HomeMy WebLinkAbout03-6523SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff,
V.
MARY E. FRAZIER and
JEAN FRAZIER,
Defendants.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO.2003- GS:L3 CIVIL TERM
CIVIL ACTION-LAW
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by an 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
SHIPPENSBURG/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff,
V. NO. 2003- 6,S_23 CIVIL. TERM
MARY E. FRAZIER and CIVIL ACTION-LAW
JEAN FRAZIER,
Defendants.
COMPLAINT
NOW, comes Shippensburg/South Hampton Manor Limited Partnership ("Shippensburg
Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within
Complaint and, in support thereof, sets forth the following:
Shippensburg/South Hampton Manor Limited Partnership is a Maryland limited
partnership duly authorized to conduct business in the Commonwealth of Pennsylvania.
Defendant, Mary E. Frazier, is an adult individual with a residence address of 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
Defendant, Jean Frazier, is an adult individual with a residence address of 7993
Nyesville Road, Chambersburg, Pennsylvania.
4. Shippensburg Health operates a resident skilled nursing facility (the "facility")
located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
On or about April 21, 1997, Jean Frazier sought to have Mary E. Frazier admitted
to the Shippensburg Health facility.
6. On or about April 21, 1997, Jean Frazier executed an Admission Agreement to
have Mary E. Frazier admitted to the facility. A true and correct copy of the execution page to
the Admission Agreement is attached hereto as Exhibit "A" and is incorporated. A true and
correct copy of the form Admission Agreement which was used in the ordinary course of its
business by Shippensburg Health as of April 21, 1997 is attached hereto as Exhibit "B" and is
incorporated by reference.
On or about April 21, 1997, Mary E. Frazier became a resident of the facility and
remains a resident as of the date of filing of this complaint.
8. A determination was made by the Cumberland County Assistance Office that
Mary E. Frazier qualified for medical assistance. The Cumberland County Assistance Office
calculated a private pay portion to be paid from the monthly income of Mary E. Frazier to
Shippensburg Health for the costs of her care not covered by medical assistance.
9. At the time of her admission, Mary E. Frazier was receiving a monthly social
security benefit of $662.00 per month.
10. Upon information and belief, Jean Frazier was receiving the social security
benefits of Mary E. Frazier during the period of time Mary E. Frazier has been a resident of the
facility.
11. At the time of filing, Mary E. Frazier owes Shippensburg Health the sum of
$6,361.96 in accordance with the Statement attached hereto as Exhibit "C" and incorporated by
reference.
2
12. Most of the balance owed has accrued from the failure of Mary E. Frazier and
Jean Frazier to pay over the private pay portion to Shippensburg Health from the social security
benefits of Mary E. Frazier.
11 Demand has been made upon Mary E. Frazier and Jean Frazier to tender the
amount due and owing to Shippensburg Health from the income of Mary E. Frazier.
14. Upon information and belief, Jean Frazier has applied the sums received on
account of Mary E. Frazier for her own use and enjoyment.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. MARY E. FRAZIER and JEAN FRAZIER
15. Plaintiff incorporates by reference paragraphs one through fourteen as though set
forth at length.
16. All conditions precedent to recovery under the Admission Agreement have been
fulfilled.
17. Jean Frazier, was obligated to use the assets and income of Mary E. Frazier to
satisfy the debt due and owing to Shippensburg Health. for the services and care provided to
Mary E. Frazier by Shippensburg Health.
18. Mary E. Frazier is obligated to pay the costs of her care provided by Shippensburg
Health which were not covered by a third party payor.
19. Mary E. Frazier and Jean Frazier have, without justification, failed and refused to
pay the amount due.
20. Mary E. Frazier and Jean Frazier have breached the Admission Agreement by
failing and refusing to pay for the services rendered. The Admission Agreements provides for
the recovery of attorney fees and costs by Shippensburg Health.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the
sum of $6,361.96, interest, costs, expenses, attorney fees and any additional amount coming due
to the date of award.
COUNT II- QUANTUM MERUIT
SHIPPENSBURG HEALTH v. MARY E. FRAZIER
21. Plaintiff incorporates by reference paragraphs one through twenty as though set
forth at length.
22. During the period of her residency at the facility, Mary E. Frazier has enjoyed the
benefit of care and services provided to her by Shippensburg Health.
23, Mary E. Frazier has failed and refused to pay for the costs of her care and services
provided by Shippensburg Health to her.
24. Mary E. Frazier has been unjustly enriched by her use and enjoyment of the
services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Mary E. Frazier for
the sum of $6, 361.96 plus costs, expenses and interest.
COUNT III-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. JEAN FRAZIER
25. Plaintiff incorporates by reference paragraphs one through twenty-four as though
set forth at length.
4
26. During the period of Mary E. Frazier's residency at the facility, Jean Frazier has
received the sum of at least $52,298.00 from the social security benefits of Mary E. Frazier.
27. The proper use of those funds would have been to pay the costs of care accruing
for the care of Mary E. Frazier.
28. At the time of receipt of these funds, Jean Frazier knew she was obligated to pay
these funds over to Shippensburg Health for the costs of Mary E. Frazier's care at the facility.
29. Jean Frazier gave no consideration for the funds of Mary E. Frazier received by
Jean Frazier.
30. Demand has been made upon Jean Frazier to tender the funds of Mary E. Frazier
to Shippensburg Health and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Jean Frazier requiring
her to:
a) return the subject matter in specie;
b) pay over the value if Jean Frazier has consumed the money in beneficial use;
C) pay its value if Jean Frazier has disposed of the funds received; and
d) award costs, expenses and interest.
Respectfully submitted,
O'BRIEN, BARIC & SCHE R
David A. Baric, Esquire
I.D. 44853
17 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
12/P.9/2003 10:40 7172495755 CBS PAGE 08
VF,RMCAT70N
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon infomtation which I have
given to my counsel, they 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 Pa.C.S. §
4904 relating to unsworn falsifications to authorities.
DATE: ! v
J
Larry Cottle, Administrator
q? ?r
'Hz
DEC 05 '02 09. nAM
Additional Documents
P.7
It is not possible to cover everything that is'ltnportant to your stay in our Facility in the body of
this Contract. Therefore, we have included additional important documents as Exhibits. These
Exhibits are pan of this Contract, Please verify that you received the Exhibits and that the
contents of the Exhibits were explained to you by placing your initials on the lice next to the
description of each Exhibit.'
MP -. Exhibit 1. Rights and Obligations of Representatives.
Exhibit 2. For Private Pay Residents;
(a) Items and services covered by daily rate.
(b) Items and services not covered by daily rate.
Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits.
Exhibit 4. (a) Items and Services Covered by Medicaid.
(b) Items and Services Not Covered by Medicaid.
_ Exhibit 5. Physicians Who Practice at the Facility.
Exhibit 6. Legal Rights of Pennsylvanians to Decide Future Medical Treatment.
Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your
Personal Property,
?r_ Exhibit 8. Services Provided by Outside Health Care Providers.
chauees in Law
Any provision of this Contract that is found to be invalid or unenforceable as a result of a change
in State or Federal law will not invalidate the remaiaing provisions of this Contract. If there are
services we have agreed to provide that are later found to be impossible to render as a result of a
change in State or Federal law, it is agreed that to the extent possible, the Resident andthe
Facility will continue to fulfill our respective obligations under this Contract consistent with the
law.
Ackwission Contract. Pase 7
u6-cm dm 1W
EXHIBIT "A"
/?EC 05 '03 09:23AM
j G
P.e
WHEREOF, the parties have executed this Contract on this a2/ t-$?' , day of
19?
4474
Witness
Resident
If the Resident has been adjudicated disabled or the Resident's doctor determines that the Resident
is incapable of understanding or exercising his or her dou and responsrbilities, the Facility may
require the signature of another person on this contract. The other person may be-. (1) An
appointed healthcare agent wader an advance directive for medical care; (2) A guardian or Power
of Attorney of the person; (3) A surrogate or family member.
rmess Re onsble Party (Harps)
a-
Title: Indicate whether you are (1), (2) or (3)
Admissigr} _Caatra_m Pare S
3dSw .dw IONS
J
DEC 05 '03 09:23RM P.9
LNMIT 1
J? RIGHTS AND O;BUGA'TZ YS OF RE ENTATIVE
The Representative shall have the right to be notified by the Facility of any event or
occurrence iavolviug the Resident which directly affects any obligation of the Representative
under this Agreement. Representative agrees to assume independently, under this Agreement, the
following obligations and is entitled to the following rights, as indicated by Representative's
initials accompanying any of the following provisions:
Representative agrees to be responsible for ensuring that any payment from the resident
to which the Facility is entitled pursuant to this Agreement "be paid to the Facility in a
timely manner. In the event the Resident is a beueftciary of Medicare, Medicaid or any
other third-party payment plan, Representative agrees to ensure that all co-payments,
co-insurance or charges and fees for non-covered items and services, together with any
late fees as described under this Agreement, shall be paid from the Resident's fiords.
Representative is subject to a civil penalty for wMf violation ofthe agreement to
distribute the Residents funds to the facility.
(Unless the Representative vohmtanly agrees to act as guarantor), Representative shallbe
responsible for any payments required under this Agreement only to the extent of the
Resident's fiords.
R- Resident is applying for admission on private pay basis, and Representative agrees to assist
the Resident in providing all financial information required by the Facility to determine the
extent of the Resident's resources. If it is ever determined the Representative participated
in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate
disclosure shall be deemed a material breach of this Agreement and the Facility reserves
the right to pursue all available legal remedies against the Representative, including but
not limited to an action for breach of contract,
Exhibit 1. Pace I
16VAILdw tans
DEC 05 '03 09:24AM
P.10
Representative is signing this Agreement as a duly authorized agent such as an appointed
healthcare agent under an advance directive or guardian appointed by a court. A copy of all
supporting documentation for this representation is attached to this Agreement.
?J F Representative is signing this Agreement on Resident's behalf, based upon a physiowa
certificate, a copy of which is attached to this Agreement, certifying that Resident does not
possess the capability to understand his or her rights and responsibilities,
-?!--VRepresentative agrees that in the event of the Resident's death, Representative shall take
responsibility of all burial arrangements for the Resident and for removal of an personal
property from the facility.
5? If it is the desire of the Resident or Representative to obtain the supplemental services of
private duty nurses in accordance with the requirements descnbed under this Agreement,
Representative agrees to be responsible for arranging independently for those services,
including ensuring any payment.
Representative agrees that in the event the Resident's private funds are exhausted during the
Resident's stay and the Resident is eligible to apply for benefits under the Medicaid Program,
the Representative shall assist the Resident and the Facility with any application for Medicaid
benefits. Representative further agrees to act, on behalf of the Resident, to facilitate any
Medicare, Veterans Administration or other third-party benefits which may be available to
cover the cost of Resident's care at the Facility.
?a the event the resident seeks to teruinnate this Agreement, the Representative agrees to
ensure that all notices required under this Agreement are provided to Facility.
Exhibit 1, page 2
DEC 05 '03 09:24RM
P.11
???Ia the event of an involuntary termination of this Agreement, if other arrangements
acceptable to the Resident cannot be made, the Representative agrees to accept the Resident
into the Representative's custody, if medically appropriate.
Z ` Representative has the right to copies of the following documents and any amendment to
them. Representative farther acknowledges receipt of the following documents, which may
be amended from tmze-to-time:
1. A copy of this Admission Agreement.
2. A list of the Facility's rates, subject to amendment on tbiry (30) days notice,
and a description of charges for services not included
3. A list of health care providers offering services at the facz'hty.
Zg& Representative acknowledges the Factlitys right to any legal remedies available under law for
Representative's breach of this Agreement.
Exhibit 1, Page 3
ld==dw 10/96
DEC 18 103 01:53PM
ADMISSION CONTRACT
OF
SEVPENSBURG HEALTH CARE CENTER
121 WALNUT BOTTOM ROAD
SHIPPENSBURG, PA 17257
P.2
This Contract is between. Shippensburg Health Care Center (the "Facility" or "we" and),
._(the "Resident" or "you") and, if you or the court have
designated an individual to'act on your behalf; or there is another individual to act on your behaK
or operation of law, ("your representative"). A check list of the
rights and responsibilities applicable to your representative is at Exhibit 1 and is incorporated into
this Contract.
Paving for Yqur Care
If you are applying to thip facility as a private-pay resident, you must provide all financial
information requested by us. If we later find that the information you or your representative
provided was incomplete or inaccurate; we will consider that as a breach of this Agreement which
gives us the right to pursue "ell legal remedies against you or your representative.
Who Can be RequiredlDVv fgr Your Care
Only you and your insurer can be required to pay for your care. No other person, (i.e. a family
member, friend, neighbor, legal representative or guardian) can be required to pay from their own
funds for your care, ahhot* he or she may knowingly and voluntarily agree to guarantee
payment for the cost of your care. We require the person responsible for making payments on
your behalf to pay for your care under the terms of this contract in a timely manner.
If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your
representative agrees to make all necessary payments from your funds. Your representative could
face a civil penalty for intentionally failing to pay required amounts from your funds and could
face a criminal penalty for abusing your funds.
Admission Contract. Page 1
ad=Gd.doc 1019$
EXHIBIT "B"
DEC 18 103 01:53PM
Private Pay Residents
P.3
The items and services inchided in our daily rate are basic room, board and general nursing care as
required by your medical condition. Payment for items and services that are included in the daily
rate and is payable one month in advance and due on the first of each month. Items and services
included in your daily rate are listed in Exhibit 2.A.
You will be charged separately for additional items and services not included in our daily rates
such as special nursing care, special equipment, pharmacy charges, laboratory charges, medical
transportation and additional services such as telephone expense, dry cleaning, beauty and barber
services and newspapers. Items and services for which you will be charged are listed in Exhibit
2.8. Payment for these additional hems and services are due after you have requested them, and;
you have received and have been billed for them Within 30 days of receiving an item or service,
you have the right to ask us for an itemized financial statement that briefly but clearly describes
each item and the amount t harged for it . You will be given an updated listing of services and
related charges, including any charges for services not covered under Medicare or by the facilities
basic per diem charges, annually on or about January 1 of each year.
Medicare Residents
We participate in the Medicare Program Medicare may pay for some or all of your nursing home
care. For information on Medicare, see Exhibit 3. If you are eligible for Medicare, you have the
right to have claims for your nursing home care submitted to Medicare.
Medicaid Residents
We participate in the Medicaid program For infomation on Medicaid, see Exhibit 3. You are
not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If
your private funds are used up during your stay here and you are eligible for Medicaid, we will
accept Medicaid payments although Medicaid may require you to pay some amount in addition to
what Medicaid pays for your care. If you are planning on applying to Medical Assistance later,
you may want to find out now if you are "medically eligible" for nursing home payment by
Medicaid.
Admlasion?Cogtact. Page 2
admomdoc 10195
DEC 18 103 01.54PM
P.4
You are responsible for applying for and obtaining Medicaid benefits and we will assist you. We
may not charge, ask for, accept or receive any gift, money, donation or consideration other than
Medicaid reimbursement as a condition of your admission or continued stay here except that
Medicaid may require you to pay certain amounts from your private fttnds.
If you receive Medicaid, most of your nursing home charges such as room, board, and general
nursing care are covered. For a list of services covered by Medicaid, see Exhibit 4.A. The local
Board of Assistance will tell you whether you have to pay part of the charge for your care and, if
so, how much. Some of the items and services that we offer are not covered by Medicaid. If you
want any items or services'which are not covered by Medicaid, you or your representative will
have to pay for them A list of the items and services not covered by Medicaid and the charges
for them are in Exhibit 4.B, Payment for items and services that are not covered by Medicaid is
due after you have requested them, and; have received and have been billed for them. Within 30
days of receiving the item or service, you have the right to ask us for an itemized statement that
briefly but clearly describes each item and the amount charged for it.
IPereases in Charees and Fees
Any time we increase a fee or charge for item or service or add a new item or service, we will
provide you and your representative with 30 days advance written notice,
Penalties
We may not charge you interest if you pay your bill in time. Your payment is on time if it is made
within 45 days of the dateShe bffi is postmarked, or 30 days after the end of the billing period,
whichever is later. The penalty we charge is 5% of the amount due, calculated on a per day basis.
If you or your representative do not pay the money you owe us and we hire a collection agency or -
attorney, you agree to be liable for their fees and court costs.
Selection of a Dogtor
You may select your own doctor. Your doctor must follow our policies. You or your insurer,
including the Medicaid Program, are responsible for your doctors payment, If you do not have
your own doctor on the day you are admitted, we will assign one to you. In case you doctor is
not available when needed, our Medical Director, or his or her designee, will render interim
medical services until your 'doctor is available
Admission Contract, Page 3
adm=d« imss
DEC 18 103 01:54PM
Private Dutv Nurses Geriatric Aides
P.5
If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting, a
person licensed and/or certified according to Pennsylvania laws and regulation. You are also
responsible for paying him or her and for letting us know that you have hired one. The person
you hire is not an employee or agent of the facility, but he or she must meet our standards and
follow our policies and procedures. Employees of the Facility may not serve as private duty
nurses or private duty geriatric aides.
Holdina Your Bed if You Leave the Facility
if you are hospitalized or on leave from the Facility, we will hold your bed for you as follows:
A. If you are a private-pay resident, or are receiving inpatient care reimbursed under
Medicare Program (and you are not covered under Medicaid), unless you notify us
otherwise, we will hold your bed for as long as you pay for it at the daily rate you are
currently being charged.
B, if Medicaid pays for part or all of your nursing home care and you need to be hospitalized,
we will hold you:: bed for up to the maximum number of days required by this state,
currently 15 days. If you leave for any other reason, we will hold your bed for up to the
=dmum number of days required by this state, currently 18 days. You have aright to be
readmitted to the facility to the first available appropriate bed, While we are holding your
bed, you are still required to pay the Facility any amount for which you are liable as
determined by the Medicaid Program,
C. If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph
B. However, if you are found to be ineligible for Medicaid, then you are required to pay
for the bed as a private pay resident as described in Paragraph A.
D. Other third-party payers mayor may not have abed hold policy. We will discuss this if it
applies to you.
Your lRieht to r4ske CorAplaints and Suggest Cbanses in Policies and Services
As a nursing home resident, you have many rights according to State and Federal law. These are
described in detail in Exhibit 6, which is attached and is part of this Contract.
Admission Contract, kne 4
adncmdw 10195
DEC 18 103 01:55PM
P.6
You may make complaints about your care in the Faoility and you may also suggest changes in the
policies and services of the Facility. You will not be harassed or discriminated against for making
a complaint or suggesting a change in a policy or service. You may present your complaints to
facility, management company or to one of the following State agencies:
(1) Larry Cottle, HNA
Administrator
Shippensburg Health Care Center
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
(717) 530-8300
(2) Peter E. Perini
Vice President
Magnolia Management, Inc.
19639 Airview Road
Hagerstown, Maryland 21742
(301) 790-3650
(3) Ombudsman
Office of Aging
Human Service Building
16 West High Street
Carlisle, Pennsylvania 17013
(717) 240.6110
(717) 532-7286 Ext.6110
Your Right to Make Decisions
(4) DepartmeutofHealth
100 North Cameron Street
2nd Floor
Harrisburg, Pennsylvania 17101
(717) 783-3790
You have the right to make your own medical decisions and to manage your personal affairs. If
you become disabled, it may be necessary for someone else to make decisions for you. For this
reason, we recommend that; you have a living will and/or advance directives for medical decisions
and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a
description of your legal rights to decide about your future medical treatment,
Transfer. Relocation and Discharge
You have the right to remain here, and you may not be transferred, relocated or discharged
against your will, except for the following reasons; (1) A medical reason (Le. the facility cannot
provide the kind of care that you need, your condition has improved so that you no longer need
the care we provide, or a medical emergency arises); (2) Your welfare or the welfare of other
residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate.
Admission Contract, Page 5
AdMC=&X 10/95
..1---- P.7-- .
DEC 10 '03 01:55PM
If we decide that you should be transferred or discharged, we will notify you, and an immediate
family member or legal representative, by letter 30 days in advance. If you are transferred
because of an emergency s#uatiou, we will provide the required notice as soon as practicable.
The letter will contain the reasons for the transfer or discharge and its effective date. The letter
will also tell you how you can appeal our decision to transfer or discharge you.
If you are discharged involuntarily, we will attempt to make other appropriate arrangements for
your care. However, if other arrangements acceptable to you or your representative cannot be
made, your representative agrees to accept you into his or her custody if it is medically
appropriate.
Your )Right to End This Contract
If you decide to end this Contract and leave the Facility, you must pay your bill before you leave,
You must give us 5 days written notice to terminate this contract. If you leave before the end of
that time, you must still pay for each day of the required notice.
In the event you die while a resident of the facility, your representative is responsible for making
the funeral arrangements. We will notify your representative immediately. If we are unable to
reach your representative, we, will contact the funeral home of your choice to facilitate
arrangements.
M10*190 Cgnt{actJans 6
aftcmdw 1W53
DEC 18 '03 01:55PM
Additional Documents
P.8
It is not possible to cover. everything that is important to your stay in our Facility in the body of
this Contract. Therefore,-we have included additional important documents as Exhibits. These
Exhibits are part of this Contract. Please verify that you received the Exhibits and that the
contents of the Exhibits were explained to you by placing your initials on the line next to the
description of each Exhibit.
Exhibit 1. Rights and Obligations of Representatives.
Exhibit 2. For Private Pay Residents:
(a) Items and services covered by daily rate,
(b) Items and services not covered by daily rate.
Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits.
Exhibit 4. (a) Items and Services Covered by Medicaid.
(b) Items and Services Not Covered by Medicaid.
Exhibit 5. Physicians Who Practice at the Facility.
Exhibit 6. Legal Rights of Pennsylvanians to Decide Future Medical Treatment.
Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your
Personal Property.
Exhibit 8, Services Provided by Outside Health Care Providers.
Cbanw in Law
Any provision of this Contract that is found to be invalid or unenforceable as a result of a change
in State or Federal law will not invalidate the remaining provisions of this Contract. If there are
services we have agreed to provide that are later found to be impossible to render as a result of a
change in State or Federal law, it is agreed that to the extent possible, the Resident and the
Facility will continue to fulfill our respective obligations under this Contract consistent with the
law.
A4mis&v jCgntrsct, Paee 7
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DEC 18 103 01:56PM
P.9
IN WITNESS WHEREOF, the parties have executed this Contract on this , day of
,19
By.
Witness Name: Larry D. Cottle
Title: Administrator
Shippenaburg Heahh Care Center
Witness Resident
If the Resident has been adjudicated disabled or the Resident'a doctor determines that the Resident
is incapable of understanding or exercising his or her rights and responsibilities, the Facility may
require the signature of another person on this contract. The other person may be: (1) An
appointed healthcare agent, under an advance directive for medical care; (2) A guardian or Power
of Attorney of the person; ;(3) A surrogate or family member.
Witness Responsible Party (name)
Title: Indicate whether you are (1), (2) or (3)
Admission irQntract, Pane S
edm dx iaMs
NOV
25 03 ii:02RM
-STATEMENT P-4
r
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Facility Phone: 717-530-8300
Resident: MARY FRAZIER
Statement Date: 11/30/03
I
JEAN FRAZIER
7993 Nyesvlile Road
J
Chambersburg, Pa 17201
J
Date Service Through qty Description Amount
Sub Total as of 12/31/02 1,447.76
s
gharge
11105/03 01/01/03 11/05/03 73 Patient Liability 8,669.84
Sub Total 8,669.84
Balance 10,117.80
Cash Recei ote/Adiustments
07128103 05131/01 04/06103 Payment -720.25
02/24/03 11/30/02 11130/02 Payment -723.88
03/27/03 12/31102 01105103 Payment -729.88
08/04103 01/06/03 04/05/03 Payment -720.25
07/28/03 03105/03 03/06/03 Payment -720.25
07/01/03 01/01/03 01/31/03 1 ADJ. CABLE -7.00
07/01/03 01/06/03 01/06/03 1 ADJ. Patient Liability -39.23
07/01/03 02/01/03 02128/03 1 ADJ. CABLE -7,00
07/01/03 02/06/03 02/06/03 1 ADJ. Patient Liability -39.23
07/01/03 03/01/03 03/31/03 1 ADJ. CABLE -7.00
07/01/03 03/06/03 03106/03 1 ADJ. Patient Liability -39.23
07/01/03 04/29/03 04/29/03 1 ADJ. Barber & Beauty -8.25
07/01/03 04/01/03 04/30/03 1 ADJ. CABLE -7.00
07/01/03 04/06/03 04/06/03 1 ADJ. Patient Liability -39.23
07101/03 05/05/03 05/06/03 1 ADJ. ADJ. Patient Liability 39.23
07/01/03 05/01/03 05/31103 1 ADJ, CABLE -7.00
07/01103 05/01/03 05/06/03 8 ADJ. Patient Liability -764.21
07/01/03 06/06/03 06/06/03 1 ADJ. Patient Liability -2.10
EXHIBIT "C"
Page 1
N (?
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1
?, 1
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SHERIFF'S RETURN - NOT SERVED
CASE NO: 2003-06523 P
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON MAN
VS
FRAZIER MARY E ET AL
R. Thomas Kline
Sheriff , who being duly sworn
according to law, says, that he made a diligent search and inquiry for
the within named DEFENDANT , to wit:
FRAZIER MARY E but was
unable to locate Her in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
NOT SERVED , as to
the within named DEFENDANT
, FRAZIER MARY E
121 WALNUT BOTTOM ROAD
SHIPPENSBURG, PA 17257
NOT SERVED PER REQUEST FROM LARRY COTTLE, PLAINTIFF'S
ADMINISTRATOR.
Sheriff's Costs: So answers,-,"
Docketing 18.00
Service 13.80
Affidavit .00 R. Thomas line --
Surcharge 10.00 Sheriff of Cumberland County
.00
41.80 OBRIEN BARIC SCHERER
01/26/2004
Sworn and subscribed to before me
this a P? day of
Prothonotary
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2003-06523 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
SHIPPENSBURG/SOUTH HAMPTON MAN
VS
FRAZIER MARY E ET AL
R. Thomas Kline
, Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT to wit:
FRAZIER JEAN
but was unable to locate Her in his bailiwick. He therefore
deputized the sheriff of FRANKLIN County, Pennsylvania, to
serve the within COMPLAINT & NOTICE
On January 26th , 2004 , this office was in receipt of the
attached return from FRANKLIN
Sheriff's Costs: So answer ' -?
Docketing 6.00
Out of County 9.00
Surcharge 10.00 R. Thomas Kline
Dep Franklin Cc 32.00 Sheriff of Cumberland County
.00
57.00
01/26/2004
OBRIEN BARIC SCHERER
Sworn and subscribed to before me
this 1r day of ?,-`7
?o-ny A. D.
P ot,hoty°
SHERIFF'S RETURN - REGULAR
CASE NO: 2003-00304 T
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF FRANKLIN
SHIPPENSBURG/SOUTH HAMPTON
VS
JEAN FRAZIER ET AL
THEODORE L KONCSOL
:.?vo3-?'Sa3
, Deputy Sheriff of FRANKLIN
County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT
FRAZIER JEAN
the
DEFENDANT , at 0008:00 Hour, on the 31st day of December , 2003
at FRANKLIN CO SHERIFF'S OFFICE 157 LINCOLN WAY EAST
CHAMBERSBURG, PA 17201 by handing to
JEAN FRAZIER
a true and attested copy of COMPLAINT
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing .00
Service .00
Affidavit .00
Surcharge .00
.00
.00
Sworn and Subscribed to before
me this ?? ?ay of
.
0 &00
So Answers:
THEODORE CSOL
By
eputy Sheriff
01/22/2004
OBRIEN BARIC AND SCHERER
NotwW SaW I
Richwd D. McCwy, N t y FuW
Chmnbmeb n Bmo, FrwMin Cm Ay
My Cmmimfco Expimu Im. 29, 2017
was served upon
Curtis R. Long
Prothonotary
Office of the Protbonotarp
Cumberfartb Countp
Renee K. Simpson
Deputy Prothonotary
John E. Slike
Solicitor
n3 - L S123 CIVIL TERM
ORDER OF TERMINATION OF COURT CASES
AND NOW THIS 5TH DAY OF NOVEMBER 2007 AFTER MAILING NOTICE OF
INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE
CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA
R C P 230.2.
BY THE COURT,
CURTIS R. LONG
PROTHONOTARY
One Courthouse Square • Carlisle, Pennsylvania 17013 • (717) 240-6195 • Fax (717) 240-6573