HomeMy WebLinkAbout08-0247IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. .
EDITH ECKART,
Defendant.
No. DS - 01q,7 CAM -rerm
CIVIL ACTION - EQUITY
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims
set forth in the following pages, you must take action within twenty (20) days after this
complaint and notice are served, by entering a written appearance personally or by
attorney and filing in writing with the court your defenses or objections to the claims set
forth against you. You are warned that if you fail to do so the case may proceed without
you and a judgment may be entered against you by the court without further notice for
any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A
LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166
(800) 990-9108
ORIGINAL
EN LA CORTE DE ALEGATOS COMU' N DEL
CONDADO DE CUMBERLAND, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No.
EDITH ECKART,
Defendant. CIVIL ACTION - EQUITY
AVISO PARA DEFENDER
Conforme a PA RCP Ndm. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de
las demandas que se presentan mas adelante en las siguientes paginas, debe tomar
accion dentro de los proximos veiente (20) dias despues de la notificacion de esta
Demanda y Aviso radicando personalmente o por medio de un abogado una
comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee
a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de
tomar accion como se describe anteriormente, el caso puede proceder sin usted y un
fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra
reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya
por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros
derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
R"QMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A
CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Tel6fono: (717) 249-3166
(800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No. Q 8- Z 7 Cuscl 71.
EDITH ECKART,
Defendant. CIVIL ACTION - EQUITY
COMPLAINT
AND NOW COMES, Plaintiff, Church of God Home, Inc. ("Plaintiff Church of
God"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within
Complaint against Defendant, Edith Eckart ("Defendant Eckart"), and in support
thereof, provides as follows:
1. Plaintiff Church of God is a Pennsylvania corporation with its principal
offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17103.
2. Defendant Eckart is an adult individual who resides at 527 D South West
Street, Carlisle, Pennsylvania 17013.
3. On or about October 21, 2002, Defendant Eckart made application on
behalf of her mother, Bertha Stone ("Ms. Stone"), for admission to Plaintiff Church of
God's skilled nursing facility located at 801 North Hanover Street, Carlisle,
Pennsylvania 17103.
4. On or about October 21, 2002, Plaintiff Church of God and Defendant
Eckart entered into a written Admission and Care Agreement ("Agreement"). Pursuant
to the Agreement, Plaintiff Church of God agreed to provide Defendant Eckart's mother
with skilled nursing care and services in exchange for Defendant Eckart's promise to
pay a specific monetary fee from her mother's resources and to cooperate fully with
Plaintiff Church of God upon becoming eligible for the receipt of Medical Assistance
benefits, such "cooperation includes, when requested, providing information, [and]
signing and delivering documents ...." A true and correct copy of the Agreement is
attached hereto as Exhibit "A."
5. Subsequent to Ms. Stone's admission to Plaintiff Church of God's skilled
nursing facility, no payment was made for services rendered to her, because she
allegedly appeared to be insolvent.
6. An application for the receipt of Medical Assistance benefits was filed
with the Cumberland County Assistance Office.
7. The Cumberland County Assistance Office denied the application for
Medical Assistance benefits on March 7, 2007, because Defendant Eckart did not
provide verification to the Cumberland County Assistance Office to determine Ms.
Stone's eligibility for the receipt of Medical Assistance benefits. See Exhibit "B."
8. An appeal of the denial of the application for Medical Assistance benefits
is currently pending before the Bureau of Hearing and Appeals of the Department of
Public Welfare of the Commonwealth of Pennsylvania.
9. If the documents requested by the Cumberland County Assistance Office
are not provided by Defendant Eckart prior to or at the time of the hearing on the
appeal, the application for Medical Assistance benefits will ultimately be denied, and
any further appeal to the Commonwealth Court would be without merit.
2
COUNTI
BREACH OF CONTRACT/SPECIFIC PERFORMANCE
10. Paragraphs 1 through 9 are incorporated herein by reference as if fully set
forth.
11. Plaintiff Church of God has provided skilled nursing care and services to
Defendant Eckart's mother in accordance with the terms and conditions of the
Agreement.
12. Defendant Eckart breached the Agreement with Plaintiff Church of God
when she failed to make timely and proper application for Medical Assistance benefits
for her mother, and Defendant Eckart continues to breach the Agreement with Plaintiff
Church of God by failing to cooperate and provide all documentation needed by the
Cumberland County Assistance Office to determine her mother's eligibility for Medical
Assistance benefits.
13. Defendant Eckart's breach of the Agreement with Plaintiff Church of God
has irreparably harmed and continues to irreparably harm Plaintiff Church of God.
14. Upon information and belief, at all times material hereto, Ms. Stone has
been financially unable to fully compensate Plaintiff Church of God for the care and
services that it has rendered to her in accordance with the terms and conditions of the
Agreement.
3
15. Accordingly, only a decree of specific performance will adequately protect
the interests of Plaintiff Church of God and provide it with the benefits and/or
protections promised under the Agreement.
WHEREFORE, Plaintiff Church of God seeks a decree from this Honorable Court
which orders specific performance of the Agreement between the parties.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: I 1 D 08
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Maria G. Macus-Bryan
Attorney I.D. No. 90947
(717) 909-8640
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
By: ??1l?Gl?4?i
Attorneys for Plaintiff
4
VF-ItIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing
Complaint are true and correct -to the best of my knowledge, information and belief. I
understand that any false statements, therein are subject to the penalties contained in 18
Pa. C.S.A. § 4904, relating to unworn falsification to authorities.
Dated.A ?U
Sharon Cramer, SR Billing/AR Spca.alist
Church of God Home, Inc
EXHIBIT "A"
- - C MCH OF GOD HOME, INC".
ADMISSION AND CARE AGREEMENT
TABLE OF CONTENTS
AGE
1. PROVISION OF SERVICES 26
2. RECURRING CHARGES . . . . . . . . . . 26
_ 3. NON-RECURRING CHARGES ." .". 27
4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES 27
5. ADMISSION 28
6._ PERIODIC BILLINGS AND PAYMENT DUE DATE .. 28
7. CHANGES IN CHARGES _ .". _ 28
8. PARTICIPATION IN MEDICARE/MEDICAID PROGRAMS 28
9. .OBLIGATIONS OF RESPONSIBLE PARTY .'. .29
10. READMISSION - BED/ACCOMMODATION HOLD POLICY ... 29
11. REFUNDS . . . . ... ' . 29
12. PERSONAL FINANCES '. 29
13. TERMINATION, TRt1NSFER OR DISCHARGE . . . . . ' . 30
14. THIRD-PARTY PAYMENTS ... - -". .31
15. PERSONAL PROPERTY . . . . . . . ."._ . . . . . . . .32
16. RESPONSIBILITIES OF RESIDENT .32
17. MISCELLANEOUS PROVISIONS 32
CHURCH OF GOD HOME, INC.
ADMI S S ION AND CARE AGREEMENT
VIA
THIS AGREEMENT is made on this day of °Z. by
and between The Church of God Home, Inc., called the "Facility," a
Pennsylvania non-profit corporation located at BO]. North Hanover
Street, Carlisle, Cumber and County, Pennsylvania,
and called "Resident"
and called "Responsible Party".
The Resident and the Responsible Party reaffirm that the
information provided in the Pre-Admission Questionnaire is true and
correct and understand that the submission of false information may
constitute grounds to terminate this Agreement.* The Resident has
applied for admission to the Facility and the Facility has approved
the. Application for Admission. Therefore, the Facility, The
Resident and Responsible Party agree to the following terms'!
1. PRDVISION OF SERVICES. The Facility will provide'
Resident with:
(a)' Skilled nursing care, i.e_ professionally supervised
nursing care and related health services-under a plan
of services regularly provided under a plan of care-
supervised by licensed personnel and, as required by
the Resident's medical condition, assistance with
activities of daily living.
.;
(b) Accommodations consistent with the level of care
provided to the Resident including heat, air
conditioning, :electricity and hot and cold water.
(c) Bed, bedding, blankets and laundered bed linens, towels
and wash cloths.
(d) Three meals each day, except as otherwise medically
indicated.
(e)' Activity programs and social services.
2. RECURRING CHARGES. In exchange for the above services,
the Resident shall pay the.following recurring charges:
(a) For skilled nursing care: $ ?` dollars.per day.
Admission and Care Agreement - continued
-3-. ETON-RECURRING CHARGES. The Resident shall pay the
following non-recurring charges:
(a) A security deposit in the amount of thirty-one (31)
times the current daily rate for the level of care
required by the resident, will be billed after
admis day. The amount of the security deposit is
$ No interest will be paid on the security
depos t. Asecurity deposit will not be charged to
residents who are receiving benefits for room and board
provided by Medicare, until the Medicare benefit
concludes. An applicant who is covered by Medicaid is
not required to pay a security deposit.
(b) The cost for enrollment in the community e
and ALS (Advance Life Support) Unit is $? This
fee must be paid prior to admission and will be billed
annually to the Resident.
a. MISCEL OUS AND OUTSIDE SE]MCES. Resident is
responsible to pay for other services provided by the-Facility
which are not covered. by the daily rate/charge. - A. list of such
services/charges is attached to this Agreement on, the "Chart of
Costs."
The services of a licensed physician and dentist; a
registered pharmacist and licensed pharmacy for the provision of
pharmaceutical supplies, a licensed hospital, and- diagnostic
services., will be made available at the Resident's expense.
THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER. OTT PHYSICIAN OR ANY
OTHER SERVICE PROVIDER SO LONG.AS THE PHYSICIAN OR OTHER SERVICE
PROVIDER IS PROPERLY LICENSED OR REGISTERED UNDER THE LAW, AND THAT
ALL APPLICAflLE GOVERNMENT RULES AND POLICIES OF THE -FACILITY ARE
MET.
In addition to the Facility's charges, the Resident is
responsible to pay 'all. fees and costs ,for goods or services
furnished to or for the Resident by anyone other than the Facility
under this Agreement. The responsibility of the Resident to pay
applies to all fees for costs of services provided for the Resident
by any physician, dentist, optometrist,' therapist, diagnostic or
testing laboratory, pharmacist, pharmacy, hospital, or any other
person;' facility or entity providing services or goods to or for
the Resident, and for all drugsx medicines, medications,
pharmaceutical supplies, corrective eye lenses,. hearing aids,
dentures, hair care, and other personal items or services for the
Resident . SUCH FEES AND COSTS ARE NOT INCLUDED IN THE HOME'S DAILY
RATE/CHARGE.
Admission and Care .Agreement - C=t4 ""'A
5 . ADMISSION. The Resident will a.. , tte Ora bed will
be reserved-for Resident, beginning on 1letw V.
?-L l pre-admission charges will be billed after admission, and
recurring charges will begin to accrue as of the above date.
The Resident may reserve an available bed by paying the
daily rate for-the bed reserved. The daily rate for the reserved
bed will continue to accrue and be payable until the reservation is
terminated, even if the Resident does not enter the - Rome for
whatever reason, including illness, injury, incapacity or death.
6. PERIOD=C BILLINGS AND PAYMENT DUE DATE..
(a) on the first of each month, Resident will be billed the
current daily rate for Resident's current level of care
times the number of days in the month. The bill is- due
and payable* upon receipt.
(b) Miscellaneous charges (refer to "Chart of Costs"
attached to this Agreement) such as hair care, personal
laundry,;: incontinency, supplies,. etc. , are. additional
chargee '?dbove•the daily rate. These miscellaneous
charges;vill be added to, and included•with, your
monthly bill _ ;
(c) Pharmacy charges will be billed as a separate part
of the Facility's monthly bill, and will require
a separate check.
(d) outside providers -will bill directly and separately.
7. CgANGFs-3:N CSARGEs. From time to time,the Facility may
change the"-amount of its charges.. In addition, from time to time,
the Facility may change how and when its charges are computed,
billed or become due. The Facility reserves the right to make any
such changes at any time., Written notice of any such changes will
be given to the -Resident thirty (30) days in advance of
implementation, unless--the change is required earlier under any.
federal-or state law or assistance program.
8. PARTICIPATION IN "MEDICARE/M®ZCA.ID" PROGRAMS. The
Facility participates in the Medicare program administered pursuant
to Title XVIII of the Federal Social Security Act and the
Pennsylvania Medical Assistance Program ("Medicaid") administered
pursuant to the Pennsylvania state plan and Title -SIX of the
Federal Social Security. Act.. However, the Facility reserves the
right to withdraw from the Medicare/Medicaid-programs at any time
in accordance with the law.
Admission and Care Agreement - continued..
-&-. QBLM&TIONS OF RESPONSISLI PARTY. The Responsible Party
is responsible for services and supplies that are billed through
the Facility or billed directly to the Resident or Responsible
Party by any other provider. The Responsible Party is responsible
to pay all fees and costs from Resident's resources.
10. READMISSION - BID HOLD POLICY. 'If the Resident leaves
the Facility for a period of hospitalization, therapeutic leave, or
any other reason, other than the Resident's death, and if the
Resident is not eligible for, or receiving medical assistance:, the
Resident's bed will be reserved and charges for the reserved bed
will continue to accrue, unless the Resident or Responsible Party
-otherwise directs in writing. If the Resident or Responsible Party
elects not to reserve a bed, then the Resident will be eligible for
readmission upon the availability of the first bed suitable for the
Resident's level of care.'.
If the Resident .i's receiving medical assistance benefits
and the Resident leaves the Facility for -a period of
hospitalization or therapeutic leave, the Resident's bed will be
reserved for the applicable maximum number of days paid for the
reserved bed under the Pennsylvania .Medical Assistance, Program.
The -current bed reservation period is fifteen (15) 'days for '
hospitalization,.regardless of level of care, fifteen (15) days for
therapeutic leave for residents receiving skilled nursing care,.. and
thirty, (30) days for therapeutic leave for residents receiving
intermediate care.. The bed reservation period may be subject to
change in accordance with any' changes in the' Medical Assistance
Program. If the period of hospitalization or therapeutic leave
ends within the reservation period under the Medical :Assistance
Program, the Resident may return to the Facility. If the period of
hospitalization or therapeutic leave exceeds the maximum time for
reservation of a bed under the - Pennsylvania Medical Assistance
Program, the Resident- must wait until a suitable bed becomes
available for readmission. The Resident is entitled to the first
available bed suitable for the Resident's level of care if, at the
time of readmission, the Resident requires the services provided by
the Home.
11. REFUNDS. The .security deposit for private pay residents,
after deductions for the payment of any outstanding bills owed to
the Facility, will be refunded within thirty (30) days after the
Resident's. discharge from the Facility or death. Those Nursing
Residents on Medical Assistance will receive their refund, if any
due within ninety (90) days. -There kill.be no other refunds, in
the absence of an overpayment, under this Agreement..
12.. PERSONAL FINANCES. The Resident has the right to manage
his/her personal funds. The Resident is and will be responsible to
provide his/her- personal funds. If the Resident elects, the
Resident may designate, in writing, that the Facility hold and
manage the Resident's personal funds... If. the Resident
Admission and Care Agreement - continued
designates someone other than the Facility to manage his/her
personal funds, the Resident or Responsible Party shall notify the
Facility promptly. The Resident- is not required to make any
designation, and 'is responsible for his/her own personal funds
unless such designation is made.
The Resident may revoke, at any time, the designation of
the Facility as *the manager of bis/her personal funds by providing
the Facility a written notice signed and dated by the Resident or
Responsible Party.
If.the Resident transfers to the Home, responsibility to
-manage the Resident's personal funds, the Facility will do so *in
accordance with the "Rights of Nursing Facility Residents", a copy
of which -is. provided at the time of your admission, and the
Facility's personal funds management policy. The Facility may
deduct, at any time, charges due to the Facility under- _this
agreement from..the Resident's personal funds managed by the
Facility.
13. TER ngWT3:=, _TR.ANsrm oR 1 3:s=RGE .
(a) By the Resident-: - The Resident may terminate this
Agreement upon thirty (3a) days written notice to the
Facility. If the Resident leaves the -Facility for any
reason other than a medical emergency or his/her death,
the Resident must give.written notice to'the. Facility
at -least thirty (30), days in advance .of the departure/
transfer/discharge or termination of the Agreement.
If advance written notice is not given to the Facility,
-there will be due to the Facility its daily.and other
charges then in effect for the Resident's current level
of care for the required thirty •(30) day notice period.
The charge applies whether or not the Resident remains
at the Facility during the thirty (30) day period.
(b) By the Facility: The'Facility may terminate the
Resident's stay and transfer or discharge the Resident
if : •
(I) the transfer or discharge is necessary.to
meet the Resident's welfare which cannot
..be.met by.the Facility;
(II) the Resident's health or condition has
improved sufficiently that'the Resident
no longer needs the services provided by
the Facility;
(III) the safety or-health of individuals in the
Facility is or otherwise would be endangered.;
Admission and Care Agreement - Continued
(IV) The charges or other amounts due to the
Facility wader this Agreement have not
been paid to the Facility or treated -as
paid to the Facility on the Resident's
behalf by Medical Assistance- under the
Pennsylvania Medical Assistancje Program
or by Federal Medicare benefits-under
Title XVIII of the Federal- Social Security
Act; OR
(V) The Facility ceases to operate.
The Facility generally will notify the Resident and
Responsible Party or if none, a family member or legal
representative of the Resident,-if known to the Facility, at least
thirty (30) days in advance of such a transfer or discharge.
However, in any case, described in subparagraph (I), (II) or (III)
above, or if the Resident has not resided at the Facility for at
least thirty. (30) clays, the Facility will give such notice before
transfer or discharge as is practicable under the circumstances.
14. TE= PARTY PA'Y?ara. The Resident may be or may
become eligible•,,to.receive financial assistance, reimbursement or
other benefits from • third-parties, such 'as through private
insurance, employee benefit plans, medical assistance under the
Pennsylvania Medical Assistance Program,' Medicare benefits,
supplementary medical :or other. health insurance, supplemental
security income' .insurance; or old-age survivors' or disability
insurance under or pursuant to the Federal social -Security Act or
Program. If the Resident becomes eligible to receive payments from
any third-parties for the stay' -and care of the Resident, . the
Resident and Responsible Party shall, at all times, cooperate fully
with the Facility and each third-party'paymeats. Cooperation
includes, when requested, providing information, signing and
delivering documents, and having the Facility designated by the
social Security 'Administration as the Resident's representative
payee for receipt of Federal Social Security benefits or any other-
governmental assistance, reimbursement or benefits to the extent of
-all charges due the Facility. The Resident irrevocably authorizes
the Facility to make claims and to take such other actions as may
be necessary for the' Facility's receipt of third-party payments.
To the fullest -extent permitted by law, the Resident hereby assigns
to the Facility, the'Resident's rights to any third-party payments
now or hereafter. payable to the. extent of " all charges due to. the
Facility.' The Resident and Responsible Party promptly shall
endorse and turn over to the Facility any payments received_ from
third-parties to the extent.necessary to satisfy the charges under
this Agreement..
Admission and Care Agreement - continued
_15. PERSONAL PROPERTY. The Resident is and will be
responsible 'To furnish and maintain his or her own clothing,
jewelry, personal possessions and other items of property. The
Facility may limit the amount or type of property that the Resident
may keep at the Facility if there is insufficient space, or if
medically indicated or necessary.to protect the rights or welfare
of others. The Facility will not be liable for damage to or loss
of any personal-property of. the Resident unless the property is
deposited with the' Facility for safekeeping. The Facility will
provide written receipt for any items of the Resident's property
deposited with the Facility.
16. RESPONSIBILITIES OF RESIDENT. The Resident shall comply
-fully with all governmental laws and regulations, the provisions of
this Agreement and the Facility's existing policies, rules and
regulations which may, from- time to time,-be altered or amended.
17. MISCELLANEOUS PROVISIONS.
(a) The Resident and Responsible Party acknowledge that
they. are adult individuals and have read and understand
the terms of this Agreement.
(b) The provisions of this Agreement shall be governed by -
the laws of the' Commonwealth of -Pennsylvania and shall
be binding upon and inure to the;benefit of each of the
undersigned parties and their respective heirs',
personal representatives., successors and assigns.
(c) The various provisions of this Agreement shall be
severable one from another. . If' any provision of this
Agreement is found by competent legal authority to be
invalid, the other provisions ..shall remain in. full
force and effect as if the invalid provision had not
been a part of this Agreement.
(d) The Facility reserves the right to modify unilaterally
the terms of this Agreement to conform to subsequent
-changes. in the law or regulation- and changes in
charges. Resident will be-provided thirty (30) days
notice of changes-in charges and, if practicable, •
-
reasonable notice of any modifications required.by law.
?? . L_;L
Dat e
E
• - • •
'01,111:11121:1614 N FEE 111,13 • • - s
BENEFIT ts,Gteie t e PE1409IG
1400-269.0173 717-240-2700
CUMBERLAND CO COF PUSUC OUNTY ASSISTANCE E OARE
FFICE
33 WESTMINSTER DRIVE
P. O. BOX 599
CARLISLE. PA 17013-OSM
ASSISTANCE After the first neck which may be a special amount you will receve 5
CHECK
?AEDICAL
ASSISTANCE
E] FOOD
STAMPS
® NURSING HOME CARE
? Twice a Momh ElOnce a Month In the Mail AI the Bank
X You have a patient pay iaNlhy of S
for the eriod
P he9Wti09 and enrFng ? Effective Date
You :rill receive 5 for the month(s) of then you wig receive toW stamps in the amount d S
a month Iran to l] M the Mad ? At the Bank
Level of ore authorized you are e,peCled to pay 5 a month townrg
yOUf GVE
THE FOLLOWING PERSONS ARE INCLUDED
LINE NAME
NAME
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) L' +ILf ??,,tt _? v2 s SL?L{''ucS o 11-1- tt? .. +
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L] FOOD STAMPS - Number of Pe -111- ED ASSISTANCE CHECK
Name EARNED Y Name
S
s
Name
TOTAL GROSS MONTHLY INCOME $
GROSS MONTHLY DEPENDENT CARE COSTS S
GROSS MEDICAL COSTS $
Telephone Water/Sewage
Electric Garbaga/Trash
Gas Utility Installeflon
Oil Other
GROSS UTILITY COSTS/UTILITY STANDARD' $
RENT/MORTGAGE $
TAXES S
INSURANCE COST ON HOME S
TOTAL SHELTER COST S
Name
TOTAL GROSS MONTHLY INCOME
GROSS MONTHLY DEPENDENT CARE COSTS
MEDICAL ASSISTANCE
Name
Name
Number of Persona
GROS&
EAFUIE
s
$
s
GROSS
l1NEARN
S
Number of Persons 00-
GROSS
EARNS
$
S
$
'The household may switch between the actual utility costs and the TOTAL GROSS MONTHLY INCOME
Standard utility allowance at the time of reapplication and one NET MONTHLY INCOME/NET SEMI-ANNUAL INCOME
additional time during each twelve-month period.
INCOME LIMIT
CO RECORD NUMBER CAT GTR DIG DI5T
21 l ?.`? l AIL' ? .
r
L
C t?,1t s?z I a ?l c }3
$
S
S
S
S
S
tI .i?x: Ltr
Worker s Sfynature
ole T6lftnhnnn RY.m6nr
a ?C?RTr
MAR 0 3 Z007
It you do not understand our decision or have any questionsiran'- y 1
-_ LEGAL HELP IS AVAILABLE AT
1 LEGAL SERVICES, INC.
8 IRVINE ROW
CARLISLE, PA 17013-3019
717-243-8400 717-766-8475
CLIENT COPY
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No. No. 08-247
EDITH ECKART,
Defendant. CIVIL ACTION - EQUITY
PETITION FOR PRELIMINARY INJUNCTION
AND NOW, COMES, Petitioner, Church of God Home, Inc. ("Petitioner"), by
and through its attorneys, SCHUTJER BoGAR LLC, and files the following Petition against
Respondent, Edith Eckart ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in
support thereof, avers:
1. On or about January 14, 2008, Petitioner filed its Complaint against
Respondent.
2. The Complaint sets forth a claim against Respondent relating to
Respondent's breach of her contractual duties owed to Petitioner by failing to cooperate
in the appeal of the denial of the Medical Assistance application of Bertha Stone, her
mother ("mother"), by providing the necessary financial documentation to the
Cumberland County Assistance Office to determine her mother's eligibility for benefits.
See Exhibit "A" to Complaint.
ORIGINAL
3. The very nature of Respondent's breach of her contractual duties presents
an issue of immediate and irreparable harm to Petitioner, as the appeal of the
Cumberland County Assistance Office's denial of Respondent's mother's Medical
Assistance application will fail due to the lack of necessary evidence to qualify
Respondent's mother for Medical Assistance benefits.
4. If Respondent does not provide the information requested by the
Cumberland County Assistance Office prior to or at the time of a hearing on that
appeal, the appeal will be finally denied and any further appeal to the Commonwealth
Court would be without merit.
5. The requested injunction would restore the parties to the status quo as it
existed immediately prior to the breach of Respondent's contractual duty.
6. Greater injury would result from the denial of the requested injunction
than from the granting of the same because absent the injunction, without the
information necessary to qualify Respondent's mother for Medical Assistance benefits,
the appeal of the denial of the Medical Assistance application will fail.
7. Petitioner's right to relief is clear. See Complaint attached hereto as
Exhibit "A."
8. Petitioner lacks an adequate remedy at law, as upon information and
belief, at all times material hereto, Respondent's mother has been financially unable to
fully compensate Petitioner for the care and services that it rendered to her and
continues to render to her in accordance with the Agreement.
2
9. A bond in the amount of $100.00 should be adequate in the event that it is
later determined that the issuance of the instant petition was in error.
WHEREFORE, Petitioner respectfully requests that the Court schedule an
immediate hearing on its request for injunctive relief and thereafter issue a decree
ordering specific performance of the contractual duty of Respondent.
Dated 21 d5
Respectfully submitted,
SCHUTJER BOGAR LLC
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Maria G. Macus-Bryan
Attorney I.D. No. 90947
(717) 909-8640
417 Walnut Street, 41h Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
3
*31
VEMICATION
The undersigned hereby venfics that the statements of fact in the foregoing
petition are true and correct to the best of my knowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C.S.A. § 4904, relating to unswom falsi fication to authorities.
Dated: AQ J -n= ,4 a6o1..t J
Sharon Crmner, SR Billing/AR Specialist
Church of God Home, Inc
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Petitioner's Petition
for Preliminary Injunction was served via first-class, United States mail, postage
prepaid, upon the following:
Edith Eckart
527 D South West Street
Carlisle, PA 17013
Dated:
By:
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William Keslar, Paralegal
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
No. 08-247
EDITH ECKART,
Defendant.
CIVIL ACTION - EQUITY
CERTIFICATION
1. Pursuant to Local Rule 208.3(a)(2), upon the information and belief of
Petitioner, a Judge has not ruled upon any other issue in the same or related matter.
2. In accordance with Cumberland County Local Rule 208.3(a)(9), Petitioner
is unaware of whether Respondent has retained counsel of record, and to date,
Petitioner has not received a Entry/Notice of Appearance of counsel of record for
Respondent.
Dated: 113doe
Respectfully submitted,
SCHurjER BOGAR LLC
By: W.
Bra ey A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Maria G. Macus-Bryan
Attorney I.D. No. 90947
(717) 909-8640
305 North Front Street, Suite 401
Harrisburg, PA 17101
Attorneys for Petitioner
ORIGINAL
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CHURCH OF GOD HOME, INC.,
PLAINTIFF
V.
EDITH ECKART,
DEFENDANT
AND NOW, this
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
08-247 CIVIL TERM
ORDER OF COURT
day of February, 2008, a hearing on the within
petition for a preliminary injunction shall be conducted in Courtroom Number 2,
Cumberland County Courthouse, Carlisle, Pennsylvania at 1:30 p.m., Wednesday,
February 20, 2008.
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M G. Macus-Bryan, Esquire
77 Walnut Street, 4th Floor
Harrisburg, PA 17101
dith Eckart
527 D South West Street
Carlisle, PA 17013
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No. 08-247
EDITH ECKART,
Defendant. CIVIL ACTION - EQUITY
AFFIDAVIT OF SERVICE
I, William Keslar, being duly sworn according to law, depose and say that
I served Defendant Edith Eckart with the attached Order of Court dated
February 5, 2008, in the above-captioned matter, via First-Class Regular Mail, to
her residence at 527 D South West Street, Carlisle, PA 17013 on the 8t" day of
February, 2008.
Dated: 'y 0 0 b
William Keslar, Paralegal
Swor t nd Subscribed before me
th' day of
2008.
Notary P, b is
My Co ' ion Expires:
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NOTARIAL SEAL
CFltiWN A. LONG, Notary Public
City of I W, isburg, Dauphin County
Commkoion Expires December 22, 2009
ORIGINAL
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SCHUTJER I BOGAR L1.C
attorneys & const,:ltants
Email: wkeslar@schutjerbogar.com
Direct Dial: (717) 909-7002
February 8, 2008
Via Regular Mail
Edith Eckart
527 D South West Street
Carlisle, VA 17013
Re: Church of God Home, Inc. v. Edith Eckart; Docket No.: 08-247
Dear Ms. Eckart:
Enclosed please find an Order dated February 5, 2008, from the Honorable
Edgar B. Bayley scheduling a hearing for Wednesday, February 20, 2008, at 1:30
p.m. in Courtroom 2, Cumberland County Courthouse, Carlisle, Pennsylvania.
If you should have any questions, please contact Maria G. Macus-Bryan at
(717) 909-8640. Thank you.
Sincerely,
SCHUTJER BOGAR LL.C
\I\"--
William Keslar
Paralegal
Enclosure
305 `NJ Front Street, Suite 401, Harric-burg, PA 17101 • Fax (717) 999-5925 • .vWw.schutjerbogar.com
CHURCH OF GOD HOME, INC.,
PLAINTIFF
V.
EDITH ECKART,
DEFENDANT
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
08-247 CIVIL TERM
ORDER OF COURT
AND NOW, this <--If? day of February, 2008, a hearing on the within
petition for a preliminary injunction shall be conducted in Courtroom Number 2,
Cumberland County Courthouse, Carlisle, Pennsylvania at 1:30 p.m., Wednesday,
February 20, 2008.
Maria G. Macus-Bryan, Esquire
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Edith Eckart
527 D South West Street
Carlisle, PA 17013
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CASE NO.: 08-247 Civil Term
AFFIDAVIT OF SERVICE
Church of God Home, Inc.
VS.
Edith Eckart
Commonwealth of Pennsylvania
County of Dauphin as.
I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 8:01 PM on
02/07/2008,1 served Edith Eckart at 527D South West Street, Carlisle, PA 17013 in the manner described below:
® Defendant(s) personally served.
? Adult family member with whom said Defendant(s) reside(s).
Relationship is
? Adult in charge of Defendant(s) residence who refused to give name and/or relationship.
? Manager/Clerk of place of lodging in which Defendant(s) reside(s).
? Agent or person in charge of Defendant's office or usual place of business.
? an officer of said Defendant's company.
? Other:
a true and correct copy of Notice to Defend, Complaint, Verification issued in the above captioned matter.
Description:
Sex: Female - Age: 70 - Skin: White - Hair: White - Height: 5' 06" ^ Weight: 150,1
Swor to and su
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20d Jo1# Shinyowsk V
Sh kowsk In tions
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Fawn Ridg
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or
Harrisburg, PA 17110
b\ (800) 276-0202
NOTARY PUBLIC COMMONWEALTH OF PENNSYLVANIA
.??. Atty File#: -Our File# 2982
NOTARIAL SEAL
PAULA K. SMITH, Notary Public
Susquehanna Twp., Dauphin County
My Commission Expires Feb. 3, 2012
Law Firm: Schutjer Bogar LLC
Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102
Telephone: (717) 909-5925
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No. 08-247
EDITH ECKART,
Defendant. CIVIL ACTION - EQUITY
ORDER
AND NOW, this day of 2008, in consideration of the
parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that:
1. Within fifteen (15) days of the date of this Order, Edith Eckart shall
provide any and all records within her possession that are required by the Cumberland
County Assistance Office for the pending appeal of the application to determine Bertha
Stone's eligibility for Medical Assistance benefits and diligently work to secure any and
all other documents necessary to obtain benefits for Bertha Stone.
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