmber on how t~~ a complaint
with the state survey and certification agency concerning resident abuse,
neglect, mistreatment and misappropriation of property. See Attachment I
(Center Supplement).
m. The Resident Handbook. See Attachment J.
n. ResidentlPatient Rights. See Attachment K.
o. MedicarelMedicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
p. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HeR Manor Care's
Limited Treatment Practices and "No Cardiopulmonary Resuscitation
Orders" and a copy of the State summazy of its laws governing the
Resident's right to direct hislher medical treatment. See Attachment M-I
and M-2.
.
q. Privacy Act Notification. See Attachment N.
r. Inventory sheet andlor policy of personal items. See Attachment O.
7
"
s. ASM Fonn. See attachment P.
t.
Consent to Photograph
See Attachment Q.
u.
See Attachment R.
v.
See Attachment S.
w.
See Attachment T,
x.
"
See Attachment U.
y.
See Attachment V.
z.
See Attachment W.
4.05 Assi{!:nment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to
me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal
-IRepresentative hereby authorizes the Center and any holder ofm~dical or other infonnation to
release such infonnation to the Health Care Financing Administration and its agents and to third
party payors any infonnation needed to determine these benefits or benefits for related services.
4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set
forth below and as set forth in the Resident Handbook under the Section Heading "Discharge".
The Resident and/or Legal Representative may terminate this Agreement before the Resident's
discharge from the Center by providing the Center written notice of the Resident's desire to leave
at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the
end of that time, the Resident must stilI pay for each day of the required notice unless the Center
fills the bed before the end of the notice period. Except in the event of an emergency or death, the
Resident shall be responsible for all charges for the Room and Board Rate and for all services
perfonned up to the end of the day that the Admission ends. Discharge from the specialized units
such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice.
If discharge or transfer becomes necessary because the Resident and/or Legal Representative or
someone else abused the Resident's funds, the Center will request that local, state and federal
authorities, as appropriate investigate, which may result in prosecution.
4.07 Indemnification, The Resident shall defend, indemnifY and hold the Center
harmless from any and all claims, demands, suit and actions made against the Center by any
person resulting from any damage or injury caused by the Resident to any person or the property
8
..... ..
of any person or entity (including the Center), except in the case of negligence of the Centers
employees and agents.
4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal law will not invalidate the remaini.,g
provisions of this Agreement and, it is agreed that to the extent possible, the Resident 8JJd the
Center will continue to fulfill their respective obligations under this Agreement consistent with the
law. ..
THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY
HAVE EACH READ AND UNDERSTOOD" THE fOREGOING AGREEMENT, AND
THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEm SATISFACTION.
Signature of Resident: X ~ ~"V Date: (-/02 -:-00
Signature of Legal Representative, if signing on behalf of Resident:
Date:
~/- -I-
Signature of Leg a! Representative, signing on hislher own behalf:
Date:
Center Representative: D_i ~ ~)()"vv\ 0. ci2.- Date: 1 ~ I (c- oJ
9
r~ ~( ~ ~
* -t-
.~ lit P
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w, r ,
~ ~~
.-..l::
~.i'
J::-
SHERIFF'S RETURN - REGULAR
CASE NO: 2001-04092 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
SOBOTOR AMELIA B ET AL
GERALD WORTHINGTON
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
SOBOTOR MICHAEL
the
DEFENDANT
, at 1905:00 HOURS, on the 3rd day of July
, 2001
at 19 HOLLY ESTATE DR
GARDNERS, PA 17324
by handing to
MICHAEL SOBOTOR
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
6.00
7.15
.00
10.00
.00
23.15
r~r",<~
R. Thomas Kline
07/13/2001
WOLFSON & ASSOCIATES
Sworn and Subscribed to before
By: A~ .t.Jr>--riJ.:-d:::-
Deput y"SlV'if f
me this .)3-<4! day of
C),p'[.;u,.v/ A, D.
n,'1<<- 0_ ~ ~
~t'othonotary . rJ
CASE NO: 2001-04092 P
SHERIFF'S RETURN - REGULAR
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
SOBOTOR AMELIA B ET AL
DOUGLAS DONS EN
, Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
SOBOTOR AMELIA
was served upon
the
DEFENDANT
, at 1040:00 HOURS, on the 12th day of July
2001
at 940 WALNUT BOTTOM RD
CARLISLE, PA 17013
AMELIA SOBOTOR
by handing to
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
18,00
3,25
.00
10.00
,00
31. 25
Sworn and Subscribed to before
me this .)3M day of
~ h-t> ( A.D.
~o~r~/j;,~
So Answers:
r~~~<~~
R. Thomas Kline
07/13/2001
WOLFSON & ASSOCIATES
By: O~ Q_
Deputy Sheriff
HCR MANOR CARE,
Plaintiff
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 01-4092 CIVIL TERM
AMELIA B. SOBOTER, Individually,
MICHAEL SOBOTER, Individually,
and on Behalf of AMELIA B. SOBOTER,
Defendants
CNIL ACTION - LAW
PRAECIPE TO ENTER APPEARANCE
To Curtis R. Long, Prothonotary:
Please enter my appearance on behalf of the defendants, Amelia B. Soboter, Individually,
Michael Soboter, Individually, and on behalf of Amerlia B. Soboter, in the above captioned case.
Respectfully submitted,
IRWIN, McKNIGHT & HUGHES
By: ~~ xJ. ;Jf.7.Rl1A
I!~~ j ~iller, Esquire
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Supreme Ct. #83776
Attorney for defendants
Date August 2,2001
HCR MANOR CARE,
Plaintiff
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
v.
NO, 01-4092 CIVIL TERM
AMELIA B. SOBOTER, Individually,
MICHAEL SOBOTER, Individually,
and on Behalf of AMELIA B. SOBOTER,
Defendants
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
I, Douglas G. Miller, Esquire, hereby certifY that a copy of attached Praecipe to Enter
Appearance was served upon the following by depositing a true and correct copy of the same in
the United States mail, First Class, postage prepaid in Carlisle, Pennsylvania, on the date
referenced below and addressed as follows:
Daniel F. Wolfson, Esquire
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, PA 17403
IRWIN, McKNIGHT & HUGHES
By:
~~At,A~ 4M~
Do~~:9OI\rnlei, ~ .
60 West PomfTet Street
Carlisle, PA 17013
(717) 249-2353
Supreme Court l.D. No. 83776
Date: August 2, 2001
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Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
v.
NO. 2001 - 4092 CIVIL TERM
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Defendants. :
CIVIL ACTION - LAW
PRELIMINARY OBJECTIONS OF DEFENDANTS
TO PLAINTIFF'S COMPLAINT
AND NOW this 4th day of September, 2001, comes the Defendants, AMELIA B.
SOBOTOR and MICHAEL SOBOTOR, Individually and on Behalf of AMELIA B. SOBOTOR,
by and through their attorneys, Irwin, McKnight & Hughes, and make the following Preliminary
Objections to Plaintiff's Complaint, and in support thereof aver the following:
I. Preliminary Objection in the Nature of a Demurrer Pursuant to Pa. R.Civ. P.
1028(a)(4).
I. Plaintiff, HCR Manor Care, filed a civil complaint on or about July 2, 2001
against Defendants in the Court of Common Pleas of Cumberland County, Pennsylvania at
Docket No. 2001 - 4092, alleging liability for health care costs incurred for the care of
Defendant Amelia B. Sobotor.
2. Defendant Michael Sobotor is the son of Defendant Amelia B. Sobotor.
3. Plaintiffs Complaint alleges that Defendant Michael Sobotor is his mother's
agent under a General Durable Power of Attorney dated October 22, 1996, and that Defendant
2
Michael Sobotor has a "fiduciary obligation to pay necessary and appropriate bills and
obligations for Defendant Amelia."
4. Defendant Amelia Sobotor III fact has limited income and property and is
currently receiving public assistance funds to help provide for her medical care costs.
5. Pa.R.Civ.P. 1019(a) requires a claimant to plead all material facts on which its
cause of action is based.
6. Plaintiffs Complaint fails to allege or aver that Defendant Michael Sobotor is a
signatory of or is otherwise bound by the alleged Admission Agreement attached to Plaintiffs
Complaint.
7. Plaintiffs Complaint fails to allege or aver any facts or cite to any legal authority
to support the individual liability of Defendant Michael Sobotor for the medical care costs of his
mother.
8. Plaintiffs Complaint fails to allege or aver any facts or cite to any legal authority
to support the liability of Defendant Michael Sobotor as agent under a General Durable Power of
Attorney for the medical care costs of his mother.
9. Plaintiffs Complaint fails to state any cause of action against Defendant Michael
Sobotor, upon which relief may be granted for the medical care costs of his mother.
WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss
Plaintiffs Complaint.
3
II. Preliminary Objection Raising Insufficient Specificity of Plaintiff's Complaint
Pursuant to Pa. R. Civ. P. 1028(a)(3).
10. Plaintiffs Complaint fails to allege with sufficient particularity alleged acts or
agreements by Defendant Michael Sobotor to support his individual liability to Plaintiff for his
mother's medical care costs.
II. Plaintiff's Complaint fails to allege with sufficient particularity alleged acts,
agreements, or other signed documents by Defendant Michael Sobotor to support his liability to
Plaintiff as an agent under his mother's General Durable Power of Attorney for her medical care
costs.
12. Plaintiff's Complaint lacks sufficient specificity to apprise Defendants of the
issues to be litigated, or to allow them to adequately prepare and assert defenses to Plaintiffs
allegations.
WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss
Plaintiff's Complaint, or in the alternative to grant their Preliminary Objection and order Plaintiff
to more specifically plead the averments of its Complaint.
III. Preliminary Objection Raising Lack of Jurisdiction Pursuant to Pa. R. Civ. P.
1028(a)(1 ).
13. Several causes of action are set forth or were attempted to be set forth against
more than one Defendant in Plaintiffs Complaint.
4
14. Although the causes of action appear to be distinct causes of action, they are not
set forth separately in the Complaint as required by Pa.R.Civ.P. 1020(a) or Pa.R.Civ.P.
1020( d)(l).
15. Plaintiffs Complaint includes allegations that Defendant Michael Sobotor is
liable to Plaintiff by virtue of his being named as an agent for his mother under a General
Durable Power of Attorney.
16. 20 Pa.C.S.A. ~ 711(22) provides that the Orphans' Court has mandatory
jurisdiction over "all matters pertaining to the exercise of powers by agents acting under powers
of attorney. ..."
17. Plaintiff s Complaint was not filed in the Cumberland County Orphans' Court
which has mandatory jurisdiction over the claims raised by Plaintiff.
WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss
Plaintiffs Complaint.
Respectfully Submitted,
Dated: September 4, 2001
IRWIN, McKNIGHT & HUGHES
By: Douglas . Milllq~
Supreme ourt ID # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Attorney for Defendants
5
CERTIFICATE OF SERVICE
I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy
of the foregoing document upon the persons indicated below by first class United States mail,
postage paid in Carlisle, Pennsylvania 17013, on the date set forth below:
Amy F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York,PA 17403
Attorney for Plaintiff
Date: September 4,2001
IRWIN, McKNIGHT & HUGHES
~~ J1. //1:11.
Douglas G. . er, ~Uile' 'f.N"\P"
Supreme Co LD. No. 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
(717) 249-2353
Attorney for Defendants
6
II
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION . LAW
AMELIA B. SOBOTOR, Individually, and
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
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 is served, by entering a
written appearance, personally of by attorney, and filing in waiting 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 document, or for any other claim or relief requested by he Plaintiff. You may
lose money or propertY or other right important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE
A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH
TO FiND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la corte. 51 used quaere defensas de esas demandas expuestas en las
paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation.
Used debe presentar una apariencia escrita 0 en persona 0 por abogado y archlvar en la corte en fonna
escrita sus defensas 0 sus objeciones a last demandas en contra de su persona. Sea avisado que sl used no se
defienda, la corte tomara medldas y psedido entrar una orden contra used sin prevlo avlso 0 notificacion y
por cualquier queja 0 allvio que es pedldo en Ia peticion de demanda. Used puede perder dinero 0 sus
propiedades 0 otros derechos Importantes para used.
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO 0 SI NO T1ENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA
EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE
ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUlR
ASSiT ANCIA lEGAL.
Lawyer Referral Service
Cumberland County Bar Assoclatlon
2 Liberty Avenue
Carlisle, PennsylvanIa 17013
(717) 249-3166
"
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
I Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
AMELIA B. SOBOTOR, Individually, and
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
AMENDED COMPLAINT
AND NOW, this 27th day of September, 2001, comes the Plaintiff, HCR Manor
Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson
& Associates, P.c., and files the within Amended Complaint and in support avers as
follows:
1. Plaintiff, HCR Manor Care, is a health care provider qualified to conduct
business in the Commonwealth of Pennsylvania with offices and/or a place of business
situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013.
2. Defendant, Amelia B. Sobotor, (hereinafter "Defendant Amelia"), is an
adult individual with a last known address of 940 Walnut Bottom Road, Carlisle,
Cumberland County, Pennsylvania 17013.
3. Defendant, Michael Sobotor, (hereinafter "Defendant Michael"), is an adult
individual with a last known address of 19 Holly Estate Drive, Gardners, Adams County,
Pennsylvania 17324.
4. That Plaintiff tiled its original Complaint against Defendants on or about July
2,2001.
"
5. That Plaintiff is filing the within Amended Complaint in an attempt to cure
Defendants' Preliminary Objections which were filed by Defendants in response to
Plaintiff's Complaint on or about September 4, 2001.
COUNT'
HCR MANOR CARE vs. AMELIA SOBOTOR
6. Paragraphs One (1) through Five (5) of Plaintiffs Amended Complaint are
incorporated herein by reference as if set forth in full.
7. That Defendant Amelia executed a General Durable Power of Attorney
("hereinafter Power of Attorney"), appointing her son, Defendant Michael, as her lawful
Attorney-In-Fact on October 22, 1996. A true and correct copy of the said Power of
Attorney is attached hereto, incorporated herein, and marked as Exhibit "A".
8. That on or about July 16, 2000, Defendant Amelia executed an Admission
Agreement which Agreement outlined various tenns of residential health care services to
be provided by Plaintiff and her Responsible Party therefor. A true and correct copy of
the Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit
"B".
9. That on or about July 16,2000, through the present, Defendant Amelia
was a health care resident of Plaintiff, where she did receive and where she continues to
receive various necessary residential health care services and health care treatment by
Plaintiff.
1 O. That Section 1 of the Admission Agreement, titled "Rights and
Responsibilities of the Resident", describes the responsibilities of Defendant Amelia, which
2
"
I
I',
responsibilities did include payment for the daily rate and charges for supplemental
services, supplies not paid by any third party, as well as applicable co-insurance and
deductibles and all expenses of discharge or transfer. See Exhibit "8", Section I previously
identified and incorporated herein.
1 1 . That Plaintiff submitted to Defendant Amelia a copy of the itemization of
services accurately showing all debits and credits for transactions with Plaintiff. A true and
correct copy of the itemization of said services is attached hereto, incorporated herein, and
collectively marked as Exhibit "C".
12. That Defendant Amelia did not object to the above mentioned Statement of
Account submitted by Plaintiff.
13. That Defendant Amelia did not pay the Plaintiff for health care services
provided pursuant to her Admission Agreement with the Plaintiff as identified in the
Statement of Account.
14. That Plaintiff sent Defendant Michael a copy of the Itemization of services
accurately showing all debits and credits for transactions with Plaintiff.
15. That Defendant Michael did not act on behalf of his mother, Defendant
Amelia, to pay her account balance with the Plaintiff.
16. As of the date of filing of this Complaint, the balance due, owing, and
unpaid on Defendant Amelia's account as a result of said charges is the sum of Eleven
Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See Exhibit "C"
previously identified and incorporated herein.
3
II
I.
17. Despite Plaintiff's reasonable and repeated demands for payment, Defendant
Amelia has failed, refused, and continue to refuse to pay all sums due and owing on the
outstanding account balance, which accrued due to residential health care services provided
I
to Defendant Amelia, all to the damage and detriment of the Plaintiff.
18. Pursuant to Section I, Paragraph 1.03 of the Admission Agreement, Plaintiff
is entitled to receive and Defendant Amelia has agreed to pay interest at a rate of eighteen
percent (18%) per year on past due balances. See Exhibit "B" previously identified and
incorporated herein.
1 9 . As of the date of the within Amended Complaint, the amount of interest
that has accrued on the past due balance is the sum of One Thousand Eighty-Eight and
10/100 Dollars ($1,088.1 O).
20. Plaintiff has retained the services of the law firm of Wolfson & Associates,
P.C, in the collection of the amounts due from Defendant Amelia.
21. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement,
Plaintiff is entitled to receive and Defendant Amelia agreed to pay reasonable attorney's
fees and all court costs If the account Is referred to an attorney for collection. See Exhibit
"B" as previously marked and incorporated herein.
22. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's
fees from the law office of Wolfson & Associates, P .C, in the collection of the amounts
due and owing by Defendant Amelia, incident to the within action, and Plaintiff shall
continue to incur such attorney's fees throughout the conclusion of the proceedings in the
4
amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by
Defendant Amelia.
23. That the amount of attorney's fees which represents thirty percent (30%) of
the principal amount due and owing is the sum of Three Thousand Three Hundred Ninety-
Five and 061100 Dollars ($3,395.06).
24. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
25. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter judgment in favor of Plaintiff and against Defendants, Amelia B. Sobotor,
Individually, Michael Sobotor, Individually and on Behalf of Amelia B. Sobotor, in the
amount of Eleven Thousand Three Hundred Sixteen and 871100 Dollars ($11,316.87),
contractual interest in the amount of One Thousand Eighty-Eight and 10/100 Dollars
($1,088.10), reasonable attorney's fees in the amount of Three Thousand Three Hundred
Ninety-five and 06/100 Dollars ($3,395.06), the costs of this action, and such other
relief as the Court deems proper and Just.
COUNT II
HCR MANOR CARE vs. MICHAEL SOBOTOR
26. Paragraphs One (1) through Twenty Five (25) of Plaintiff's Amended
Complaint are incorporated herein by reference as If set forth in full.
5
"
27. That Defendant Michael knew or should have known his mother, Defendant
Amelia, was a resident of Plaintiff and was admitted pursuant to a written agreement.
28. That Defendant Michael represented himself to be the Attorney-in- Fact for
his mother, Defendant Amelia, pursuant to her Power of Attorney. See Exhibit "A"
previously identified and incorporated herein.
29. That Defendant Michael knew or should have known the Plaintiff's services
were being provided to the Plaintiff for a fee and thereby Defendant Amelia would incur
debts with the Plaintiff for said services pursuant to their agreement.
30. That Defendant Michael knew or should have known he was authorized to
act on behalf of Defendant Amelia and to use her financial resources to pay any bills
connected with her agreement with the Plaintiff and that the Plaintiff was directed in the
Power of Attorney, to accept and rely on it to bind her agent. See Exhibit "A" at page
two (2), Clauses 2 (two) and 4 (four).
3 I . That Defendant Michael unequivocally accepted fiduciary responsibility and
obligations as his mother's agent under the Power of Attorney as he signed it as the person
to whom the power of attorney was given. See Exhibit "A", page two (2).
32. That Defendant Michael knew or should have known that the Plaintiff
expected to be paid for services provided to his mother pursuant to their agreement,
either by her, or by him as her agent under the Power of Attorney.
33. That pursuant to the Power of Attorney, Defendant Michael is the person
appointed and authorized to act on behalf of Defendant Amelia and, among other things,
". . . to pay any and all claims and demands now or hereafter payable by me . . .", and ". .
6
II
Ii
. to contract with and arrange for my entrance to any hospital, nursing home, health
center, convalescent home, or similar institution and to pay all bills in connection therewith
" See Exhibit "A" as previously marked and incorporated herein.
34. That Defendant Michael accepted the duty and responsibility to act on behalf
of his mother in matters regarding and relevant to her medical treatment on or about
October 22, 1996, the date of execution of her Power of Attorney, well in advance of
her admission as a resident of the Plaintiff. See Exhibit "A" as previously marked and
identified herein.
35. That Plaintiff submitted to Defendant Michael a copy of the itemization of
services accurately showing all debits and credits for his mother's transactions with Plaintiff.
See Exhibit "8" previously identified and incorporated herein.
36. That Defendant Michael did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendant Michael.
37. That Defendant Michael willingly failed to act on behalf of his mother, in
violation of her responsibilities pursuant to her Admission Agreement with the Plaintiff,
when he did not timely pay the Plaintiff upon demand.
38. That Defendant Michael's willful failure to act as agent, on his mother's
behalf pursuant to her Power of Attorney, was a breach of the fiduciary duties therein.
39. That Defendant Michael's breach of the Power of Attorney fiduciary duties
resulted in the Plaintiff not being paid for their services.
40. As of the date of filing of this Complaint, the balance due, owing, and
unpaid on Defendant Amelia's account as a result of said charges Is the sum of Eleven
7
Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See Exhibit "B"
previously Identified and Incorporated herein.
41 . Despite Plaintiff's reasonable and repeated demands for payment, Defendant
Michael has failed, refused, and continue to refuse to pay all sums due and owing on the
outstanding account balance, which accrued due to residential health care services provided
to Defendant Amelia, all to the damage and detriment of the Plaintiff.
39. Plaintiff has made numerous requests to Defendant Michael, to pay the
outstanding balance of his mother Defendant Amelia pursuant to his obligations under her
Power of Attorney and Admission Agreement.
40. That Section II, Paragraphs 2.01 and 2.02 of the Admission Agreement
indicated that Defendant Amelia's Legal Representative was to promptly pay the Plaintiff
for services provided under the Agreement.
41 . That Plaintiff made repeated requests to Defendant Michael as Attorney-in-
Fact for Defendant Amelia, demanding that the sums due and owing to Plaintiff be paid,
and Defendant Michael has ignored his fiduciary obligation, as the Attorney-in-Fact under
his mother's Power of Attorney, and therefore also as the Legal Representative and/or and
Responsible Party for Defendant Amelia under the Admission Agreement, to pay necessary
and appropriate bills and obligations for Defendant Amelia as outlined in the
aforementioned Power of Attorney and Admission Agreement. See Exhibits "A" and "B"
as previously marked and Incorporated herein.
42. Pursuant to Section I, Paragraph 1.03 of the Admission Agreement,
executed July 16, 2000 by Defendant Amelia, Plaintiff is entitled to receive and
8
II
Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on
past due balances. A true and correct copy of the Admission Agreement is attached
]
I
hereto, incorporated herein, and marked as Exhibit "B".
43. As of the date of the within Amended Complaint, the amount of interest
that has accrued on the past due balance Is the sum of One Thousand Eighty-Eight and
10/100 Dollars ($1,088.10).
44. Plaintiff has retained the services of the law firm of Wolfson & Associates,
P.c., in the collection of the amounts due from Defendants.
45. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement,
Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney's fees
and all court costs If the account is referred to an attorney for collection. A true and
correct copy of the Admission Agreement is attached hereto, incorporated herein, and
collectively marked as Exhibit "C".
46. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's
fees from the law office of Wolfson & Associates, P.c., in the collection of the amounts
due and owing by Defendants, incident to the within action, and Plaintiff shall continue to
Incur such attorney's fees throughout the conclusion of the proceedings In the amount of
thirty percent (30%) of the principal balance due and owing to the Plaintiff by the
Defendants.
47. That the amount of attorney's fees which represents thirty percent (30%) of
the principal amount due and owing is the sum of Three Thousand Three Hundred Nlnety-
Five and 06/100 Dollars ($3,395.06).
9
rr
48. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
49. The amount In controversy Is within the Jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter judgment in favor of Plaintiff and against Defendants, Amelia B. Sobotor,
Individually, Michael Sobotor, Individually and on Behalf of Amelia B. Sobotor, In the
amount of Eleven Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87),
contractual Interest in the amount of One Thousand Eighty-Eight and 10/100 Dollars
($1,088.10), reasonable attorney's fees In the amount of Three Thousand Three Hundred
Ninety-Five and 06/100 Dollars ($3,395.06), the costs of this action, and such other
relief as the Court deems proper and just.
Respectfully Submitted,
ci?=L:~
WOLFSON & ASSOCIATES, P.c.
267 East Market Street
York, PA 17403
(717) 846.1252
1.0. No. 20617
Attorney for Plaintiff
10
"
VERIFICATION
Daniel F. Wolfson, Esquire, hereby states that he is the attorney for the Plaintiff,
HCR Manor Care, and he is authorized to take this veriflcation on behalf of said Plaintiff in
the within action and verifies that the statements made in the foregoing Amended
Complaint are true and correct to the best of his knowledge, information, and belief, based
upon Information provided by the Plaintiff.
The undersigned understands that false statements herein are made subject to the
penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities.
Date: September 27, 2001
Daniel F. Wolfson, quire
WOLFSON & ASSOCIATES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 2061 7
Attorney for Plaintiff
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GENERAL DURABLE POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, That I, AMELIA B. SOBOTOR,
Manor Care, 940 walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania 17013, do hereby appoint my son, MICHAEL P. SOBOTOR,
19 Holly Estates Drive, Gardners, Cumberland Ccunty, Pennsylvania
17324, as my agent ("my agent"), tor me a"a orr my behalt, in my
name or in his own name, to take a~l actions and to perform all
acts concerning my affairs as he may deem necessary or advisable,
in his absolute discretion, as fully as I could do if personally
present, including, without limiting the generality of the
foregoing, for me and in my name and on my behalf, as fcllows:
1. Inclusiveness. To receive and receipt for all sums of
money or payments due or becoming due to me from any source; to
enter my safe deposit boxes in any and all banking institutions,
and to add to and to remove any of the contents thereof; to
endorse all checks and other instruments payable to me and
deposit and withdraw any and all moneys, checks and other
instr~ments to which I may be at any time entitled in my name in
any financial institutions; to pay any and all claims and demands
now or hereafter payable by me; to draw and sig" checks, drafts
and other orders for the payment of money upo" my checking
account or upon any other bank accounts or deposits now or
hereafter belonging to me; to borrow money and to mortgage,
pledge or hypothecate any property, real or personal, now or
hereafter owned by me as security therefor: to sell, possess,
insure, manage, maintain, improve, lease, mortgage, pledge!
encumber, convey, and otherwise dispose of, or take any other
action with respect to any property, real or personal, now or
hereafter owned by me, on such terms and conditions as my agent
considers appropriate, and in the event of any sale of my real
estate to execute the sales agreement and the deed in my name and
to make settlement and receive the proceeds; to purchase/ rent or
ot~erwise acquire any property! real or personal, for me and to
pay for the same; to contract with and arrange for my errtrance to
any hospital, nursing home, health center, convalescent home, or
similar institution and to pay all bills in connection therewith;
to arrange for and consent to or to withhold medical,
therapeutical and surgical procedures for me, including the
administration of drugs; to institute and to engage in and
compromise any litigation on my behalf; for me and in my name and
as my act to execute, endorse, acknowledge and deliver all
documents: to prepare, execute and file any tax returns,
governmental reports and other instruments of w~atever kind; to
engage and dismiss agents; and to manage, make and transact all
and every kind of business or eve~y nature.
,j.'M "",,.-'
... ___.._ .__._. rr._," .'...._....._.~.__,._._.~..._,.._....._ "_"M'_,__~""""",,~._~., _0..'_._..-._____
.-",-.... .~.lo':I',..\....'h ..........:.,
2. General Au~ho~ity. To co all other ~hings wnlcn m]
agent shall deem necessary and proper in order to carry out t~e
foregoing powers which shall be construed as broadly as possible,
giving and granting unto my said agent full power and authority
to do and. perform all a~d every act! deed! matter. and thing
wnatsoever i~ and about my estate, property, and affairs as fully
and effectuaLly to all i~tents and purposes as I might O~ could
do in my own proper pe=son it personally present, the above
special iy e:1.umerated PO'''/''!:"S oeing :itn aid, and exemplification 0:
the full, comp~ete, and general power herein granted, and not in
limitation or definition thereof; and hereoy ratifying and
confi!:"ming all that my said agent shall lawfully do or cause to
oe done by virtue of these presents.
3, Durability. This power of attorney shall not be
affected by my s~bsequent disability or incapacity. All acts
done by my agent pursuant to this power during any period of my
disability or incapacity shall have the same effect and enure to
my benefit and bind me and my successors in interest as if t were
competent and not disabled.
4, Reliance on Powe!:". This power may be accepted and
relied upon by anyone to whom it is presented until such person
either receives written notice of revocation by me or a guardian
or similar fiduciary 0: my estate or has actual knowledge of my
death.
5, Hold Harmless. All ac"~ons of my agent shall bind me
and my heirs, distrioutees. legal representatives, successors and
assigns, and for the purpose of inducing anyone to act in
accordance with the powers I have granted herein, r hereby
represent, warrant and agree that if this power of attorney is
terminated or amended for any reason, I and my heirs,
distributees, legal representatives, successors and assigns will
hold such party or par~ies harmless from any loss suffered or
liability incurred by s~ch party or parties while acting in
accordance wit~ this pc~er p=ior to that party's ~eceipt of
written notice of any s~ch termination or amendment.
The following is the specimen signature of the person to
whom this power of attorney is given:
~~~{~L#
?age 2 of 3 pages
-"--- .
,
cf.
2..2-
I have signed this power of attorney this
day of
oc./eh-r , 1996.
Witnesses:
~~~cff~
AMELIA B. SO BOT OR
'fJ1l,dI!M M,h1&c4 71ft
/87 -06- '3))7"
Social Security No.
CO~~ONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
.L
On this ;2.2,; day of O~~ , 1996, personally appeared
before me, a Notary Public in and for the said county and state,
the above-named AMELIA B. SOBOTOR, who acknowledged the foregoing
power of attorney to be her act and deed and desires the power of
attorney might be recorded according to law.
I have signed my name
and~~~
Notary Public
NOTARIAL SEAL " \
WILLIAM S, DANIELS. NOIari Public
CaIIlsle Boro. Cumberiond Cauncy
My Commission Expl.... Oct. 19, 2000
~~nQ ~ of 3 oaces
EXHIBIT "B"
.. .. .~.4 _. _ _
HCR Manor Care
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Care, the Resident, and the
Legal Representative, for the purpose of providing for the rights and responsibilities of the parties
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
( _, Center:. :1 ~v-I!.~c~ .8, ~~-^--
~R.OR I~~"") _' - . _
.
Legal Representative:
Admission Date: I ~ I G - () 0 Deposit: S ~
Term: This Agreement shall begin on the day the Resident enters the Center and end on
the day the Resident is discharged.
I. RIGHTS AND RESPONSmILITIES OF THE RESIDENT
_.1_
1.01 Room and, Board Rate.1 For the basic services provided for in Section 3.01, th~j-
Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto.
The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room
and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (I O~ day
of each month. The Resident shall be responsible for the Room and Board Rate for the day of
admission as well as the day of discharge. This Section shall not apply if the Resident is covered
under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care
Organization (see Section 1.06).
1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for
additional medical, therapeutic; or personal care services or supplies that may be requested by the
Resident, ordered by the attending physician, or provided in the Resident's Plan of Care, The
Center reserves the right to charge for personal care items of the Resident if necessary for the
well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and
a current ancillary charge list is maintained at the Center's business office for review during
regular business hours. Ancillary Charges shall be included in the Resident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(lOth) day of the month.
~,.. "". ."",.
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shaI1 be
subject to a service charge equal to the highest legal rate of interest permitted by State law as set
forth in Attachment A on the past due balance each month until such time as the balance due is
paid in full. Should the Resident's account for any reason be turned over for collection, the
Resident agrees to pay the Center's collection costs, including attorney's fees.
1. 04 Independent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Resident's attending physician for any health or
personal program in accordance with'the terms of the program.
1. 0 5 Governmental Programs. If the Resident is eligible for coverage under any
governmental program, such as Medicare, Meditaid, or through the Veterans Administration, and
the Center participates in such program, the Center shall accept payments under such program in
accordance with the terms of the program on the contract the Center has with the program. The
Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according
to the same terms and conditions applicable to private pay residents. The Resident must comply
with all program requirements. In the event the Resident's coverage under the governmental
program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay
residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: .1LMedicare, 1L-Medicaid and/or _VA.
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the
_ ,_ Resident's care, there is a required co-payment, which-Medicare updates yearly. If the Resident
also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable
charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative
agree to pay any required deductible, any required co-insurance, and any non-covered services
according to the same terms and conditions applicable to private pay residents. For Medicaid, see
Attachment L for additional information. The Resident and/or Legal Representative' are
responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of the Room and Board Rate from their monthly income,
The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this
Agreement, the contribution amount as determined and periodically adjusted by the State and/or
local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the
contribution amount, the Center may take such legal action as necessary, including requesting a
court to order such payment.
._J
1.06 Third Party Payors and Manall:ed Care Organizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident shall be responsible for any co-payments, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents. If the Center has
not executed a provider agreement with the Resident's third party payor, the Center
2
will bill the Resident's third party payor as a service, but the Resident remains liable for charges'
not paid or covered by that third party payor including charges not paid within a reasonable
period of time.
" .
1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident has not been determined to be eligible for Medicaid.
The Resident and/or Legal Representative agree to notify the Center promptly if there is
insufficient income or assets to meet the financial obligations to the Center or to make prompt
application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify
the Center in writing when application to Medicaid is made. The Resident and/or Legal
Representative agree to cooperate fully in applying for Medicaid and in the eligibility
determination process. If the Resident is no 10ng'1l' able to pay for care at the Center and the
Resident is not eligible for Medicaid, the Resident will be'notified of the Center's intention to
discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook
and State and federal laws.
1.08 Admission Infonnation. It shall be the responsibility of the Resident and/or Legal
Representative to notify the Center and to provide any needed infonnation regarding all third
party payors or governmental coverages on admission and throughout the stay including copies of
insurance cards, identification or verification of eligibility and coverage infonnation. '
_ J _ The Resident and/or Legal Repfesentative agree to provide tJ1e Center ..Y4!.h notice
within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage,
failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as
the Center relies on the infonnation supplied regarding such coverage. The Resident and/or Legal
Representative acknowledge that if they fail to provide such infonnation, they may be responsible
for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs
associated with the failure to provide such notice in accordance with the tenns and conditions of
this Agreement.
1.09 Application for Benefits. It shall be the responsibility of the Resident and/or Legal
Representative to apply for coverage and to establish eligibility under any governmental, third
party payor, managed care or private insurance program. The Center shall be under no
obligation to bill any third party payor other than the Legal Representative and, when applicable, a
governmental program third party payor or managed care organization with which the Center is
under contract,
1.10 Primary Responsibility for Payment. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall remain primarily li!lble
for any and all charges for which the Center may agree to bill a third party. The Resident and/or
Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or
managed care provider may not pay for non-covered services, supplies, equipment, medicatio~,
and other care and services which may be delivered by the Center or its subcontractors. This
3
"
Agreement serves as a written notice that the Center has notified the Resident and/or Legal
R:presentative that services provided at .the. Center may not be covered by a governmental payor,
third party payor or managed care orgaruzatlon. The Resident and/or Legal Representative agrees
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
1.11 Personal Physician. The Resident has the right to choose a personal physician,
provided that the physician selected is properly licensed and agrees to abide by applicable law and
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name ofhis/her personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notify the Center of
the new physician's name. If the physician chosen by the Resident fails to provide needed
coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have
the right to call another physician to attend the Resident and the fees charged by such physician
shall be borne by the Resident.
1.12 Phannacy. The Resident and/or Legal Representative acknowledge the light to
choose a phannacy of choice, provided the phannacy selected is properly licensed, packages and
supplies phannaceuticals in accordance with State law and agrees to abide by the Center's policies
and procedures and the phannacy has a medication distribution system similar to the Center's
ancillary phannacy's medication distribution system.
II.
RIGHTS AND RESPONSmILITY OF THE LEGAL REPRESENTATIVE
I ,
_1-
,-1-
2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal
access to the Resident's income or resources and that the documents supporting such authority, if
any, have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative
agrees to pay promptly from the Resident's income or resources all fees and charges for which the
Resident is liable under this Agreement. The Legal Representative shall not incur personal
liability on behalf of the Resident except for a breach of the duty to provide payment from the
Resident's income or resources for the fees and charges provided for in this Agreement.
2.03 Requested Items. The Legal Representative shall be personally liable for any
services or products specifically requested by the Legal Representative to be supplied to the
Resident, unless such services or products are covered by a governmental program.
2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such
that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must
notify the Center in writing when the application for Medicaid is made, If the ~
Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and
proper manner, the Legal Representative shall be personally liable for all charges and fees. not
covered by Medicaid which otherwise would have been covered had application been made m a
timely and proper manner.
4
-1-
., .
"
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid. the
Legal Representative shall provide such infonnation about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally respoDSlble
for any charges denied the Center due to any lack of cooperation.
2.06 Acceptance Upon Dischar~e. Upon tennination of this Agreement as provided in
the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of
the Resident from the Center. If after notice the Resident is not removed as requested, then the
Center is authorized and empowered to remove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Representative, if
the Resident's condition permits, who shall uncpnditionally be obligated to accept the Resident
and to pay promptly all charges.
2.07 Additional Responsibilities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement and
Attachments.
ID. RIGHTS AND RESPONSffiILITIES OF THE CENTER
3.01 Room and Standard Services. As part of the Room and Board Rate, the Center
shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and
bedding, I general nursing care, personal assessment, social services,_a,@ such other personal _1_
services as may be required pursuant to the plan of care prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general well-being of the
Resident.
3.02 Other Services. The Center shall act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, ifany, noted at
the beginning of this Agreement. The Deposit shall be applied to the charges for the first month
of the Resident's stay at the Center. '
3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by
the Center within thirty (30) days after discharge or transfer or within the time frame required by
Slate law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days
of the Center's receipt of the final Medicaid payment for care of the Resident.
IV. GENERAL PROVISIONS
4.01 Consent to Release of Information. The Resident and/or Legal Represent~tive
hereby consents to the release of hislher medical records to the following persons: Center
personnel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organization responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
s
., .
" -
reviews or payment audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily
activities; and general nursing care, the administration of medications and treatments, and the
performance of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time iDj,the exercise of good nursing judgment, subject to
any rights provided to the Resident by federal and/or state law,
As applicable, the undersigned Legal Representative hereby represents that he/she
has the legal authority to make health care decisions on behalf of the Resident, that documents
supporting such authority have been delivered to the Center, and that such Legal Representative
hereby consents on behalf of the Resident to the Treatment described above.
4.03 Consent to Photograph. The Resident andlor Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifying the Resident; fer
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to identify the Resident.
_J_ .
4.04 Notice of Services. Policies and Additional Information. The Resident and/or
Legal Representative acknowledge that the items listed below have been explained and have
received copies of the items or policies and procedures, if applicable. The Resident and/or Legal
Representative acknowledge they have had the opportunity to ask questions and questions have
been answered satisfactorily.
a. Authorization for Release or Review of Medical Information. See
Attachment C.
b. Authorization for Payment of Benefits. See Attachment D.
c. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Determination Notice. See Attachment F.
e. Medicare Secondary Payor Questionnaire. See Attachment G.
f. At the request of the Resident and/or Legal Representative, the Ce/).ter
shall maintain the Resident's personal funds in compliance with the laws
and regulations relating to the Center's management of such funds. A
description andlor policies and procedures of protection of resident funds
and the Personal Trust Fund Agreement, Resident Personal Funds
6
,. 'r ..
p.
q.
r,
., .
Authorization and any other related documents. See Attachment H-l and
H-2.
g. The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
h, Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
i. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
I'
J. The location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state survey and certification
agency, the state licensure office, the state ombudsman program, the
protection and advocacy network and the Medicaid fraud control unit. See
Attachment I (Center Supplement).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phon~.number on how t~~ a complaint
with the state survey and certification agency concerning resident abuse,
neglect, mistreatment and misappropriation of property, See Attachment I
(Center Supplement).
m.
The Resident Handbook. See Attachment J.
n.
ResidentlPatient Rights. See Attachment K.
0,
MedicarelMedicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Care's
Limited Treatment Practices and "No Cardiopulmonary Resuscitation
Orders" and a copy of the State summary of its laws governing the
Resident's right to direct hislber medical treatment. See Attachment M-l
and M-2,
.
Privacy Act Notification. See Attachment N.
Inventory sheet and/or policy of personal items. See Attachment 0,
7
... . I ~
,~ r I r
s. ASM Form. See attachment P.
t.
Consent to Photograph
See Attachment Q.
u.
See Attachment R.
v.
See Attachment S,
w.
See Attachment T.
x.
/'
See Attachment U.
y.
See Attachment V,
z.
See Attachment W.
4,05 Assignment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to
me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal
-JRepresentative hereby authorizes the Center and any holder of m~tlical or other information to
release such information to the Health Care Financing Administration and its agents and to third
party payors any information needed to determine these benefits or benefits for related services.
4.06 Termination. Discharg;e and Transfer. This Agreement may be terminated as set
forth below and as set forth in the Resident Handbook under the Section Heading "Discharge".
The Resident and/or Legal Representative may terminate this Agreement before the Resident's
discharge from the Center by providing the Center written notice of the Resident's desire to leave
at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the
end of that time, the Resident must still pay for each day of the required notice unless the Center
fills the bed before the end of the notice period. Except in the event of an emergency or death, the
Resident shall be responsible for all charges for the Room and Board Rate and for all services
performed up to the end of the day that the Admission ends. Discharge from the specialized units
such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice.
If discharge or transfer becomes necessary because the Resident and/or Legal Representative or
someone else abused the Resident's funds, the Center will request that local, state and federal
authorities, as appropriate investigate, which may result in prosecution.
4.07 Indemnification. The Resident shall defend, indemnifY and hold the Center
harmless from any and all claims, demands, suit and actions made against the Center by any
person resulting from any damage or injury caused by the Resident to any person or the property
8
.. ,. ..
of any person or entity (including the Center), except in the case of negligence of the Center's
employees and agents.
4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal Jaw will not invalidate the remaining
provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the
Center will continue to fulfill their respective obligations under this Agreement consistent with the
law. .'
THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY
HAVE EACH READ AND UNDERSTOOD" THE FOREGOlNG AGREEMENT, AND
THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEm SATISFACTION.
Signature of Resident; X O'~....... ~-u Date: -;-1 & -:-oD
Signature ofLegal Representative, if signing on behalf of Resident:
Date:
_1_ _S-
Signature oftega! Representative, signing on his/her own behalf
Date:
Center Representative: D. jJ ~ L. J ~ "t c.I2-- Date: 1 ~ /0 - DJ
9
<,'~: A.
EXHIBIT "e"
.._~.__~___~___'__"'_""""""'''V''''';':'=~~............-.''''__
HCR.MailorCare
MANOR CARE CARLISLE 372
940 WALNUT BOTTon ROAD
CARLISLE, PA 17013
(717)-249-0085
MIKE S080TOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
SOBOTOR. AMELIA B
I'
96129
Statement
MEDICAID
PRIVATE
ROOr'1 109 -A
Please Return Tllis Portion
With Your Payment
11/01/00
01/31/01
------------------------------------------------------------------------
t."',TE or:
SEf=l.VIGE
01/01/01
01/01/01
02/01/01
! CODE I SERVICE RENOERED
: j
BALANCE fOR.JARO
11900 MCB PREMIUM
ADV PVT PORTION
( OTY
PAYMENT DUE BY THE
10TH OF THE MONTH
CHARGES I
10,366.52
1-)
1,000.36
AI~OUNT DUE
CREDITS
50.0
11,316.87
"'.""__'~._"""-'~',;,,;,,;=,;;"~.~"_l..............;;,-,...,,'"
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/201
10/31/96 TV CABLE $5.00
11/30/96 TV CABLE $5.00
11/30/96 INTEREST UNPAID 1.50% ON 5.00 $0.08
12/18/96 PAYMENT-THANKYOU ($5.01
12/18/96 PAYMENT-THANKYOU ($5.01
12/31/1996 RESIDENT PORTION $784.45
1/1-1/31/97 RESIDENT PORTION $806.45
01/21/97 PAYMENT-THANKYOU ($220.0C
02/28/97 TV CABLE $5.00
2/1-2/28/97 RESIDENT PORTION $806.45
02/28/97 INTEREST UNPAID 1.50% ON 1326.98 $19.90
03/04/97 PAYMENT - THANK YOU ($784.52
03/04/97 PAYMENT-THANKYOU ($564.4S
03/04/97 PAYMENT-THANKYOU ($784.4S
03/12/97 PAYMENT-THANKYOU ($5.00
03/12/97 PAYMENT-THANKYOU ($806.45
03/14/97 PAYMENT-THANKYOU ($5.00
3/1-3/31/97 RESIDENT PORTION $804.35
$56.80
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
03/31/1997 BEGINNING BALANCE $56.80
03/31/97 TV CABLE $5.00
03/31/97 REVERSE INTEREST 2/28/97 ($19.90)
04/1/97 TRANSFER MISAPPLIED PAYMENT ($100.00)
04/10/97 PAYMENT-THANKYOU ($811.45)
4/1-4/30/97 RESIDENT PORTION $804.35
05/12/97 PAYMENT-THANKYOU ($701.53)
05/31/97 TV CABLE $5,00
5/1-5/31/97 RESIDENT PORTION $804,35
06/1 0/97 PAYMENT - THANK YOU ($4.92)
06/1 0/97 PAYMENT - THANK YOU ($806.53)
06/30/97 TV CABLE $5.00
6/1-6/30/97 RESIDENT PORTION $804.35
07/30/97 PAYMENT - THANK YOU ($4.92)
07/30/97 PAYMENT-THANKYOU ($806.53)
07/31/97 TV CABLE $5.00
711-7/31/97 RESIDENT PORTION $804.35
08/13/97 PAYMENT-THANKYOU ($601045:
06/30/97 MIS APPLIED PAYMENT ($210.00
($773.03
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/2001
08/31/97 ADJ BEGINNING BALANCE ($773.03)
08/31/97 TV CABLE $5.00
08/31/97 RESIDENT PORTION $804.35
09/16/97 PAYMENT-THANKYOU ($4.92)
09/16/97 PAYMENT-THANKYOU ($806.45)
09/16/97 PAYMENT - THANK YOU ($0.08)
09/30/97 TV CABLE $5.00
9/1-9/30/97 RESIDENT PORTION $804.35
10/31/97 TV CABLE $5.00
10/1-10/31/97 RESIDENT PORTION $804.35
11/07/97 PAYMENT - THANK YOU ($5.00)
11/07/97 PAYMENT - THANK YOU ($806.45)
11/30/97 TV CABLE $5,00
11/1-11/30/97 RESIDENT PORTION $804.35
12/19/97 PAYMENT-THANKYOU ($4.92)
12/19/97 PAYMENT-THANKYOU ($811.53)
12/19/97 PAYMENT - THANK YOU ($806.45)
12/31/97 TV CABLE $5.00
12/31/97 RESIDENT PORTION $804.35
$27.92
. '
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
12/31/97 ADJ BEGINNING BALANCE $27.92
01/12/98 PAYMENT-THANKYOU ($4.92)
01/12/98 PAYMENT-THANKYOU ($806.53)
01/06/98 BEAUTY CHARGES $32.00
1/1-1/31/98 RESIDENT PORTION $914.50
01/31/1998 INTEREST 0.08
02/09/98 PAYMENT-THANKYOU ($32,00)
02/09/98 PAYMENT - THANK YOU ($806.53)
02/28/98 TV CABLE $5.00
2/1-2/28/98 RESIDENT PORTION $914.50
03/12/98 PAYMENT-THANKYOU ($4.92)
03/12/98 PAYMENT - THANK YOU ($806.53)
03/31/98 TV CABLE $5.00
3/1-3/31/98 RESIDENT PORTION $914.50
04/30/98 TV CABLE $5.00
4/1-4/30/98 RESIDENT PORTION $914.50
05/15/98 PAYMENT-THANKYOU ($4.92)
05/15/98 PAYMENT-THANKYOU ($806.61)
05/31/98 TV CABLE $5.00
$465.04
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE. PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS. PA 17324
MEDICAID
PRIVATE
ROOM125-A
SOBOTOR. AMELIA
96129
09/03/96
05/10/01
04130/2001
5/3198 ADJ BEGINNING BALANCE $465.04
5/1-5/31198 RESIDENT PORTION $914.50
05/31/1998 INTEREST $0.07
06/29/98 PAYMENT - THANK YOU ($4.92)
06/29/98 PAYMENT-THANKYOU ($806.61)
06/30/98 TV CABLE $5.00
6/1-6/30/98 RESIDENT PORTION $914.50
07/31/98 TV CABLE $5.00
711-7/31/98 RESIDENT PORTION $914.50
07/31/1998 INTEREST $12.25
08/17/98 PAYMENT-THANKYOU ($4.91)
08/17/98 PAYMENT-THANKYOU ($811.45)
08/17198 PAYMENT - THANK YOU ($183.64)
08/31/98 TV CABLE $5.00
8/1-8/31/98 RESIDENT PORTION $914.50
08/31/1998 INTEREST $9.60
09/18/98 PAYMENT - THANK YOU ($640.06)
09/18/98 PAYMENT - THANK YOU ($171.47)
09/30/98 TV CABLE $5.00
9/1-9/30198 RESIDENT PORTION $914.50
09/30/98 INTEREST $9.74
$2,466.14
__....-~.._..C<i"""'~~ ....~,...".. ...._,'-"..,.,""',;...._
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
09/30/98 ADJ BEGINNING BALANCE $2,466.14
10/27/98 PAYMENT-THANKYOU ($611.5
10/31/98 TV CABLE $5.00
1 0/29/98 BEAUTY CHARGES $32.00
10/1-10/31/98 RESIDENT PORTION $914.50
10/31/1998 INTEREST $12.89
11/30/98 TV CABLE $5.00
11/1-11/30/98 RESIDENT PORTION $914.50
11/30/1998 INTEREST . $25.73
12/08/98 PAYMENT-THANKYOU ($38.0
12/08/98 PAYMENT-THANKYOU ($511.9:
12/31/98 TV CABLE $5.00
12/1-12/31/98 RESIDENT PORTION $914.50
12/31/1998 INTEREST 30.04
01/07/99 PAYMENT-THANKYOU ($309.2'
01/07/99 PAYMENT-THANKYOU ($590.71
01/31/99 TV CABLE $5.00
01/01-01/31/99 RESIDENT PORTION $933.76
01/31/99 INTEREST $29.16
$4,231.6!
.~,-_._._- ..._:-,~';;'~"';;"........;......>_..,,~......._....,
. ., ...
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
01/31/99 ADJ BEGINNING BALANCE $4,231.69
02/24/99 PAYMENT-THANKYOU ($265.51
02/24/99 PAYMENT-THANKYOU ($554.4:
02/28/99 TV CABLE $5.00
02/01-02/28/99 RESIDENT PORTION $933.76
02/28/99 INTEREST $27.56
03/31/99 PAYMENT-THANKYOU ($282.71
03/31/99 PAYMENT-THANKYOU ($547.2-
03/31/99 TV CABLE $5.00
03/01-03/31/99 RESIDENT PORTION $933.76
03/31/99 INTEREST $33.43
04/30/99 TV CABLE $5.00
04/13/99 BEAUTY CHARGES $32.00
04101-04/30/99 RESIDENT PORTION $933.76
04/30/99 INTEREST $48.01
05/31/99 TV CABLE $5.00
05/01-05/31/99 RESIDENT PORTION $933.76
05/31/99 INTEREST $63.29
$6,541.0
______~___.__~~_~_,_"'"'....>..>;_,._....................'....___.-. .~._"_,...;....,o~.....;...;~="""_""._____~_.,~...,.
. .. .
. .' ~
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM125-A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
05/31/99 ADJ BEGINNING BALANCE $6,541.02
06/02/99 PAYMENT-THANKYOU ($294.25
06/02/99 PAYMENT - THANK YOU ($755.75
06/21/99 PAYMENT-THANKYOU ($880.00
06/30/99 TV CABLE $5.00
06/01-06/30/99 RESIDENT PORTION $933.76
07/31/99 TV CABLE $5.00
07/01-07/31/99 RESIDENT PORTION $933.76
08/09/99 PAYMENT-THANKYOU ($966.32
08/09/99 PAYMENT - THANK YOU ($433.68
08/31/99 TV CABLE $5.00
08/01-08/31/99 RESIDENT PORTION $933.76
09/20/99 PAYMENT-THANKYOU ($889,45
09/20/99 PAYMENT - THANK YOU ($10.55
09/30/99 TV CABLE $5.00
09/30/99 BEAUTY CHARGES $32.00
09/01-09/30/99 RESIDENT PORTION $933.76
$6,098.0e
.
. l' ..
, " .
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
09/30/99 ADJ BEGINNING BALANCE $6,098.06
10/31/99 TV CABLE $5.00
10/01-10/31/99 RESIDENT PORTION $933.76
11/30/99 TV CABLE $5.00
11/01-11/30/99 RESIDENT PORTION $933.76
12/31/99 TV CABLE $5.00
12/01-12/31/99 RESIDENT PORTION $933,76
01/06/00 PAYMENT-THANKYOU ($1,930.26;
01/06/00 PAYMENT. THANK YOU ($269.74:
01/31/00 TV CABLE $5.00
01/01-01/31/00 RESIDENT PORTION $1,000.35
01/31/00 MCB PREMIUM ($45.50
02129/00 TV CABLE $5.00
02/01-02/29/00 RESIDENT PORTION $1,000.35
02129/00 MCa PREMIUM ($45.5C
03/03/00 PAYMENT-THANKYOU ($750.0[
03/31/00 TV CABLE $5.00
03/01-03/31/00 RESIDENT PORTION $1,000.35
$8,889.3
. ., ~
. .' ~
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
03/31/00 ADJ BEGINNING BALANCE $8,889.39
03/31/00 MCB PREMIUM ($45.50)
04/17/00 PAYMENT-THANKYOU ($1,450.00)
04/30/00 TV CABLE $5.00
04/01-04/30/00 RESIDENT PORTION $1,000.35
04/30/00 MCB PREMIUM ($45.50)
04/30/00 BEAUTY CHARGES $36.00
05/31/00 TV CABLE $5.00
05/11/00 BEAUTY CHARGES $9.00
OS/25/00 BEAUTY CHARGES $9.00
05/01-05/31/00 RESIDENT PORTION $1,000.35
05/31/00 MCB PREMIUM ($45.50)
06/30/00 TV CABLE $5.00
06/01-06/30/00 RESIDENT PORTION $1,000.35
06/30/00 MCB PREMIUM ($45.50)
07/03/00 PAYMENT-THANKYOU ($1,300.00)
07/31/00 TV CABLE $5.00
07/01-07/31/00 RESIDENT PORTION $1,000.35
$10,032.79
.. ,. .
" .
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03196
05/10/01
04/30/01
07/31/00 ADJ BEGINNING BALANCE $10,032.79
07/31/2000 MCB PREMIUM ($45.5l
08/16/00 PAYMENT-THANKYOU ($1,000.Ol
08/31/00 TV CABLE $5.00
08/01-08/31/00 RESIDENT PORTION $1,000.35
08/31/00 MCB PREMIUM ($45.51
09/30/00 TV CABLE $5.00
09/01-09/30/00 RESIDENT PORTION $1,000.35
09/30/00 MCB PREMIUM ($45.51
10/18/00 PAYMENT-THANKYOU ($1,200.01
10/31/00 TV CABLE $5.00
11/30/00 TV CABLE $5.00
11/17/00 BEAUTY CHARGES $36.00
11/01-11/30/00 RESIDENT PORTION $1,000,35
11/30/00 MCB PREMIUM ($45.5'
12/22/00 PAYMENT - THANK YOU ($1,000.01
12/31/00 TV CABLE $5.00
1 2/06/00 BEAUTY CHARGES $9.00
$9,721.8
....';;..... -'l;
. "
. ., ..
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
12/31/00 ADJ BEGINNING BALANCE $9,721.84
12/20/2000 BEAUTY CHARGES $9.00
12/01-12/31/00 RESIDENT PORTION 1000.35
12/31/00 MCB PREMIUM ($45.50)
01/31/01 TV CABLE $5.00
01/01-01/31/01 RESIDENT PORTION $1,031.85
01/31/01 MCB PREMIUM ($50.00)
02128/01 TV CABLE $5.00
02/01-02/28/01 RESIDENT PORTION $1,031.85
02/28/01 MCB PREMIUM ($50.00)
03/19/01 PAYMENT-THANKYOU ($1,000.00)
03/31/01 TV CABLE $5.00
03/01-03/31/01 RESIDENT PORTION $1,031.85
03/31/01 MCB PREMIUM ($50.00)
05/31/01 TV CABLE $5.00
05/01-05/31/01 RESIDENT PORTION 1,031.85
05/31/01 MCB PREMIUM ($50.00)
04/01/97 REVERSE TX MISAPPLIED PMT $100.00
06/01/97 REVERSE TX MISAPPLIED PMT $210.00
$13,943.09
II
I.. ., ...
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYL VANIA
'HCR MANOR CARE,
Plaintiff
NO. 01.4092 Civil Term
vs.
CIVIL ACTION - LAW
AMELIA B. SOBOTOR, Individually, and
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
CERTIFICATE OF SERVICE
AND NOW, this 27th day of September, 2001, I, Daniel F. Wolfson, Esquire, do
hereby certify that I have served a copy of the foregoing Amended Complaint upon the
counsel of record by Regular Mall - Postage Pre-paid and addressed as follows:
Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
(Counsel for Defendants)
:;::::7~ ?dP~
Daniel F. WOlfson,~~ -
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 20617
Attorney for Piaintiff
"
, ,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION. LAW
AMELIA B. SOBOTOR, Individually, and
MICHAEL SOBOTOR, Individually,
and on Behalf of AMELIA B. SOBOTOR,
Defendants
PRAECIPE TO AMEND CAPTION
TO THE PROTHONOTARY OF SAID COURT:
Kindly amend the above caption to reflect that Defendant, Amelia B. Sobotor, is
now deceased, as follows:
MICHAEL SOBOTOR, Individually, and
on Behalf of Amelia B. Sobotor, Deceased,
Defendant
Respectfully submitted,
--- />
~~~/!A
Daniel F. Wolfson, Esquire
WOLFSON & ASSOC TES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 2061 7
Attorney for Plaintiff
"
,I
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
CERTIFICATE OF SERVICE
AND NOW, this 16th day of September, 2002, I, Daniel F. Wolfson, Esquire, do
hereby certify that I have served a copy of the foregoing Second Amended Complaint
upon the counsel of record by regular mall, postage pre-paid and addressed as follows:
Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
---P~*?;L~ "
Daniel F. Wolfson, Esquire '
WOLFSON & ASSOCIA T S, P.c."-"
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 2061 7
Attorney for Plaintiff
.'~ '
-c
"
')
"
J
"
-'-j
,;:)
"
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
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 is served, by
entering a written appearance, personally of by attorney, and filing in waiting 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 document, or for any other
claim or relief requested by he Plaintiff. You may lose money or property or other right important
to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE
A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH
TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTlClA
Le han demandado a used en la corte. Si used quaere defensas de esas demandas expuestas en las
paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en
la corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra de su persona.
Sea avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra
used sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedldo en la peticion de
demanda. Used puede perder dinero 0 sus propiedades 0 otros derechos importantes para used.
LLEVE EST A DEMANDA A UN ABOGADO IMMEDIA T AMENTE. SI NO TIENE ABOGADO
o SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVIClO VAYA EN PERSONA
o LLAME POR TELEFONO A LA OFIClNA CUYA DIRECCION SE ENCUENTRA ESCRITA
ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASSIT ANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 1 701 3
(717) 249-3166
If
4. That Plaintiff is filing the within Second Amended Complaint in an attempt
to cure Preliminary Objections which were filed by Defendants in response to Plaintiff's
original Complaint on or about September 4,2001.
5. That Amelia B. Sobotor, Deceased, executed a General Durable Power of
Attorney, appointing her son, Defendant, as her lawful Attorney-in-Fact, on October 22,
1 996. A true and correct copy of said Power of Attorney is attached hereto,
Incorporated herein, and marked as Exhibit "A".
6. That pursuant to said Durable Power of Attorney executed by Decedent, the
Defendant was given specific power, which Included, but was not limited to, the ability to
"contract with and arrange for my entrance to any hospital, nursing home, health center,
convalescent home, or similar institution and to pay all bills in connection therewith". See
Exhibit" A", Page 1, as previously Identified and incorporated herein.
7. That Defendant inquired to Plaintiff's health care facility for the purpose of
admitting Decedent as a resident on or about July 31, 1996. A true and correct copy of
said Application for Residency is attached hereto, incorporated herein and marked as
Exhibit "B".
8. That Defendant warranted and represented that the information he provided
regarding the Decedent in the Application for Residency was complete and accurate and
that the Plaintiff could rely on the information in admitting Decedent. See Exhibit "B",
page 4, previously identified and incorporated herein.
2
II
9. That Defendant warranted and represented that the Decedent received
monthly social security and pension benefits in the amount Nine Hundred Twelve and
50/1 00 ($912.50) Dollars per month. See Exhibit "B", pages 3 and 4, as previousiy
identified and incorporated herein.
10. That on or about August 9, 1996, Defendant executed an Admission
Agreement on behalf of the Decedent, which Agreement outlined various terms of
residential health care services to be provided by Plaintiff and the Responsible Party
therefor. A true and correct copy of the Admission Agreement Is attached hereto,
incorporated herein, and marked as Exhibit "C".
11. That on or about August 9, 1996, pursuant to the aforementioned
Admission Agreement, the Decedent was admitted as a health care resident of Plaintiff.
12. That from August 9, 1996 through July 2000, Decedent was a
health care resident of Plaintiff, where she did receive various necessary residential health
care services and health care treatment by Plaintiff. A true and correct copy of the
itemization of services is attached hereto, incorporated herein and marked as Exhibit "D".
13. That by executing said Admission Agreement, Defendant did acknowledge
that Plaintiff would be relying on the "Conditions" of the Responsible Party Appointment,
which Is part of the Admission Agreement, In admitting the Decedent, and that if
Defendant did not follow through with said Conditions, Plaintiff will have detrimentally
3
'.1
'elied upon said Conditions and Plaintiff will suffer financial harm and loss. See Exhibit "C"
IS previously Identified and incorporated herein.
1 4. That Defendant agreed to remit payment to the Plaintiff from the assets of
the Decedent, for services provided by Plaintiff, and to have payment of any available
government or third party payor benefits due and owing the Decedent assigned to the
Plaintiff. See Exhibit "C", specifically, the Admission Agreement's Condition No.1 of the
Responsible Party Appointment, as previously identified and incorporated herein by
reference.
1 5. That the Decedent incurred a debt in the amount of Ten Thousand Thirty-
Two and 79/100 ($10,032.79) Dollars to Plaintiff while a Resident of Plaintiff's health
care facility for health care treatment and services provided pursuant to the Admission
Agreement, that was not compensated by a third party payor or government program, and
which is comprised of resident portion payments and small private balances as a result of
barber and beauty treatment and cabie charges.
16. That Plaintiff sent Defendant a copy of the itemization of services accurately
showing all debits and credits for transactions with Plaintiff.
17. That Defendant did not object to the above mentioned itemization of services
submitted by Plaintiff to Defendant.
18. As ofthe date of filing of this Complaint, the balance due, owing, and
unpaid on Decedent's account as a result of said charges is the sum of Ten Thousand
4
II
Thirty-Two and 79/100 Dollars ($10,032.79) Dollars. See Exhibit "D" as previously
identifled and incorporated herein by reference.
19. Despite Plaintiff's reasonable and repeated demands for payment, Defendant
has failed, refused, and continues to refuse to pay all sums due and owing on Decedent's
account balance, all to the damage and detriment of the Plaintiff.
20. Plaintiff has made numerous requests to Defendant, as Power of Attorney
and Legal Representative/Responsible Party for Decedent, demanding that the sums due
and owing to Plaintiff be paid, and Defendant, as Power of Attorney and Legal
Representative/Responsible Party for Decedent, has ignored both his fiduciary obligation
and contractual obligation to pay necessary and appropriate bills and obligations for his
mother, the Decedent.
2 1. That Defendant's willful failure to remit Decedent's monthly social security
and pension benefits income to Plaintiff was a direct violation of the Admission Agreement
Defendant executed with Plaintiff. See Exhibit "C" as previously identified and
incorporated herein.
22. That at all times relevant thereto, said social security and pension benefits
payments were not made to Plaintiff nor received by Plaintiff.
23. That the finances and income of the Decedent rightfully belonged to the
Decedent for her necessary and appropriate medical services and treatment rendered by
5
I'
Plaintiff to the Decedent, however Defendants failed to utilize Decedent's finances for that
intended purpose.
24. That Defendant knowingly violated his fiduciary and contractual duties and
responsibilities as the Legal Representative/Responsible Party for Decedent, under the
Admission Agreement, by failing to utilize Decedent's flnancial resources to pay Plaintiff
when he knew or should have known there were outstanding medical bif/s for the care of
the Decedent.
25. Plaintiff has retained the services of the law firm of Wolfson & Associates,
P.c., in the collection of the amounts due from Defendant.
26. Pursuant to Paragraph 8 of the Fee Schedule, which was attached as part of
the aforementioned Admission Agreement, Plaintiff is entitled to receive and Defendant
has agreed to pay reasonable attorney's fees and all court costs if the account is referred to
an attorney for collection. See Exhibit "B" as previously identified and incorporated
herein.
27. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's
fees from the law office of Wolfson & Associates, P.c. in the collection of the amounts due
and owing by Defendant incident to the within action, and Plaintiff shall continue to incur
such attorney's fees throughout the conclusion of the proceedings in the amount of thirty
percent (30%) of the principal balance due and owing to the Plaintiff by the Defendant.
6
II
I:
28. That the amount of attorney's fees which represents thirty percent (30%) of
the principal amount due and owing is the sum of Three Thousand Nine and 84/100
($3,009.84) Dollars.
29. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
30. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter judgment in favor of Plaintiff and against Defendant, Michael Sobotor,
Individually and on behalf of Amelia B. Sobotor, Deceased, in the amount of Ten
Thousand Thirty-Two and 79/100 ($10,032.79) Dollars, reasonable attorney's fees in
the amount of Three Thousand Nine and 84/100 ($3,009.84) Dollars, the costs of this
action, and such other relief as the Court deems proper and just.
Respectfully submitted,
~
Daniel F. Wolfson, Esquire
WOLFSON & ASSOCIATE
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 2061 7
Attorney for Plaintiff
7
VERIFICATION
I, Michelle Thureson, being the Senior Financial Consultant for HCR Manor Care,
verify that the statements made in the foregoing Amended Complaint are true and correct
to the best of my knowledge, information and belief. I understand that false statements
herein are made subject to the penalties of 18 P~. C.S. Section 4904, relating to unsworn
falsification to authorities.
HCR Manor Care
DATE: ~/,c.lo'2..
f!21~~dd~n7711-~4.~,
Senior Financial Services Consultant
EXHIBIT "A"
"~~~~!W;.~
,,;> .4~..t,~., ,)'1., ,.
.,,;<;~,';') ,'.~;.I"i1;.~ .d- "
;J~,llj:, {" Whl;, ~jL_
. . .-:':, ;:~:;'t:::i-_'~~li~~jij\~; ~- ~."'I:"i~l~J~i!%~iii~J;f,'.'
.: . ,1,"!1 ,.:.....I~..,!CI. '.' ~~~-d:It;..:Jl~.~',:'.:.l,.~I::
, ". '.' r ~.' ."~ .li<\"" .. i t. 'i~" .'.....''!r'' '", - .
c.; i.~:.,.:.,~...:".,.,~t:"l~,ji!~;'I:t.'t~" "~I.;R' ~.'" ,. :i"'.l:~',
. l\"....~.. l{. iI;(., .' . I ",,"'l\; .
. ',." )."'1.. .!] ..,L- . .:\ i .....,"'!I.", ,~..... ;
. .,', . ~i'.-,;.~11.. .t",i...~~..i:'i~..i!' .,,!j..:J';..~r..:'.:
" :;:':,
.";' .
GENE;RAL DUEABI,E POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, That I, AMELIA B. SOBOTOR,
Manor Care, 940 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania 17013, do hereby appoint my son, MICHAEL P. SOBOTOR,
19 Holly Estates Drive! Gardners! Cumberland County, Pennsylvania
17324, as my agent ("my agent"), for me and on my behalf, in my
name or in his own name, to take all actions and to perform all
acts concerning my affairs as he may deem necessary or advisable,
in his absolute discretion, as fully as I could do if personally
present, including, without limiting the generality of the
foregoing, for me and in my name and on my behalf, as follows:
1. Inclusiveness. To receive and receipt for all sums of
money or payments due or becoming due to me from any source; to
enter my safe deposit boxes in any and all banking institutions,
and to add to and to remove any of the contents thereof; to
endorse all checks and other instruments payable to me and
deposit and withdraw any and all moneys, checks and other
instr~ments to which I may be at any time entitled in my name in
any financial institutions; to pay any and all claims and demands
now or hereafter payable by me; to draw and sign checks, drafts
and other orders for the payment of money upon my checking
account or upon any other bank accounts or deposits now or
hereafter belonging to me; to borrow money and to mortgage,
pledge or hypothecate any property, real or personal, now or
hereafter owned by me as security therefor: to sell, possess,
insure, manage, maintain, improve, lease, mortgage, pledge,
encumber, convey, and otherwise dispose of, or take any other
action with respect to any property, real or personal, now or
hereafter owned by me, on such terms and conditions as my agent
considers appropriate, and in the event of any sale of my real
estate to execute the sales agreement and the deed iil my name and
to make settlement and receive the proceeds; to purchase, rent or
ot~erwise acquire any property, real or personal, for me and to
pay for the same; to contract with and arrange for my entrance to
any hospi'tal, nursing home, health center, conval~scent home, or
similar institution and to pay all bills in connection therewith;
to arrange for and consent to or to withhold medical,
therapeutical and surgical procedures for me, including the
administration of drugs; to institute and to engage in and
compromise any litigation on my behalf; for me and in my name and
as my act to execute, endorse, acknowledge and deliver all
documents; to prepare, execute and file any tax returns,
governmental reports and other instruments of w~atever kind; to
engage and dismiss agents; and to manage, make and transact all
and every kind of business of every nature.
" .--,., ~ ,'<' _~~ .~...,~.o: ~".", ...,-~_. '": --:__....,~' -.~~~--,._ '. -,---, ~~ ".~-~,!,.~. .,.,.......,1""-"""'_....... ,_,.~ .
2. Genera! Autho~ity. To do all other things which my
agent shall deem necessary and proper in order to carry out tie
foregoing powers which shall be construed as broadly as possible,
giving and granting unto my said agent full power and authority
to do and perform all a~d every act, deed, matter, and thing
wnatsoever i~ and about my estate, property, and affairs as fully
and effectually to a:1 i~tents and purposes as : might or could
do in my own proper pe~son if personally preseDt, the above
special~y enumerated powe~s being in aid and exemplificatio~ 0:
the full, comp:ete, and general power herein gra~ted, and not in
limitation or definition thereof; and hereby ratifying and
confirming all that my said agent shall lawfully do or cause to
be done by virtue of these presents.
3. Durability. This power of attorney shall not be
affected by my subsequent disability or incapacity. All acts
done by my agent pursuant to this power during any period of my
disability or incapacity shall have the same effect and enure to
my benefit and bind me and my successors in interest as if I were
competent and not disabled.
4. Reliance on Power, This power may be accepted and
relied upon by anyone to whom it is presented until such person
either receives written notice of revocation by me or a guardian
or similar fiduciary of my estate or has actual knowledge of my
death.
5, Hold Harmless. All act~ons of my agent shall bind me
and my heirs, distributees. legal representatives, successors and
assigns, and for the p~rpose of inducing anyone to act in
accordance with the powers I have granted herein, I hereby
represent, warrant and agree that if this power of attorney is
terminated or amended for any reason, I and my heirs,
distributees, legal representatives. successors and assigns will
hold such party or par:ies harmless from any loss suffered or
liability inc~rred by s~ch party or parties while acting in
accordance with this po~e~ prior to that party's receipt of
written notice of any s~ch termination or amendment,
The following is the specimen signature of the person to
whom this power of attcrney is given:
~~{~L#
Page 2 of 3 pages
..
d
I have signed this power or attorney this 22- day or
o~~
, 1996,
Witnesses:
(~~cff~
AMELIA B, SOBOTOR
'1J1l;jJ 4'/1 A PJ1!1tJ 7!fr
/87~0'6- '5)/~
Social Security No.
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
.L
On this ;z.~ day or oc./.:>~ , 1996, personally appeared
before me, a Notary Public in and for the said county and state,
the above-named &~ELIA B. SOBOTOR, who acknowledged the roregoing
power of attorney to be her act and deed and desires the power of
attorney might be recorded according to law.
I have signed my name
and ~~~~~~
Notary Public
\ NOTARIAL SEAL '. \
WilLIAM S. DANIELS. Notary Public
Carli.le Bora. Cumberland County
My Commi.sion Expi.... Oct 19, 2000
Page 3 or 3 pages
EXHIBIT "B"
f'" J~.V(L~'r'\. ~1Yo..U'\.Jl., - .:x:J.-LU!-X
APPLlCA liON FOR RESIDENCY
e
e
To apply for admission a.t our Nursing Center, please complete the following questionnaire,
sign, and return it to the Admissions Office. This application will become a part of the
"Admission Agreement" and should be completed in its entirety. All information will be held
in confidence. The complete medical history and physical examination results will be
recorded on another form.
Date: Oij31!Qto
~:~de~trospectiveAme,I\cc.B,~bo+nr Sex: r::- Age: 78
Address: ;) l.Q 3 l)). D6I.l\o\..e.j v:k br
Alh~ GI?' ',-~IIOl
TelephoneNo.:~I~ '09>'3 - g) 31 ~pcial Security No.: \ <(\7 - 06- 31 { 4
Date of Birth: Month n \ Day 05 Year t B
Place of Birth: City
State (County)
Widowed X
Relationship: -5oG W\er
Telephone No.:Q(2.. - 43V- ~3Y~
Marital Status: Married Single
Name of Inquirer: [;ve\y VI Si-r-C\ck e....
Address: polrnyroJ MU. .(;w \
kl k)~ Ge- .J1701
Other persons to contact (in case of emergency)
Name b L Relationship Address Telephone NOi I
'f) '",,\'ill. So o-nr D I L- C!>; 91;),-438-5 & w"f
PQtSdho~r (ElL) (q f/of1J.J.r fsfrd:J Or' (/.JJ ') f).J../5 - J.3tl
~~\~) ~G'Y\) r;cvt.&VIUJ)/J;J /73;;(ftH) LfAlo - 8J3~
How did you hear about ~ Nursing Center
1. Personal Referral 6. Newspaper/Magazine
2. Hospital 7. Television/Radio
3. Physician 8. Yellow Pages
4. Other Nursing HomelACLF 9. Mailing/Brochure
5. Health Dept. ' . i hi. Mt ~ 1 f1. f'tY't oJ
HAVE YOU VISITED ANY OTHER NURSING CENTERS? ~ES
NO
. .' " ".' " "l "', ,,'c, ,.'.:, ""'" ,'...,'
- 'llil5 '
~,.i.C;.'}-k&.sh';;,ffl .:;A.~' ),c'J1~ :0::,. .....,.,., ..,.,.' ...;-;:.,~;, ...., ,,' .."
'<,' ,j:".;,t~,',~,', ,"7""',f&,.,..,~t,c;:;,,.,;,.;};..;,.;f$:N,.<,:. .,"";,.;.,'<".,.,. '.," .,. ..,.;dJ.Y:i..'.?,'" ;.;,..~..,' ?":~',\'.i":i, ,co.,."""':....'', :"cO',' _, ',"'~,',', '",-,", ~",',", ,e , >,'
, ...,.,"~,-;;c";);,,"'.MANOR'C'ARE ..'.LEADER"..AMERICANA'~'FOUR.'SEASONS;7'i!.;,,-.t'''';.~r''',.:''''
',"',","'cll:,~. "",>d'~' ~~, 'o~""""",', ,.,',,',"....,"" ''''',,'''''_',,'~~' ":., "'"~','''''''.",',''''' ."-,,,.' ",.'."", ""'1'T~, '. ",-."",""""""'~ ..."',.~.""".,."~"..~..,,,',_"."'.,,"',",>~'.'','.,'~..", ,.."'",, ..~,."..",,',"'," "","', ",',
:";'", "1~';" "'r:<1~;HA''E'W''''7'T' ""'1!t>;\1 ""7'J<N::e:"',::z..l/'" ';'~'>""~~7'''''' """"'0:;ti!' &,' ~"..' c. ." ". " ,*'~
~'-.";~'~;@~.~7.<l\~~ ' ,",,,,~~~~'i2' ~~;";~~~~:'~~;;::'~:J
!~"'''ft-.''''I-'--''' ~...."....,.......""""-~,. r:. . ' ''''''''',''ll'> ~~.., .'UI,.-,--'Of
;"""':>11101 '~'1lL\m'~ ..' """;;;'~~" it. c"''',.,ij,i.'i..61\h''''''''''l' '," " . ,."_.""'~"'...,..~"'~ .... ~8-6_{~
,'~ "" ,,'. " ", ,",,,... ~~.... " - .Jl, _ I!If fllR. ._r..lll'Lf'fiii
~
.
. IF YES, WHICH ONES? " '8Y1r\~ ~ -i.e'~ ~~
MEDICAUPERSONAL DATA
Diagnosis: Jh5~&i(\ tk.~n.&.wl ciicJ;eh'C) fVo+ vJ(j'J11JJ ) 1hjp-tr--kV1S~cryV
Resident's Current Physician:
Physician to Follow at Facility: n r. On/Y\~1JJJ '
1. J Mentally Alert 7. Bed Ridden
2. Slightly Forgetful 8. Requires Special Diet
3. Confused
4. Ambulatory
5. ---:t<Walks with Assistance
6. Requires Bedrails
9.
Able to Eat Without
_ ,,-Assistance
X Requires Assistance with
Eating
Incontinent
10.
11.
12. Continent
Resident No At:00\U1vlbio... PlLl.l,~r4. ~(
~v- nJ.
~ Clf)J) P~rYI{l hA. 4'\..
P 6 PJrJX <...) /C(OPv l
A U?CVl'Lj , ,C "3170/
(Ci/().) 43Lf -C}?,LfLf
The Name(s) of the person(s), other than the resident, who will e'iihanci'ally responsible
for the cost of care (the "guarantor"), if any. While a guarantor is not required for admission,
the facility does require that a source of payment be identified to pay for the Resident's
care.
Admission Desired On: -Asf14J
Reason for Seeking Admission:
I ,una ~Jf P '/:;(') evJJIQ ,~) ~
- {)".. ' D
Name
Address
Home Telephone
(Any person(s) whose names are listed here must also sign this application.)
H" . lru" .""'"'" be., .""",h"" V., ~ No
Has a power of attorney conferred on the person(s) to be financially responsible?
~; ;,+~;-* Ye~ .--t No If yes, please provide a copy. .
4
l.~*~~,~~~.:1,?~~~~~~~;~',~;;"",~" \(. . ,:.. . -, c," .... ',,'_'., ,,_' r ,', ..
~ ~~"V''''''~';''-;t;'rt'J'' \'.-' ,";Z',,'J' ., 2-:.~'/.\of"'" ".""'i~""<'R.<.lf..,\""",,,,,,,,,t'h,,___,,,,/ """!"',.- 'l"'",,,,. ,-..,
~ _ _ _ l ' ' ~' _ _ _ '_~r;.._j:;.';.:~:r:~ ,__;.i;:'<_:'~_,; :,' _ "~'l ':,~..;- ,,~,,;~.''1~-::<:~ .,~'.' :'~:;:~ . _," ~<~ ::~;;.: ':;_~'.,("-:'~T"/.i"":",:::~"t;."'r."",>;~:',~~,,_,;~,,, :~'"';;,,,~,"-.'<,\,y~\; ;'_, --;:L":,; ",;":"':..1
." -'''_."_i.,.''__'I~'~K.~,_ '~.~,__'._'.'_:-,-, ~__il_;{~__1;j~~~~~-
, C'-"iC:~' ,~;',':':f-',;,;_ _,:: :,'_ ,-,'
'J:
e
" " >:',-i:~:':'~'
To process your applicati()ri~th~jouowin9i~fol111ati6n is needed. The information supplied
is confidential and allows us to assist you in your long-term planning, The financial data
should be that of the Resident and/or the Guarantor. All income and amounts listed,
whether under the Resident or Guarantor section, must either be owned by the Resident or
in fact be available to the Resident to pay for the Resident's stay while at the facility. Your
cooperation is appreciated in order to expedite admission, Please note that it is not
mandated that a Resident have a Guarantor, only that an adequate source of payment be
identified. Thus, any person who agrees to be a Guarantor is doing so voluntarily.
MONTHLY INCOME RESIDENT GUARANTOR (if any)
Salary $ (j) $
-Social Security - ~.
11~,5D
Pensions/Annuities
IRA
e Interest/Dividend Income
Rental Income
Trust
Investments/Other
TOTAL MONTHLY INCOME $QI2=.SV $
ASSETS:
Cash (Itemize by bank/account #)
$2) () 00
$
Securities (Stocks/bonds) $
~;~:;;'~;L. . '~.(... $
~ ,;. '*~~~~~~t~$~~tl~!-" ."
_..'~~, ,"'; ,~,--.':".
~~;'-T:,.~_~:':;:
Please Sign Below:
i hereby warrant and represent that the information provided is accurate and complete. I
understand that the nursing facility will rely upon the accuracy and completeness of the
above financial information in making an admission decision. I also understand that if any
of the information is not accurate or not complete, the Facility will have detrimentally relied
upon the above financial information and will suffer financial loss and harm, The assets
listed are in fact available to the Resident to pay for the Resident's care.
"4~J1r~(1 t ~
,Aesidenti or Responsible Party's Signature Date
Guarantor's Signature
Date
Reviewed by: ,
<.-:UC\~/,;U, Nm ,',' O~)OI qlp , "~
,.' 'Admissions Direc~f(~ Signature ',' ',' , '. " Date .~"'!' ' ,,' JII
fL,;.';~,~~,'~;:t~::t~r;..::~0~'!\'''~~~~~~:;'':_)'~':'!~:~>-':,~:;~::~,~:!"~,:'r:. :'~~:'.""~",;r":':~,i~'&;'!~~!,li,;:,~\:'~~;~;'~ .t.>~;~.)".~!:",~ '~, l, <':, :.. .,..". :;1~~.~ti:,;
", """'Admlnlstrator's Signature . ,," ...,." ',"0> . . '~"";"""" '...., n.o'. "0 'Date -. ."~"...,.,,,,.,,.,~,,,,. ~ 'co'.<< '~..~1!Ii
..... '-:" ".. ........: .....-.....-.,_ .....-..: ....~.,_.,.' "':"'^", ......-..,.'.,., ..'_ _.._.:..... ..'-_"-~,,..c.,......',..':._.~ ... ,.~.:........'f~t~:,..',.
C' ,:.:...,.!ill,,~'.~li~i'~i:"'~~~<1.~, " .~ .~,...'/!ili'i"'d.~..~~,'.."..A~.;"':*~it...'iiO-..'1il~~~>iIlt_
.' . ' aiO~Il.~ti.~~"," . ",. . . " " . '" ~'.,', " ' t'f':\~-&;",~
'.-,', ,'" _.-. ......1'~,,~._....>_~"'__7;._.,." w._;~.~.:;~~~~:
EXHIBIT "e"
C., · "A DM'ISSION '...A ,G REEM EN,"Il...,. ,..,;..,',.'......,",..,.:1....:;:::;;:;;:\\)..,.,
" . . ..', r.."'''.'o.'''c:'':,:':'{'N''j;':'':<;:<;';>>:''.
CONTRACT BETWEEN PATIENT IRESIDENT AND.. FACILITY .
rTHIS ADMISSION AGRE~MENT (the "Agreement") is entered into this {)#7. day of""
Ik.l();f...!:d- , 19 (..j!"p ,between LEADER - CARLISLE (the "Facility"), and
./lmjJ;jo "'~()(Z (the "Patient/Resident"), and/or m/ ~ SDb04SR.
(the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible
Party, if any. The parties agree as follows;
1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident
to the Facility,
2. Termination of Agreement, Discharge and Transfer.
a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by
giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible
for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually
leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (j) before the attending
physician discharges the Patient/Resident, or (ij) against medical advice, the Patient/Resident and
Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and
hereby release the Facility, its employees and agents, from all liability connected with such departure.
b, Termination by Facility. The Facility may terminate this Agreement and discharge the Pat-
ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs
cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi-
duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the
Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the
services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be
transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or
discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents
a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not
resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The
Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right
to appeal a discharge decision with State authorities and the appeals process. If this Agreement is
terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees
to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate
the Patient/Resident's discharge,
3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party
appointment.
4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and
charges for supplemental services and supplies not paid by any third party as described in the Fee
Schedule, attached as Exhibit S, as well as applicable co-insurance and deductible amounts and all
expenses of discharge or transfer,
5. Release of Information, The Patient/Resident hereby authorizes all persons and/or entities to
release all or any part of his/her medical/health records to the Facility. The Patient/Resident also
authorizes the release of records or information to any health care institution to which the Patient/
Resident may be transferred, any provider involved in the care of the Patient/Resident, any third
party payor, including, but not limited to, government and private insurers, or any other person entitled
or authorized to receive such information by law or by the Patient/Resident.
MANOR HEALTIICARE
.....
MHC-Ooa.20 (Rev.4/96) pg 3
.'1A"ORC.-\RE'U'.o\.ll~R.^MEIllCA."A'IUl:RSEASU:-"~
ij,d:,-It"'r;.I';;;~'';0-;'ili~~;i'f.,f.''
.-I
1 of 3
"6, Refunds.' Refurids shall be paid within thirty (30) days after discharge or transfer.
'\
7, Funding Sources. The Facility makes no assurances that the Patient/Resident's care will be
covered by any third party payor.
8. Payment Policy. All amounts due shall be paid promptly within ten (10) days of billing. Failure
to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds
for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in
full shall be subject to a one and one-half percent (1'12%) service charge on the past due
balance each month until the balance due is paid in full. This amounts to eighteen percent
(18%) annually on the unpaid balance. If the maximum annual service charge allowed by state
law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall
apply. Should the Patient/Resident's account be turned over for collection to an attorney or
collection agency, or should the Facility seek to interpret or enforce any other provision of the
Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees
of the Facility if the Facility prevails.
9. Responsibilities. The Patient/Resident is responsible for, and shall pay, the daily rate and charges
for supplemental services/supplies not paid by any third part9, as well as applicable co-insurance
and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/
Resident is transferred to a different room or the level of care or payor status changes. The Patient/
Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or
Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility
is released from all liability for harm which may result.
Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is
established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident
enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for
all charges. The Patient/Resident is responsible for payment for items covered by Medicare supple-
mental insurance and for applying for reimbursement from his/her insurer.
Medicaid Beneficiaries: (circle correct number)
1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who
are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate
proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the
Facility with at least four (4) months prior written notice of the Patient/Resident's becoming eligible
Gior the Medicaid coverage or their being unable t~~ay privately;
2 The Facility currently participates in the Medicaid program. If the Patient/Resident believes
e/she qualifies for Medicaid, he/she shall promptly complete and submit all documents required
to apply for coverage, including pre-admission approval. If Medicaid coverage is denied, the Patient/
Resident will be liable for all charges from the admission date. When Medicaid pays for only a
portion of the incurred charges, the Patient/Resident shall be responsible for paying his/her portion,
as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the
Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay-
ment of Facility's cUrrent charges for any requested non-Medicaid covered services/supplies. The
Patient/Resident will provide financial information regarding monthly credits, increases/decreases in
the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaid
, representatives.
~
Conditions (collectively referred to as "Conditions")
1. The assets of the Patient/Resident will be utilized to pay, when due, all .costs jncurred by
the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth
in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of
personal clothing and care supplies as needed or desired by the Patient/Resident and as
required by the Facility,
2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other
property of the facility, other Patient/Residents or employees of the facility damaged by the
Patient/Resident.
3. All of the information, including but not limited to that contained on the attached Application
for Residency, dated , 199 ,and which is attached hereto and
made part of this Exhibit and of the Admission Agreement, is true and accurate as of this
date and all assets listed in the application are in fact available to the Patient/Resident for
the Patient/Resident's care while at the facility,
4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other-
wise transfer the Patient/Resident's assets and/or assets which are available for the Pat-
ient/ Resident's care so as to prevent such assets from being used to pay for the care of
the Patient/Resident while at the facility.
5. When the assets available to pay for the Patient/Resident's care at the Facility are not
sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident
will $0 notify the Facility and will file, on behalf of the Patient/Resident, all applications and
other documents necessary or advisable to qualify him/her for all third party payor programs
for which he/she may be eligible, including Medicaid.
6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/
Resident will provide financial information regarding monthly credits, increases and decreases
in the Patient/Resident's bank account(s) and other assets to the Facility to enable the
Facility to provide requested data to Medicaid representatives.
7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident
will be utilized to pay extra charges not covered by the third party payor in a timely manner,
and to notify the administrator of the Facility of any problem anticipated in paying such charges.
The undersigned understands and acknowledges that the Facility is relying upon the above Conditions
in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above
warranties and representations are not true, or if the above covenants and agreements are not
complied with, the Facility will have detrimentally relied upon them and the Facility will suffer financial
harm and loss, RlL1Yl~~t~2J;b
m I ~J 3o}-yrt-C)Q
Responsible Party - Printed Name
D21~10L ql IC]qLP
.....
MHc.ooe.20 (Rev. 4/96) pg 7
~
2 of 2
r
. Federal Resident Rights
. Resident Responsibilities
. Life Sustaining Treatment Policy
. Medical/Nursing Education
. Dental, Vision and Hearing Services
. Interdisciplinary Care Conference
. Utilization Review Meetings (if applicable)
. Personal Laundry Policy
"'\
. Barber jBeauty Services
. Mail Policy
. Voting Materials
. Photo/Media Events
. Personal Fund Account Procedure
. Tobacco Policy
. Grievance Procedures
. State Resident Rights (if applicable)
14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED iN
ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS
LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW
SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH
ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH
AMENDMENTS SHALL BE A PART OF THIS AGREEMENT.
15. Miscellaneous, The provisions of this Agreement shall bind the parties, their respective executors,
administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default
of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions
of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the
entire agreement and any changes shall be in writing and signed by both parties.
IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day
and year above written.
(I/y9(cy' !jStr!, sstL
Facility Representative - Signature
~ lillr~ 1'Y1 iJ~ ~~).!) t\.
Facility Representative -fjPrinted Name & Title
~I j(VJ& q. ,qq( 0
Date ~O'
4n1!!a~f! ~
'1Y)1 ~1 2ol')[)-l()"R
Responsible Party - Printed Name
-Clilfi/lbL q I /q Cj( .Q
Date '0'
.
(EXHIBit A":' RESpoNsIBLE PARTVApPOINTMENT)
. .
rThe PatientiResident's Responsible Party may be any person legally responsible for the Patient/'"
Resident. A competent Patient/Resident shall not be required to designate a Responsible Party.
Please check one of the four following, whichever is most appropriate.
D
The undersigned has been legally appointed guardian, conservator and/or holder of a power
of attorney to act on the behalf of the Patient/Resident and shall serve as Responsible Party
for the Patient/Resident. The undersigned has delivered to the Facility copies of the legal
documents designating him/her as the guardian, conservator and/or holder of a power of
attorney of the Patient/Resident. In consideration of the Facility's agreement to admit the
Patient/Resident to the Facility, the undersigned, individually and personally, hereby warrants,
represents, covenants and agrees to the Conditions (as herein atter set forth and defined).
~
The Patient/Resident does not have a legally appointed representative(an9 wi~hes to give
the responsibility to someone else. I hereby appoint trl f 1'17 [) f'/ U () b 0 f-t; r
as my representative (the "Responsible Party") and hereby authorize him/her to handle my
finances, pay my expenses, receive my personal funds and, if I am unable, to execute the
Admission Agreement on my behalf. Any signature of Patient/Resident or Responsible Party
on the Admission Agreement and/or this or any other exhibit or document attached thereto
or referenced therein shall be considered binding on both the Patient/Resident and the
Responsible Party. The undersigned hereby agrees to the Conditions (as herein after set forth
and defined),
Facility f3epresentative - Signature
C/fJ I ~- l:"x1U ",iJ.h-~.
Facility Representative tJPrinted Name & Title
-PIJ.(\{ ulf., q I lQqLo
Date ~O'
Patient/Resident - Signature
+:l~.ilCl SJtLWR.
Patient/Resident - Printed Name
-OIl(\{ 1J-2f~ Q J /qqLp
Date 'Zj'
D The Patient/Resident is competent and does not have a court-appointed guardian, conser-
vator or power of attorney and has not appointed a Responsible Party, but alone shall execute
the Agreement. In consideration of his/her admission to the Facility, the undersigned hereby
agrees, warrants and represents to the Conditions (as herein after set forth and defined).
D The Patient/Resident is mentally or physically incapable of executing this Agreement, handling
his/her own affairs or appointing a Responsible Party and does not have a guardian, conser-
vator or durable power of attorney. The Patient/Resident's physician will certify in writing
that the Patient/Resident is incapable of executing the Agreement and that placement in the
Facility is appropriate, The undersigned voluntarily agrees, on behalf of the Patient/Resident,
to act and serve as ResponSible Party for the Patient/Resident. In consideration of the Facility's
agreement to admit the Patient/Resident to the Facility, the undersigned individually hereby
warrants, represents, covenants and agrees to the Conditions (as herein after set forth and
defined).
~ ~
MHC-OOS-20 (Rev. 4/96) pg 6
1 of 2
(" .. ,..' , .. ')
'EXti'~ITB-I:EE SCHEDULE
r1, Daily Rate. The daily rate is $-1-1 () . 00. The monthly rate equals the daily rate multiplied by the....
number of days in the month. The daily rate is billed one month in advance and includes:
. Routine Nursing Care · Linens · Social Services
. Meals (additional fees may appl · ctivities · Housekeeping
. Room (circle one): Private Semi-Private Triple
The following are paid by Medicare in addition to the items included in the daily rate:
. Approved Rehabilitative/Therapy Services · Approved Medications
. Approved Nursing Supplies · Approved Equipment
The following are paid by Medicaid in addition to the items included in the daily rate (to the extent
covered and paid for by the state program):
· Approved Rehabilitative/Therapy Services
· Approved Nursing Supplies
· Approved Routine Personal Hygiene Items/Services
. Other approved services/items covered and paid for under the state Medicaid program.
. Approved Medications
· Approved Equipment
2. Supplemental Services & Supplies. The daily rate may not include the following items, which
will be provided at request of Patient/Resident and/or by physician order at the rate set forth in
the attached facility rate sheet and will be the responsibility of the Patient/Resident.
ITEM
RATE
· Private Room Based on location & level of care
· Prescription & Non-Prescription Drugs As determined by pharmacy
. Nursing & Personal Care Supplies See business office for current prices
· Transportation As determined by transport company
· Nursing Care (Other than ordinary nursing care) See attached fee list
· Physical, Occupational & Speech Therapies See attached fee list
· Phone, Cable TV, Newspaper, Barber/Beauty See attached fee list
· Special Equipment See attached fee list
· Bed Hold Fees See attached fee list
· Personal Laundry (Personal Clothing) See attached fee list
· Nutritional Supplements See attached fee list
· Alternative Nutrition (Tube Feeding, TPN, etc.) See attached fee list
3. Bed Hold Fee, The Facility charges a daily fee for reserving a bed whenever a Patient/Resident
leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law.
4, Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies
which may be needed by and provided to the Patient/Resident, all additional costs/charges may
not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect
associated charges and he/she agrees to pay them in accordance with the Agreement.
5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior
written notice, or, in case of emergency or change in level of care, with such prior notice as is
reasonably possible, Adjustments shall be deemed agreed to by the Patient/Resident unless the
Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the
Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the
~acility no later than the day before the rate increase is effective. J
........."...... .... Ir::o_.. .. Inr:>' ~_ 0
~ _ r ....,.
,
eI!'WflBf"'%'~~~'ffA~MACY'AGREEfIIIENT)
r The Facilito/ has €Jeveloped policies and procedures for drug therapy, distribution and control which'"
provide for a uniform medication distribution system. The Facility has selected a pharmacy (the
"Designated Pharmacy") to provide medication under such distribution system. The Facility reserves
the right to change the Designated Pharmacy at any time.
The Patient/Resident is hereby notified that the Facility's parent corporation (i.e., Manor HealthCare
Corp. or one of its affiliates) has a significant financial interest in Vitalink Pharmacy Services, Inc.,
which operates under the following names: Vitalink, Northern Nursing Home Pharmacy, West End
Family Pharmacy, Pro pac Pharmacy, Apothecary Pharmacy Services, Parker's Pharmacy, Home
Intravenous Care and Brentview Pharmacy, The Facility may have selected one of these entities as
the Designated Pharmacy.
The Patient/Resident has the right to use any pharmacy so long as that pharmacy will furnish the
same medication distribution system noted above, and comply with the Facility policies and pro-
cedures and all applicable laws and regulations. For Medicaid Patient/Residents, the Designated
Pharmacy will file claims for payment directly with the Medicaid Program for any covered claims. If
the Patient/Resident utilizes a different pharmacy, the Patient/Resident must make arrangements
with such pharmacy for similar filing of claims for payment.
All charges shall be billed to the Patient/Resident or the Patient/Resident's third party payor directly
and shall be payable in full. The Designated Pharmacy reserves the right to terminate any account
fOJY reason after written notice of such intent has been given to the Patient/Resident.
The undersigned selects the Designated Pharmacy (as may be changed by the Facility
from time to time) as the supplier of medications prescribed for the Patient/Resident while
at the Facility.
The undersigned selects as the
supplier of medications prescribed for the Patient/Resident while at the Facility. The
undersigned understands and agrees that such pharmacy must comply in all respects with
the Facility's uniform medication distribution system, all Facility policies and procedures
and applicable law. If such pharmacy fails to do so, the undersigned shall be required to
select another pharmacy. The above pharmacy shall acknowledge and agree in writing
that it will comply with the Facility's uniform medication distribution system, the Facility's
policies and procedures and applicable law.
+-" YY\ Alt.; P S~
Responsible Party - Signature
mk 5'1f:i*-cJQ
Responsible Party - Printed Name
nuflltrJ. 0 I )qCU p
Date()
......
J
MHC-OOS-20 (Rev. 4/96) pg 10
1 of 1
C '. EXHI811" O:":"STATE'LAWA,bbENOUM )
r ~
The Admission Agreement is amended in the following manner, in order to comply with state law
and/or regulation:
(Indicate additions to, and/or deletions from, the Admission Agreement required by state law. If no
additions/deletions are necessary, indicate "NONE".)
11 NONE II
I....
~
MHc-ooe.20 (Rev. 4/96) pg 11
1 of 1
EXHIBIT "0"
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/200
10/31/96 TV CABLE $5.00
11/30/96 TV CABLE $5.00
11/30/96 INTEREST UNPAID 1.50% ON 5.00 $0.08
12/18/96 PAYMENT-THANKYOU ($5.00;
12/18/96 PAYMENT-THANKYOU ($5.00J
12/31/1996 RESIDENT PORTION $784.45
1/1-1/31/97 RESIDENT PORTION $806.45
01/21/97 PAYMENT - THANK YOU ($220.00)
02/28/97 TV CABLE $5.00
2/1-2/28/97 RESIDENT PORTION $806.45
02/28/97 INTEREST UNPAID 1.50% ON 1326.98 $19.90
03/04/97 PAYMENT-THANKYOU ($784.53)
03/04/97 PAYMENT - THANK YOU ($564.45)
03/04/97 PAYMENT-THANKYOU ($784.45)
03/12/97 PAYMENT-THANKYOU ($5.00)
03/12/97 PAYMENT-THANKYOU ($806.45)
03/14/97 PAYMENT - THANK YOU ($5,00)
3/1-3/31/97 RESIDENT PORTION $804.35
$56.80
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) - 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR.
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/01
03/31/1997 BEGINNING BALANCE $56.80
03/31/97 TV CABLE $5.00
03/31/97 REVERSE INTEREST 2/28/97 ($19.90)
04/1/97 TRANSFER MISAPPLIED PAYMENT ($100.00)
04/1 0/97 PAYMENT - THANK YOU ($811.45)
4/1-4/30/97 RESIDENT PORTION $804.35
05/12/97 PAYMENT - THANK YOU ($701,53)
05/31/97 TV CABLE $5.00
5/1-5/31/97 RESIDENT PORTION $804.35
06/1 0/97 PAYMENT-THANKYOU ($4.92)
06/1 0/97 PAYMENT-THANKYOU ($806.53)
06130/97 TV CABLE $5.00
6/1-6/30/97 RESIDENT PORTION $804.35
07/30/97 PAYMENT - THANK YOU ($4.92)
07/30/97 PAYMENT - THANK YOU ($806.53)
07/31/97 TV CABLE $5.00
7/1-7/31/97 RESIDENT PORTION $804.35
08/13/97 PAYMENT - THANK YOU ($601.45)
06/30/97 MISAPPLIED PAYMENT ($210.00)
($773.03)
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) . 249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/200
08/31/97 ADJ BEGINNING BALANCE ($773.03
08/31197 TV CABLE $5.00
08/31/97 RESIDENT PORTION $804.35
09/16/97 PAYMENT. THANK YOU ($4.92
09/16/97 PAYMENT-THANKYOU ($806.45:
09/16/97 PAYMENT-THANKYOU ($0.08:
09/30/97 TV CABLE $5.00
9/1-9/30/97 RESIDENT PORTION $804.35
10/31/97 TV CABLE $5.00
10/1-10/31/97 RESIDENT PORTION $804.35
11/07/97 PAYMENT. THANK YOU ($5.00)
11/07/97 PAYMENT-THANKYOU ($806.45)
11/30/97 TV CABLE $5.00
11/1-11/30/97 RESIDENT PORTION $804.35
12/19/97 PAYMENT. THANK YOU ($4.92)
12/19/97 PAYMENT-THANKYOU ($811.53)
12/19/97 PAYMENT-THANKYOU ($806.45)
12/31/97 TV CABLE $5.00
12/31/97 RESIDENT PORTION $804.35
$27,92
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/1 % 1
04/30/01
12/31/97 ADJ BEGINNING BALANCE $27.92
01/12/98 PAYMENT-THANKYOU ($4.9,
01/12/98 PAYMENT-THANKYOU ($806.5<
01/06/98 BEAUTY CHARGES $32.00
1/1-1/31/98 RESIDENT PORTION $914.50
01/31/1998 INTEREST 0.08
02/09/98 PAYMENT-THANKYOU ($32.00
02/09/98 PAYMENT-THANKYOU ($806.53
02/28/98 TV CABLE $5,00
2/1-2/28/98 RESIDENT PORTION $914.50
03/12/98 PAYMENT-THANKYOU ($4.92
03/12/98 PAYMENT-THANKYOU ($806.53
03/31/98 TV CABLE $5.00
3/1-3/31/98 RESIDENT PORTION $914.50
04/30/98 TV CABLE $5.00
4/1-4/30/98 RESIDENT PORTION $914.50
05/15/98 PAYMENT-THANKYOU ($4.92)
05/15/98 PAYMENT-THANKYOU ($806.61)
05/31/98 TV CABLE $5.00
$465.04
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
FOR AMELIA SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/201
5/3198 ADJ BEGINNING BALANCE $465.04
5/1-5/31/98 RESIDENT PORTION $914.50
05/31/1998 INTEREST $0.07
06/29/98 PAYMENT-THANKYOU ($4.9:
06/29/98 PAYMENT-THANKYOU ($806.6
06/30/98 TV CABLE $5.00
6/1-6/30/98 RESIDENT PORTION $914.50
07/31/98 TV CABLE $5.00
7/1-7/31/98 RESIDENT PORTION $914.50
07/31/1998 INTEREST $12.25
08/17/98 PAYMENT-THANKYOU ($4.91
08/17/98 PAYMENT-THANKYOU ($811.41
08/17/98 PAYMENT-THANKYOU ($183.6~
08/31/98 TV CABLE $5.00
8/1-8/31/98 RESIDENT PORTION $914.50
08/31/1998 INTEREST $9.60
09/18/98 PAYMENT-THANKYOU ($640.06
09/18/98 PAYMENT-THANKYOU ($171.47
09/30/98 TV CABLE $5.00
9/1-9/30/98 RESIDENT PORTION $914.50
09/30/98 INTEREST $9.74
$2,466.14
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
09/30/98 ADJ BEGINNING BALANCE $2,466.14
1 0/27/98 PAYMENT-THANKYOU ($611.5
10/31/98 TV CABLE $5.00
1 0/29/98 BEAUTY CHARGES $32.00
10/1-10/31/98 RESIDENT PORTION $914.50
10/31/1998 INTEREST $12.89
11/30/98 TV CABLE $5.00
11/1-11/30/98 RESIDENT PORTION $914.50
11/30/1998 INTEREST $25.73
12/08/98 PAYMENT-THANKYOU ($38.0
12/08/98 PAYMENT-THANKYOU ($511.9
12/31/98 TV CABLE $5.00
12/1-12/31/98 RESIDENT PORTION $914.50
12/31/1998 INTEREST 30.04
01/07/99 PAYMENT-THANKYOU ($309.2,
01/07/99 PAYMENT-THANKYOU ($590.71
01/31/99 TV CABLE $5.00
01/01-01/31/99 RESIDENT PORTION $933.76
01/31/99 INTEREST $29.16
$4,231.6!
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125 - A
SOBOTOR, AMELIA
96129
09/03/96
05/1 0/01
04/30/01
01/31/99 ADJ BEGINNING BALANCE $4,231.69
02/24/99 PAYMENT-THANKYOU ($265.5
02124/99 PAYMENT-THANKYOU ($554.4
02/28/99 TV CABLE $5.00
02/01-02/28/99 RESIDENT PORTION $933.76
02/28/99 INTEREST $27.56
03/31/99 PAYMENT-THANKYOU ($282.7'
03/31/99 PAYMENT-THANKYOU ($547.2,
03/31/99 TV CABLE $5.00
03/01-03/31/99 RESIDENT PORTION $933.76
03/31/99 INTEREST $33.43
04/30/99 TV CABLE $5.00
04/13/99 BEAUTY CHARGES $32.00
04/01-04/30/99 RESIDENT PORTION $933.76
04/30/99 INTEREST $48.01
05/31/99 TV CABLE $5.00
05/01-05/31/99 RESIDENT PORTION $933.76
05/31/99 INTEREST $63.29
$6,541.0:
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM125-A
SOBOTOR. AMELIA
96129
09/03f96
05/10/01
04/30/01
05/31/99 ADJ BEGINNING BALANCE $6,541.02
06/02/99 PAYMENT-THANKYOU ($294.2,
06/02/99 PAYMENT-THANKYOU ($755.7:
06/21/99 PAYMENT-THANKYOU ($880.01
06/30/99 TV CABLE $5.00
06/01-06/30/99 RESIDENT PORTION $933.76
07/31/99 TV CABLE $5.00
07/01-07/31/99 RESIDENT PORTION $933.76
08/09/99 PAYMENT-THANKYOU ($966.3:
08/09/99 PAYMENT-THANKYOU ($433.61
08/31/99 TV CABLE $5.00
08/01-08/31/99 RESIDENT PORTION $933.76
09/20/99 PAYMENT - THANK YOU ($889.4!
09/20/99 PAYMENT-THANKYOU ($10.51
09/30/99 TV CABLE $5.00
09/30/99 BEAUTY CHARGES $32.00
09/01-09/30/99 RESIDENT PORTION $933.76
$6,098,Oe
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
MEDICAID
PRIVATE
ROOM 125-A
SOBOTOR, AMELIA
96129
09/03/96
05/10/01
04/30/01
09/30/99 ADJ BEGINNING BALANCE $6,098.06
10/31/99 TV CABLE $5.00
10/01-10/31/99 RESIDENT PORTION $933.76
11/30/99 TV CABLE $5.00
11/01-11/30/99 RESIDENT PORTION $933.76
12/31/99 TV CABLE $5.00
12/01-12/31/99 RESIDENT PORTION $933.76
01/06/00 PAYMENT-THANKYOU ($1,930.21
01/06/00 PAYMENT-THANKYOU ($269.7'
01/31/00 TV CABLE $5.00
01/01-01/31/00 RESIDENT PORTION $1,000.35
01/31/00 MCB PREMIUM ($45.5C
02/29/00 TV CABLE $5.00
02/01-02/29/00 RESIDENT PORTION $1,000.35
02/29/00 MCB PREMIUM ($45.5C
03/03/00 PAYMENT-THANKYOU ($750.0C
03/31/00 TV CABLE $5.00
03/01-03/31/00 RESIDENT PORTION $1,000.35
$8,889.39
MANORCARE HELATH SERVICES 372
940 WALNUT BOTTOM RD
CARLISLE, PA 17013
(717) -249-0085
MIKE SOBOTOR
19 HOLLY ESTATE DR
GARDNERS, PA 17324
SOBOTOR, AMELIA
96129
09/03/96
MEDICAID
PRIVATE
ROOM 125-A
0511 0/01
04/30/01
03/31/00 ADJ BEGINNING BALANCE $8,889.39
03/31/00 MCB PREMIUM ($45.51
04117/00 PAYMENT-THANKYOU ($1,450.0(
04/30/00 TV CABLE $5.00
04/01-04/30/00 RESIDENT PORTION $1,000.35
04/30/00 MCB PREMIUM ($45.5C
04/30/00 BEAUTY CHARGES $36.00
05/31/00 TV CABLE $5.00
05/11/00 BEAUTY CHARGES $9.00
05/25/00 BEAUTY CHARGES $9.00
05/01-05/31/00 RESIDENT PORTION $1,000.35
05/31/00 MCB PREMIUM ($45.50
06/30/00 TV CABLE $5.00
06/01-06/30/00 RESIDENT PORTION $1,000.35
06/30/00 MCB PREMIUM ($45.50
07/03/00 PAYMENT-THANKYOU ($1,300,00
07/31/00 TV CABLE $5.00
07/01-07/31/00 RESIDENT PORTION $1,000.35
$10,032.79
"
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
CERTIFICATE OF SERVICE
AND NOW, this 16th day of September, 2002, I, Daniel F. Wolfson, Esquire, do
hereby certify that I have served a copy of the foregoing Second Amended Complaint
upon the counsel of record by regular mail, postage pre-paid and addressed as follows:
Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
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- I5aniel F. Wolfson, Esquire
WOLFSON & ASSOCIA
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 2061 7
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
vs.
NO. 01-4092 Civil Term
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
PRAECIPE FOR JUDGMENT
Enter Judgment in favor of Plaintiff and against Defendant, Michael Sobotor, for want of
ANSWER TO 2"d AMENDED COMPLAINT.
(X) Amount due
Attorney's Commission
TOTAL
$10,032.79
$ 3,009.84
$13,042.63, plus interest and court costs
(X) I certify that the foregoing assessment of damages is for specified amounts alleged
to be due in the complaint and is calculable as a sum certain from the complaint.
(X) Pursuant to Pa.R.C.P. 237 (Notice of Praecipe for final judgment or decree), I
certify that a copy of this praecipe has been mailed to each other party who has appeared in the
action or to hislher Attorney of Record.
(X) Pursuant to Pa.R. C.P. 237.1, I certify that written notice of the intention to file
this praecipe was mailed or delivered to the party against whom judgment is to be entered and to
his/her Attorney of Record, if any, after the default occurred and at least ten days prior to the date
of the filing of this praecipe and a copy of the notice ~tached. .
DATE: Signature: It- t 0l{M..if
Amy Wolfson, Esquire
ID#: 062
Atto ey for Plaintiff
267 East Market Street
York, PA 17403
(717) 846-1252
, 20~, JUDGMENT IS ENTERED AS ABOVE.
LL,~~. k.~~
Prothonotary/Clerk, Civil ~sion
--.Iiy: An-..,.e.~
Deputy
NOW, {).pi\ 1. P
ATIORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
Caprice Hicks Bunting
James K. Reed*
Gordon A. LynO.:"
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
BRANCH OFFICE:
267 East Market Street
York, Pennsylvania 17403
8 Manchester Street
Glen Rock, PA 17327
(717) 235-5014
PARALEGALS
Margaret L. Burg
Michele M, McHugh
(717) 846-1252
(800) 321-8467
FAX (717) 848-1146
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFICE
.Ucensed in Pennsylvania & Maryland
^ licensed in MaIyland Only
e-mail: dfwolfson@debtcollection.net
4 December 2002
MICHAEL SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
,<.;::: i1CZ ,vlancf Care \i5 dicnael Sobotor
Docket No. 01-4092
Dear Mr. Sobotor:
We enclose a 1 O-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civil
Procedure.
Sincerely,
WOL!i.SON & ASSOCIATES, P.c.
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Amy F. W61fson, EsJl!fUire
AFW\lwe
Enclosure
cc: HCR Manor Care - Carlisie (w/enc.)
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYL VANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
TO: MICHAEL SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
DATE OF NOTICE: December 4, 2002
IMPORTANT NOTICE
iGU ,-dZE iN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE
A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE
TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
..
Court Administrator
Cumberland County Court House
I Court House Square, 4'" Floor
Cariisle, Pennsylvania 1 701 :3
(7]7) 240-6200 ~
BY: ~.,
Amy F. Wol n, EsqUi~
WOLFSON & ASSOCIATES, p,c.
267 East Market Street
York, Pennsylvania 17403-2000
Telephone: (717) 846-1252
I.D. # 87062
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
AFFIDAVIT OF NON-MILITARY SERVICE
COMMONWEAL TH OF PENNSYL VANIA
COUNTY OF YORK
I, Amy F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my
knowledge, information and belief Defendant, Michael Sobotor, above named, is over 21 years
of age; is last know to reside at 19 Holly Estate Drive, Gardners, Adams County, Pennsylvania;
is not in the military service ofthe United States or its Allies, or otherwise within the provisions
of the Soldiers' and Sailors' Civil Relief Act of Congress of 1940 and its Amendments.
&~,
Attorney for the Plainti
Attorney ID# 87062
Wolfson & Associates, P.c.
267 East Market Street
York,PA 17403
~
SWORN and SUBSCRIBED
to before me this /o't day
of /fl..{-/ ,20 oJ .
, II)
cp~f",/
NotaItaI Seal
Melissa Dee sweeney, Notary PubliC
Qty Of YOlk, York County
My CommissIon ExpIres September 12, 2006
Member, Pennsyll/ania Association ex Nolaries
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
( x ) Notice is hereby given that a DEF AUL T JUDGMENT in the above-captioned
matter has been entered against you in the amount of $10,032.79, plus interest,
reasonable attorney's fees and costs, on {:)..1~I2-,i l. p , 2n.~
( x ) A copy of all documents filed with the Prothonotary in support of the within
judgment is/are enclosed.
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Prothonotary Civil Division ~
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If you have any questions regarding this Notice, please contact the filing party.
Amy F. Wolfson, Esquire, Esquire
267 East Market Street
York, PA 17403
(717) 846-1252
(This Notice is given in accordance with Pa.R.C.P. 236.)
NOTICE SENT TO: MICHAEL SOBOTOR
19 HOLL Y ESTATE DRIVE
GARDNERS, PA 17324
"
I
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01-4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
AFFIDAVIT OF SERVICE
Commonwealth of Pennsylvania
ss.
County of York
AND NOW, TO WIT, this 3rd day of April, 2003, comes Amy F. Wolfson,
Esquire, who being duly sworn according to law, deposes and says that she is the Attorney
for the Plaintiff in:fe above-captioned action; that on September 16, 2003, she caused a
k ~~o~~omplaint in the above-captioned action to be sent by regular mail,
postage pre-paid, to the counsel of record, Douglas G. Miller, Esquire, at IRWIN,
McKNIGHT & HUGHES, West Pomfret Professional Building, 60 West Pomfret Street
Carlisle, PA 17013-3222.
SWORN and SUBSCRIBED to
before me this j)-r[ day
of HfHL , Jo03
~/L M /;
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NotaI1aI SBaI public
Melissa Dee~' No18lY
CllyOfVOIl<, V= 12. 2006
My c;onmsaIon E>qJr89 , ()I.Nda1'oes
, Membor,_~'....".;ation
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HCR MANOR CARE,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 2001 - 4092 CIVIL TERM
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
CIVIL ACTION - LAW
Defendants.
DEFENDANTS' PETITION TO STRIKE OFF / OPEN
DEFAULT JUDGMENT
AND NOW this 21sT day of April, 2003, comes Defendants, MICHAEL SOBOTOR,
Individually and on Behalf of AMELIA B. SOBOTOR, Deceased, by and through their
attorneys, Irwin, McKnight & Hughes, and respectfully petition this Court to strike off or open
the default judgment entered against Defendants on or about April 8, 2003, and in support
thereof aver as follows:
1. Plaintiff commenced this action against Defendants on or about July 2, 2001 by
Complaint that in summary alleges failure to pay for expenses by Plaintiff made on behalf of
Amelia Sobotor prior to her decease.
2. On or about September 4, 2001, Defendants, by and through the undersigned
counsel, timely filed Preliminary Objections to the original Complaint raising several defenses,
including lack of capacity to sue.
3. On or about September 27, 2001, Plaintiff filed an Amended
Complaint in response to the Preliminary Objections of Defendants.
4. Subsequently, several telephone conversations and correspondence took place
between legal counsel for the respective parties, regarding among other issues, the lack of factual
support in Plaintiff's complaints for a judgment against Mr. Sobotor individually.
5. Rather than file additional Preliminary Objections to the Amended Complaint,
legal counsel for the parties agreed to extend the time in which to file a response.
6. Ultimately, Plaintiff filed a Second Amended Complaint on or about September
16, 2002, attaching additional documents purportedly in support of its allegations, as well as a
Petition to Amend Caption to reflect the decease of Amelia Sobotor.
7. Additional telephone conversations and correspondence continued to take place
between legal counsel for the respective parties in order to review and discuss the additional
documents attached by Plaintiff to its Second Amended Complaint.
8. Additional extensions of time were granted by Plaintiff's legal counsel for these
purposes.
9. On or about November 5, 2002, Plaintiff sent a ten (10) day notice to legal
counsel for Defendants addressed "MICHAEL SOBOTOR; c/o Douglas G. Miller, Esquire." A
true and correct copy of said notice is attached hereto and incorporated herein as Exhibit "A."
10. However, said notice attached as Exhibit "A" was not sent to the Defendants
individually in accordance with Pa. R. Civ. P. No. 237. 1 (a)(2)(ii).
11. Apparently, on or about December 4, 2002, Plaintiff sent a subsequent ten (10)
day notice only to Defendants individually. A copy of said notice as attached to Plaintiffs
Praecipe for Judgment is attached hereto and incorporated herein as Exhibit "B."
12. Plaintiff did not send the notice attached as Exhibit "B" to Defendants' legal
counsel of record in accordance with Pa. R. Civ. P. No. 237.1 (a)(2)(ii).
13. Between December 16, 2002 and January 16, 2003, several correspondence was
exchanged between legal counsel for the parties. These letters are collectively attached hereto
and incorporated herein as Exhibit "Co"
14. The understanding of Defendants and their legal counsel was that an initial
extension to December 20, 2002, was by the subsequent correspondence and telephone
conversations extended indefinitely to obtain additional documentation.
15. Plaintiffs letters attached as Exhibit "C" fail to specify the time within which the
required action must be taken, and fail to sufficiently communicate the intention to take a default
judgment upon the failure to plead,
16. Based on the above, it clearly appears from the record that Plaintiffs Praecipe for
Judgment was not entered in conformity with the requirements ofPa. R. Civ. P. No. 237.1.
17. Accordingly, the default judgment against Defendants was entered improperly
and must be stricken from the record.
18. The failure of Defendants to otherwise take additional steps to protect their
interests was due to the failure of Plaintiff to properly communicate its intention to take a default
judgment upon the failure to plead.
19. As the Cumberland County Courthouse was closed on Friday, April 18, 2003, this
Petition is being filed within ten (10) days of the entry of default judgment on April 8, 2003.
20. Defendant possesses a meritorious defense to Plaintiffs Second Amended
Complaint and the default judgment should therefore be opened.
WHEREFORE, Defendants, MICHAEL SOBOTOR, Individually and on Behalf of
AMELIA B. SOBOTOR, Deceased, respectfully request that this Honorable Court strike off
and/or open the default judgment entered of record in the above captioned matter and allow
Defendants to pursue their defense of this action, and that any and all execution proceedings
upon the contested judgment be stayed pending resolution of the Petition to Strike Off J Open
Judgment pending such determination.
Respectfully Submitted,
IRWIN, McKNIGHT & HUGHES
Dated: April 21, 2003
~~
By: _ 'W ~
Dou as . Mi squire
Supreme ourt ill # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Attorney for Defendants
EXHIBIT "A"
-..-..--..... -~...._'----~-_._..
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 01.4092 Civil Term
vs.
CIVIL ACTION. LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of Amelia B. Sobotor, Deceased,
Defendant
TO: MICHAEL SOBOTOR
c/o Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
CarlislePA 17013-3222
DATE OF NOTICE: November 5', 2002
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU FAilED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A lAWYER AT ONCE. IF YOU DO NOT HAVE
A lAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOllOWING OFFICE
TO FIND OUT WHERE YOU CAN GET lEGAL HELP.
Court Administrator
Cumberland County Court House
1 Court House Square, 4'" Floor
Carlisle, Pennsylvania 1701 J
(717) 240-6200 ~' .
BY: /~U'tleA
Amy. . W son, Esquire
WOLFSO & ASSOCI ES, P.c.
267 East Market Street
York, Pennsylvania 17403-2000
Telephone: (717) 846-1252
1.0.1/87062
Attorney for Plaintiff
EXHIBIT "B"
__"m~."_~._,~_.,,_...,.
ATIORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
Caprice Hicks Bunling
James K. Reed'
Gordon A. LynlJ.:"
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
267 East Market Street
York, Pennsylvania 17403
PARALEGALS
Margaret 1. Burg
Michele M. McHugh
(717)846-1252
(800) 32 I -8467
FAX (717) 848-1 146
.Ucensed in Pennsylvania & Maryland
" lIcerlsed in Maryland Only
e-mail: dfwolfson@debtcollection.net
4 December 2002
MICHAEL SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
;(E: ;-:c:< ivj",ncr Care V$ dicllael Sobotor
Docket No. 01-4092
Dear Mr. Sobotor:
BRANCH OFFICE:
8 Manchester Street
Glen Rock, PA 17327
(717) 235-5014
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFiCE
We enclose a 1 O-Day Notice pursuant to RuJe237.1 of the Pennsylvania Rules of Civil
Procedure.
Sincerely,
WOL&50N & ASSOClA TES, P.c.
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Amy F. w'l;fson, ~~re
AFW\lwe
Enclosure
cc: HCR Manor Care - Carlisle (w/enc.)
'.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
.' Plaintiff
NO. 01.4092 Civil Term
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually,
and on Behalf of AmeUa B. Sobotor, Deceased,
Defendant
TO: MICHAEL SOBOrOR
1 9 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
DATE OF NOTICE: December 4, 2002
IMPORTANT NOTICE
,ell ,<~,; iN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (1 0) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE
A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE
TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
~
Court Administrator
Cumberland Couney Court House
I Coure House Square, 4'" Floor
CJriisle, Pennsylvania I 70 J 3
(717) 240-6200 /I , ,
BY: A//Jtc/ftocfi/ - ,
Amy F. Wo/flbn, EsqUi?dPT\.
WOLFSON & ASSOClA TES, P.c.
267 East Market Street
York, Pennsylvania 17403-2000
Telephone: (717) 846-1252
I.D. # 87062
Attorney for Plaintiff
"
EXHIBIT "e"
ATTORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
Caprice Hicks Bunting
James K. Reed*"
Gordon A Lynn ^
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
BRANCH OFFICE:
267 East Market Street
York, Pennsylvania 17403
8 Manchester Street
Glen Rock, PA 17327
(717) 235-5014
PARALEGALS
Margaret L. Burg
lIichele M. McHugh
(717) 846-1252
(800) 321-8467
FAX (717) 848-1146
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFICE
'LiclllSed in Pellnsylvania & Maryland
'" licenserl in Malyland Only
e-mail: dfwolfson@debtcollection.net
26 December 2002
Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
1P)~~ltUW If','~jl
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DEe 3 1 2002
RE: HCR Manor Care vs. Amelia and Michael Sobotor
Cumberland County Docket No. 01-4092 Civil Term
IRWIN M KI!'('I'T ,-, 'I""H[C
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Dear Attorney Miller:
I have had an opportunity to discuss the invoice which was printed in error and forwarded
to your client, pursuant to the above referenced matter. Kindly note that the credit
baiance which is reflected on the billing is the result of adjustments for therapies which
were done incorrectly. In the event that there is a credit balance after the adjustments are
completed, and are confirmed to be correct, that credit balance would be credited towards
the outstanding balance which we believe your client owes to HCR Manor Care. However,
my client has indicated to me that they do not believe that there will be a credit balance
pursuant to this account.
In the event that you have any questions, or if you would like to discuss this matter in
greater detail, please do not hesitate to contact the undersigned.
Sincerely,
WOLFSON & ASSOCIATES, P.c.
Arrw
Amy F. Wolfson, Esquire
AFW /Iwe
LAW OFFICES
IRWIN McKNIGHT & HUGHES
ROGER D. IRWIN
MARCUS A. McKNIGHT, 1fI
JAMES D. H(iGHES
REBECCA R. HUGHES
DOUGLAS G. MILLER
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE, PENNSYLVANIA 17013.3222
1717) 249.2353
FAX (717) 249.6354
~MAn:IMHLAW@SUPERNET.COM
HAROLD S. IRWIN (19J5.N77)
HAROLDS./RWIN. JR. (J954-19H6)
IRWIN. IRWIN & IRWIN (/956-/986)
IRWIN, fRff7N & McKNIGHT (/986-/994)
IRWIN, MclGVJGHT & HUOHES (1994- )
December 16, 2002
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VIA FACSIMILE (717) 848-1146 and U.S. MAIL
AMY F. WOLFSON, ESQUIRE
WOLFSON & ASSOCIATES, P.C.
267 EAST MARKET STREET
YORK, PA 17403
RE: HCR MANOR CARE v. SOBOTOR. et al.
No. 2001 - 4092, Civil Term, Cumberland County
Dear Attorney Wolfson:
I had scheduled Friday; December 13,2002, to follow up with you concerning the above-
referenced matter. Unfortunately Mr. Sobotor had only received copies of the bank account
infonnation on December 6th, and I did not receive them from him until the middle of last week.
Because of the bad weather and a recent illness, I have also not yet been able to review the
infonnation,
Accordingly, I propose to contact you on Friday, December 20, 2002, to discuss this
matter once I have had the opportunity to review the account infonnation, Please contact me
immediately if this is not acceptable and I will file the appropriate response to your client's
amended complaint
In addition, I am enclosing a copy of recent correspondence from HCR Manor Care to
Mr. Sobotor. According to the envelope it was postmarked December 5, 2002. It is in part
because of this type of correspondence that my client has concerns regarding the accuracy of the
billing system,
In the event that I do not hear from you earlier, I will assume that you are in agreement to
delay this matter until Friday, December 20, 2002, as indicated above.
Very truly yours,
IRWIN, McKNIGHT & HUGHES
jj~
DGM:tds
Enclosure
cc: Michael p, Sobotor
VERIFICATION
The foregoing Petition on behalf of the Defendants is based upon information which has
been gathered by counsel for the Defendants in the preparation of this document. The statements
made in this document are true and correct to the best of the counsel's knowledge, information
and belief. The Defendants' verification cannot be obtained within the time allowed for filing
the pleading. The undersigned is therefore verifYing on behalf of the Defendants according to 42
Pa.C.S.A. S 1024(c)(2). The undersigned understands that false statements herein made are
subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to
authorities.
G.~r1i!!e~
Date: April 21, 2003
CERTIFICATE OF SERVICE
I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy
ofthe foregoing document upon the persons indicated below by first class United States mail,
postage paid in Carlisle, Pennsylvania 17013, on the date set forth below:
Amy F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
Attorney for Plaintiff
Date: April 21, 2003
IRWIN, McKNIGHT & HUGHES
Douglas G. iller, E;~
Supreme CoUrt ill # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
(717) 249-2353
Attorney for Defendants
HCR MANOR CARE,
PLAINTIFF/RESPONDENT
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
MICHAEL SOBOTOR, Individually and
on behalf of AMELIA B. SOBOTOR,
Deceased,
DEFENDANTS/PETITIONERS 01-4092 CIVIL TERM
ORDER OF COURT
AND NOW, this 24th day of April, 2003, upon consideration of the foregoing
petition, IT IS ORDERED:
(1) A Rule is issued against respondent, HCR Manor Care, to show cause why
the petition to strike off/open judgment should not be granted.
(2) Respondent shall file an answer to the petition within fifteen (15) days of
service.
(3) The petition shall be decided under Pa. Rule of Civil Procedure 206.7.
(4) Any depositions shall be completed within thirty-five (35) days of service.
(5) Briefs shall be filed in chambers and argument shall be held on Monday,
June 23,2003, at 8:45 a.m., in Courtroom No. II of the Cumberland County
Courthouse.
(6) Notice of the entry of this order shall be provided to all parties by petitioner.
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(7) All proceedings shall stay pending further ord~r of co~
By tl)e Cou
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8 U :U ~lV c {~ u~rj rei,
Amy F. Wolfson, Esquire
For Plaintiff/Respondent
Douglas G. Miller, Esquire
For Defendants/Petitioners
:sal
-2-
HCR MANOR CARE,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 2001-4092 CIVIL TERM
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
CIVIL ACTION - LAW
Defendants.
NOTICE TO PLEAD
You are hereby notified to file a written response to the enclosed Ans wer with Ne w
Matter within twenty (20) days from service hereof or a judgment may be entered against you.
IRWIN, McKNIGHT & HUGHES
tJ. hA
Douglas . Miller, Esquire
Supreme ourt J.D. No. 83776
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Attorney for Defendant
Date: July 31,2003
HCR MANOR CARE,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2001 - 4092 CIVIL TERM
v.
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
CIVIL ACTION - LAW
Defendants.
ANSWER WITH NEW MATTER
TO PLAINTIFF'S SECOND AMENDED COMPLAINT
AND NOW this 31st day of July, 2003, comes the Defendant, Michael Sobotor, by and
through his attorneys, Irwin, McKnight & Hughes, and respectfully files this Answer with New
Matter to the Plaintiff's Second Amended Complaint, and in support thereof aver as follows:
1. The averments of fact contained in paragraph one (1) of the Plaintiff's Second
Amended Complaint are admitted.
2. The averments of fact contained in paragraph two (2) are admitted.
3. The averments of fact contained in paragraph three (3) are admitted.
4. The averments contained in paragraph four (4) are conclusions of law to which no
response is required.
5. The power of attorney referenced by Plaintiff in paragraph five (5) and identified
as Exhibit "A" speaks for itself and therefore no response is required.
received certain services and treatment. The remaining averments in paragraph twelve (12) are
specifically denied and strict proof thereof is demanded at trial.
13. The averments contained in paragraph thirteen (13) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
14. The averments contained in paragraph fourteen (14) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
15. The averments contained in paragraph fifteen (15) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
16. The averments of fact contained in paragraph sixteen (16) are admitted in part and
denied in part. It is admitted that a copy of the itemization of services was sent to Defendant.
The remaining averments in paragraph sixteen (16) are specifically denied and strict proof
thereof is demanded at trial.
17. The averments contained in paragraph seventeen (17) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
3
18. The averments contained in paragraph eighteen (18) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
19. The averments contained in paragraph nineteen (19) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
20. The averments contained in paragraph twenty (20) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
21. The averments contained in paragraph twenty-one (21) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
22. The averments contained in paragraph twenty-two (22) are specifically denied and
strict proof thereof is demanded at trial.
23. The averments contained in paragraph twenty-three (23) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
24. The averments contained in paragraph twenty-four (24) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
4
25. Upon information and belief, the averments contained in paragraph twenty-five
(25) are admitted.
26. The averments contained in paragraph twenty-six (26) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
27. The averments contained in paragraph twenty-seven (27) are conclusions of law
to which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
28. The averments contained in paragraph twenty-eight (28) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
29. The averments contained in paragraph twenty-nine (29) are conclusions of law to
which no response is required. To the extent that a response is required, the averments are
specifically denied and strict proof thereof is demanded at trial.
30. The averments contained in paragraph thirty (30) are admitted.
WHEREFORE, Defendant Michael Sobotor, respectfully requests this Honorable Court
to enter a judgment in his favor and against Plaintiff in this matter, together with reasonable costs
and attorney fees, and such other and further relief as this Court deems just.
5
NEW MATTER
3 I . The averments of fact contained in the Answers to the Second Amended
Complaint are hereby incorporated by reference and are made part of this New Matter to the
Second Amended Complaint of the Plaintiff.
32. Plaintiff received adequate compensation for the services and treatment provided
to Decedent while she was a resident in Plaintiffs facility.
33. Defendant was not aware of nor did he agree to be responsible for excess costs
alleged to have been incurred by Plaintiff.
34. Defendant was not made aware of nor did he agree to be responsible for alleged
private balances claimed to be owed to Plaintiff.
35. Plaintiff's Complaint fails to state claims or causes of action upon which relief
can be granted.
36. Plaintiffs claims may be barred by the defense of the applicable statute of
limitations.
37. Plaintiff's Complaint may barred by the defense of laches.
38. All or some of Plaintiff's claimed damages are attributable to persons and/or
causes other than Defendant.
6
39. Plaintiff's claims may be barred and/or limited by Plaintiff's failure to mitigate or
to properly mitigate its damages.
WHEREFORE, Defendant Michael Sobotor, respectfully requests this Honorable Court
to enter a judgment in his favor and against Plaintiff in this matter, together with reasonable costs
and attorney fees, and such other and further relief as this Court deems just.
Respectfully Submitted,
Dated: July 31,2003
IRWIN, McKNIGHT & HUGHES
By: ~'~~A.4~
D.;;;;J;s~er, Esquire
Supreme Court ID # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Attorney for Defendant,
Michael Sobotor
7
VERIFICATION
The foregoing Answer with New Matter on behalf of Defendant Michael Sobotor is based
upon information which has been gathered by counsel for the Defendant in the preparation of this
document. The statements made in this document are true and correct to the best of the counsel's
knowledge, information and belief. The Defendant's verification cannot be obtained within the
time allowed for filing the pleading. The undersigned is therefore verifYing on behalf of the
Defendant according to 42 Pa.C.S.A. S 1024(c)(2). The undersigned understands that false
statements herein made are subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to
unsworn falsification to authorities.
Date: July 31, 2003
CERTIFICA TE OF SERVICE
I, Douglas G. Miller, Esquire, do hereby certifY that I have served a true and correct copy
of the foregoing document upon the persons indicated below by first class United States mail,
postage paid in Carlisle, Pennsylvania 17013, on the date set forth below:
Amy Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
(Attorney for Plaintiff)
Date: July 31, 2003
IRWIN, McKNIGHT & HUGHES
Douglas G ille~~
Supreme Court ID # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
(717) 249-2353
Attorney for Defendant
II
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-4092 CIVIL TERM
vs.
CIVIL ACTION. LAW
MICHAEL SOBOTOR, Individually, and
on Behalf of Amelia B. Sobotor, Deceased,
Defendant
PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER TO
PLAINTIFF'S SECOND AMENDED COMPLAINT
AND NOW, this gllvday of September, 2003, comes the Plaintiff, HCR Manor
Care, by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of Wolfson
& Associates, P.C, and files the following Plaintiff's Reply to Defendant's New Matter, and
in support thereof avers as follows:
The allegations and averments contained within paragraphs 1 through 30 of the
Plaintiff's Second Amended Complaint are incorporated herein by reference as if set forth
in full.
31 . Paragraph 31 of Defendant's New Matter is an incorporation paragraph to
which no response is required. To the extent that a response is necessary, same is denied
and the allegations contained in Plaintiff's Second Amended Complaint, are incorporated
herein by reference as if set forth in full.
32. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a belief as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial. By way of further
I'
II
response, while there were some sporadic payments made on the account balance of
Decedent while Decedent was a resident of Plaintiff's facility, the total amount of
Decedent's monthly social security and/or pension income was not forwarded to Plaintiff
!by Defendant as required by state and federal law. Therefore, it is denied that Plaintiff
received all of the compensation due to Plaintiff for the healthcare services and treatment
provided to Decedent by Plaintiff.
33. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a belief as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial. By way of further
response, on or about August 9, 1996, Defendant knowingly, voluntarily and intelligently
executed an Admission Agreement on behalf of the Decedent, which Agreement outlined
various terms of residential health care services to be provided by Plaintiff, including the
costs associated therewith, and the Responsible Party therefor. By so executing said
Admission Agreement, Defendant did acknowledge that Plaintiff would be relying on the
"Conditions" of the Responsible Party Appointment, which is part of the Admission
Agreement, in admitting the Decedent, and that if Defendant did not follow through with
said Conditions, Plaintiff will have detrimentally relied upon said Conditions and Plaintiff
will suffer financial harm and loss. By way of further response, pursuant to the terms of the
aforementioned Admission Agreement, Defendant agreed to remit payment to the Plaintiff
from the assets of the Decedent for services provided by Plaintiff that were not
compensated by a third party payor or government program. Defendant violated the
terms of said Admission Agreement as the total amount of Decedent's monthly social
2
II
security and/or pension income was not forwarded to Plaintiff by Defendant as required by
state and federal Jaw.
34. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a bellef as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial. By way of further
response, on or about August 9, 1996, Defendant knowingly, voluntarily and intelligently
executed an Admission Agreement on behalf of the Decedent, which Agreement outlined
various terms of residential health care services to be provided by Plaintiff and the
Responsible Party therefor. By so executing said Admission Agreement, Defendant did
acknowledge that Plaintiff would be relying on the "Conditions" of the Responsible Party
Appointment, which is part of the Admission Agreement, in admitting the Decedent, and
that if Defendant did not follow through with said Conditions, Plaintiff will have
detrimentally relied upon said Conditions and Piaintiff will suffer financial harm and loss.
By way of further response, pursuant to the terms of the aforementioned Admission
Agreement, Defendant agreed not to dissipate the assets of the Decedent, and to remit
payment to the Plaintiff from the assets of the Decedent for services provided by Plaintiff
that were not compensated by a third party payor or government program. Defendant
violated the terms of said Admission Agreement as the total amount of Decedent's
monthly social security and/or pension income was not forwarded to Plaintiff by Defendant
as required by state and federal law.
35. Denied. The allegation contained in paragraph 35 of Defendant's New
Matter is a conclusion of law to which no response is required. To the extent that Plaintiff
3
II
is required to answer, Plaintiff specifically denies the allegation contained in this paragraph
and demands strict proof thereof.
36. Denied. The allegation contained in paragraph 36 of Defendant's New
Matter is a conclusion of law to which no response is required. To the extent that Plaintiff
is required to answer, Plaintiff specifically denies the allegation contained in this paragraph
and demands strict proof thereof.
37. Denied. The allegation contained in paragraph 37 of Defendant's New
Matter is a conclusion of law to which no response is required. To the extent that Plaintiff
is required to answer, Plaintiff specifically denies the allegation contained in this paragraph
and demands strict proof thereof.
38. Denied. After reasonable investigation, Plaintiff is without sufficient
information or knowledge to form a belief as to the truth or veracity of this allegation.
Therefore, same is denied and strict proof is demanded at trial.
39. Denied. The allegation contained in paragraph 39 of Defendant's New
Matter is a conclusion of law to which no response is required. To the extent that Plaintiff
is required to answer, Plaintiff specifically denies the allegation contained in this paragraph
and demands strict proof thereof.
4
II
WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss
Defendant's New Matter and enter judgment in favor of Plaintiff and against Defendant,
along with the allowable costs of this action, and such further relief as the Court deems
appropriate.
Respectfully submitted,
,{t-t5krd----
Amy F. W~~~, EsqUil/,?/
WOLFSON & ASSOCIATES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
J.D. No. 87062
Attorney for Plaintiff
5
I'
VERIFICATION
Amy F. Wolfson, Esquire, hereby states that she is the attorney for the Plaintiff,
HCR Manor Care, and she is authorized to take this verification on behalf of said Plaintiff in
the within action, and verifies that the statements made in the foregoing Reply to New
Matter are true and correct to the best of her knowledge, information, and belief, based
upon information provided by the Plaintiff.
The undersigned understands that false statements herein are made subject to the
penalties of 1 8 Pa.C.S. Section 4904, relating to unsworn falsification to authorities.
Date: 9/8/03
4~~
Amy F. W fson, Esquir
WOLFSO & ASSO A TES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
II
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-4092 CIVIL TERM
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually, and
on Behalf of Amelia B. Sobotor, Deceased,
Defendant
CERTIFICATE OF SERVICE
AND NOW, this 8th day of September, 2003, I, Amy F. Wolfson, Esquire, do
hereby certify that I have served a copy of the foregoing Reply to New Matter upon the
counsel of record for the Defendant by Facsimile and First Class Mail - Postage Pre-paid,
and addressed as follows:
VIA FAX: (717) 249-6354
Douglas G. Miller, Esquire
IRWIN, McKNIGHT & HUGHES
West Pomfret Professional Building
60 West Pomfret Street
D";,'" PA 17013~
Art(y F. Wol on, Esqu' e
WOLFSO & ASS TES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYL VANIA
HCR MANOR CARE,
Plaintiff
NO. 2001 - 40~CIVIL TERM
vs.
CIVIL ACTION - LA W
MICHAEL SOBOTOR, Individually, and
on Behalf of Amelia B. Sobotor, Deceased,
Defendant
RULE 1312-1.
The Petition for Appointment of Arbitrators shall be substantially in the following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Amv F. Wolfson, Esquire ,counsel for the plaintiff/defendant in the above action (or actions).
respectfully represents that:
1. The above-captioned action (or actions) is (are) at issue.
2. The claim of the plaintiff in the action is $13,042.63 plus interest and court costs.
The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators:
Douglas G. Miller, Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall
be submitted.
Respe . Ily su m~'tted
, ,I,
ORDER OF COURT
AND NOW, ] I1'<L#</.df j /3 ,'tt.3 , in consideration of the
foregoing petition, 1(,.kCL /~~_~ Esq.~ ~ b. /lo;t~
Esq., and :t'd/llAV /c:.~ Esq., are appointed arbitrators in the above captioned action (or
lctions) as prayed for.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HeR MANOR CARE,
Plaintiff
NO. 2001-4092 CIVIL TERM
vs.
CIVIL ACTION - LAW
MICHAEL SOBOTOR, Individually, and
on Behalf of Amelia B. Sobotor, Deceased,
Defendant
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PRAECIPE TO VACATE JUDGMENt
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TO THE PROTHONOTARY OF SAID COURT:
Please vacate the above captioned judgment entered on April 8, 2003.
Respectfully submitted,
Amy F. ,olfson, uire
WOLFSON & ASSOCIATES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
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Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
v.
NO. 2001- 4092 CIVIL TERM
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
CIVIL ACTION - LAW
Defendants.
PETITION TO CONFIRM STIPULATION
AND NOW COME Defendants, by and through their attorneys, Irwin & McKnight, and
in support of the Petition to Confirm Stipulation Defendants aver as follows:
1. The Default Judgment entered on or about April 8, 2003, shall be opened and
removed without prejudice to the Defendants in the above-captioned matter.
2. The parties hereby waive any hearing with regard to the Petition to Strike Off /
Open the Default Judgment filed by Defendants, so that the litigation may proceed in due course.
3. The Prothonotary is requested to amend the docket in accordance with this
Stipulation.
Respectfully Submitted,
IRWIN, McKNIGHT & HUGHES
By:
Dated: March 3, 2004
Douglas ( Miller, Esquire
. Supreme Court ID # 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249..2353
Attorney for Defendants
HCR MANOR CARE,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 2001 - 4092 CIVIL TERM
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
CIVIL ACTION - LAW
Defendants.
STIPULATION TO OPEN JUDGMENT
TO THE PROTHONOTARY:
THIS STIPULATION, made and entered into as of this ~ day of
K-~
, 2004, by and between counsel for respective parties in the above-
captioned matter.
WHEREAS, on or about April 8, 2003 a Default Judgment was entered by the Plaintiff
in the above-referenced matter; and
WHEREAS, on or about April 21, 2003, Defendants filed a Petition to Strike Off / Open
the Default Judgment; and
WHEREAS, prior to a hearing on Defendants' Petition the parties through their
respective legal counsel agreea to open a..'1d :-emove the Default Judgment in exchange for
Defendants filing an Answer to the Plaintiffs Second Amended Complaint; and
WHEREAS, Defendants filed an Answer with New Matter on or about July 31, 2003, in
accordance with the agreement of the parties.
NOW, THEREFORE, intending to be legally bound hereby, the parties hereby agree as
follows:
1. The Default Judgment entered on or about April 8, 2003, shall be opened and
removed without prejudice to the Defendants in the above-captioned matter.
2. The parties hereby waive any hearing with regard to the Petition to Strike Off /
Open the Default Judgment filed by Defendants, so that the litigation may proceed in due course.
3. The Prothonotary is requested to amend the docket in accordance with this
Stipulation.
Dated:
3/J- /dr
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Dated:
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CERTIFICATE OF SERVICE
I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy
of the foregoing document upon the persons indicated below by first class United States mail,
postage paid in Carlisle, Pennsylvania 17013, on the date set forth below:
Amy F. Wolfson, Esquire
Wolfson & Associates, P.c.
267 East Market Street
York, PA 17403
Attorney for Plaintiff
Date: March 3, 2004
IRWIN & McKNIGHT
"l')~, i .Af;f&
Douglas G. Iller, sqUIre
Supreme Court LD. No. 83776
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
(717) 249-2353
Attorney for Defendants
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HCR MANOR CARE,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2001 - 4092 CIVIL TERM
CIVIL ACTION - LA W ~004
v.
MICHAEL SOBOTOR, Individually, and:
on Behalf of AMELIA B. SOBOTOR,
Deceased,
Defendants.
ORDER
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AND NOW, thIS ,
day of ~
, 2004, upon presentation and
consideration of the attached stipulation and agreement of the parties, it is hereby ordered and
decreed that the attached Stipulation is made an Order of Court.
BY
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IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
No. 2001-4092
vs.
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR. Individually, and on
Behalf of AMELIA B. SOBOTOR,
Defendants
PRAECIPE FOR JUDGMENT
Enter Judgment in favor of Plaintiff and against Defendant, MICHAEL SOBOTOR, pursuant to
ARBITRATION AWARD.
( X ) Amount due
Interest from March 15,2001
Filing Costs
TOTAL
$ 9.000.00
$ to be determined
$ 128.90
$ 9,128.90 plus costs & interest
( X ) I certify that the foregoing assessment of damages is for specified amounts alleged to be
due in the complaint and is calculable as a sum certain from the complaint.
(X) Pursuant to Pa.R.C.P. 237 (Notice of Praecipe for Final Judgment or Decree), I certify that
a copy of this praecipe has been mailed to each other party who has appeared in the action or to hislher
Attomey of Record.
(X) Pursuant to Pa.R.c.P. 237.1. I certify that written notice of the intention to file this
Praecipe was mailed or delivered to the party against whom judgment is to be entered and to hislher
Attorney of Record, if any, after the default occurred and at least 10 days prior to the date of the filing of
:::;~c1711;ifthe notice is ::::::re: fAt J ~/A .
Am1{~s~n, Es
ID# 87062 /
Attorney for Plaintiff
267 East Market Street
YORK, PA 17403
(717) 846-1252
, 20~, JUDXMENT IS ENTERED. AS fJOVE.
('-(~)K.~~
Prothonotary/Clerk, Civil Divisioe7
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Deputy
NOW, J)'Pn...i. L . L q
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
No. 2001-4092
vs.
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR, Individually, and on
Behalf of AMELIA B. SOBOTOR,
Defendants
( X ) Notice is hereby given that a JUDGMENT in the above-captioned matter has been
entered against you pursuant to the Arbitration Award in the amount of $9,128.90
plus interest, reasonable attorney's fees and costs, on
,q pn \. L d- (,) , 20 6'1 .
( X ) A copy of all documents filed with the Prothonotary in support of the within
judgment is/are enclosed.
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If you have any questions regarding this Notice, please contact the filing party.
Amy F. Wolfson. Esquire
267 East Market Street
YORK, PA 17403
(717) 846-1252
(This Notice is given in accordance with Pa.R.c.P. 236.)
NOTICE SENT TO:
MICHAEL SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
DOUGLAS G. MILLER, ESQUIRE
IRWIN, MCKNIGHT and HUGHES
WEST POMFRET PROFESSIONAL BUILDING
60 W. POMFRET STREET
CARLISLE, PA 17013-3222
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
No. 2001-4092
vs.
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR, Individually, and on
Behalf of AMELIA B. SOBOTOR,
Defendants
AFFIDAVIT OF NON-MILITARY SERVICE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
I, Amy F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my knowledge,
information and belief, Defendant, MICHAEL SOBOTOR, above named, are over 21 years of
age; is last know to reside at 19 HOLLY ESTATE DR., GARDNERS, PA 17324, ADAMS
County, Pennsylvania; is not in the military service of the United States or its Allies, or otherwise
within the provisions of the Soldiers' and Sailors' Civil Relief ct of Congress of 1940 nd its
Amendments.
tit
Amy F. Wo son, Esq
Attorney for the Plain
Attorney ID# 87062
Wolpoff & Abramson, L.L.P.
267 East Market Street
York, PA 17403
.-/
SWORN and SUBS~RmED
To before me this ....::L- day
Of ~\ \ , 2o::ll.
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Notary Public
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IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
No. 2001-4092
vs.
AMELIA B. SOBOTOR, Individually,
MICHAEL SOBOTOR, Individually, and on
Behalf of AMELIA B. SOBOTOR,
Defendants
CERTIFICATE OF RESIDENCE
I, Amy F. Wolfson, Esquire, due hereby certify that the last known address of the above
referenced Defendant is as follows:
MICHAEL SOBOTOR
19 HOLLY ESTATE DRIVE
GARDNERS, PA 17324
Respectfully submitted,
Date: April 6, 2004
J
Amy F. W
WOLPO & AB
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
)
HCR MANOR CI>RE, )
Plaintiff )
v. )
AMELIA B. SOBOTOR, individuall~,
MIClffiEL SOBOTOR, individually,)
and on behalf of AMELIA B. SOBPTOR,
Defendants
:lQ-w1'/QSc;
In The Court of Common Pleas of
Cumberland County, Pennsylvania
:-10. 200~ - 4092
1?9X
OATH
.' l..e do solemnly swear (or affi=)
( the Constitution of the United States
. wealth and that we will discharge the
that we will support, obey and derend
and the Consti~tiQ~ or this Common-
duties~with fidelity.
~. Chair:nan
~~O'lY~~{ritA1:-
AWARD (/
We, the undersigned arbitrators, having been duly appointed and sworn
(or affirmed), make the following award:
(Note: If damages for delay are awar~ed, they shall be
separately stated.)
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Arbitrator, dissents. (Insert name if
applicable. )
Date of Hearing: !114~~:3, 2(:)(1'1
Date of Award: I/{~". J..1J1J1
ffhw~
Chair:nan
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Now, the dd.. day of '7u.~
award was entered upon the docket and
parties or their attorneys.
, I'.ldOOY, at 9;vq , fI..~j., the above
llotice thereof given by mail to the
Arbitrators' compensation to be
paid upon appeal:
$ ;2 90. I.JV
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o ,Prothonotary
By: CJru-. 0 ~,;",~
Deputy
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Plaintiff
In The Court of Common Pleas of Cumberland
(.\Mdl~ f3 S'oboh \'. J~.
Defendant
County, Pennsylvania No....QL- 'i b 1;Lo
Civil Action - Law.
Oath
We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United
States and the Constitution of this Commonwealth and that we will discharge the duties of our office
with fidelity.
Signature
Signature
Signature
{(e,1-/, O. f31i'~AJ"-'e-fII1AU
Name (Chairman)
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Name
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Name
A. CUM/lfhVj'5
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Law Finn
P.O~ey> 3/.'
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Address
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Law Firm
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Address
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Address
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City, . Zip
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Award "/(.S13
We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the
following award: (Note: If damages for delay are awarded, they shall be separately stated.)
C!.A./f.' :st,
City, '
Q ) 101]
Zip
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ty,
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Zip
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. Arbitrator, dissents. (Jnsert name if applicable.)
Date of Award:
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KpfiGN j, C.u n'UVI Irvt).s
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(Chairman) :11III
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Date of Hearing:
f,--ifJ. ('). /3n ,.nv".MIl<J
Notice of Entry of Award
Now, the 3.""( dayof ~ ,20 0,/ ,at 9:09' ,k.M.,theaboveawardwas
entered upon the docket and notice thereof given by mail to the parties or their attorneys.
n to be paid upon appeal: $ olCi".<50
By:
Deputy
Prothonotary
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HCR MANOR CARE, )
Plaintiff }
v. )
AMELIA B. SOBOTOR, individuall~r
M:LCHAEL SOBOTOR, individually,S
and on behalf of AMELIA B. SOBPTOR,
Defendants
In !he Court of Common Pleas of
Cumberland County, Pennsylvania
:-lo. 200~ - 4092
P9X
OATH
.' I.e do solemnly swear (or affirm) that we will support, obey and defend
( the Constitution of the United States and the Constitut~o~ of this Common-
, wealth and that we will discharge the .duties~with fidelity.
AWARD
We, the undersigned arbitrators, having been duly appointed and sworn
(or affirmed), make the following award:
(Note: If dll3llages for delay are award,ed, they shall be
separately stated.)
.:IN f:.1VM. IJ'r tflfl.vfu:::p IiNtI tlft2/'/1'.rr ijfMd'..r,vf- ~;,re(t./
S(;l;tJla~ IN 7X tt~lflllf- '! #' f.t1dtf.~o t/"y/ ~s-h t:?fJ
t'1h '; ~ ~;"'; .
Arbitrator, dissents. (Insert name if
applicable. )
Date of Hearing: jf?lflf~ ), 2iPPY
Date of Award: /Jf~ J, J.~Q'I
7l?h.A 0. /IJ"yr,{
Chair:nan
W/~~""'f'~
NOTICE OF ENTR.Y OF AWARD
A J ~ -:;//'~
it /d'~ ~ .
Now, the}u..day of '7k~~ , lllolltJ'/, at q:oq, /1"l1., the above
award was entered upon the docket and notice ~eof gIVen bY-mail to the
parties or their attorneys.
Arbitrators' compensation to be
paid upon appeal:
$ ;)..90.00
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~rothonotary
By: C);.u.. 0 "7h,.1C;,.
Deputy
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