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HomeMy WebLinkAbout08-1584IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. CHARITY GILES, Defendant. No. 08-1584 0,1yi(Te"M 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 COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. CHARITY GILES, Defendant. CIVIL ACTION - EQUITY AVISO PARA DEFENDER Conforme a PA RCP Num. 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 action como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. 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. D F _ ???% C CHARITY GILES, _ Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW COMES, Plaintiff, Church of God Home, Inc. ("Plaintiff Church of God"), by and through its attorneys, SCH"ER BOGAR LLC, and files the within Complaint against Defendant, Charity Giles ("Defendant Giles"), 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 Giles is an adult individual who resides at P.O. Box 251, Boiling Springs, Pennsylvania, 17007. 3. On or about August 13, 2007, Defendant Giles made application on behalf of her mother, Jean Clepper ("Ms. Clepper"), for admission to Plaintiff Church of God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17103. 4. On or about August 13, 2007, Plaintiff Church of God and Defendant Giles entered into a written Admission and Care Agreement ("Agreement"). Pursuant to the Agreement, Plaintiff Church of God agreed to provide Defendant Giles' mother with skilled nursing care and services in exchange for Defendant Giles' 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 "[c]ooperation 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. Clepper's admission to Plaintiff Church of God's skilled nursing facility, Ms. Clepper allegedly became insolvent. 6. On or about December 20, 2007, 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 January 23, 2008, because Defendant Giles did not provide verification to the Cumberland County Assistance Office to determine Ms. Clepper'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. 2 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant Giles 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. 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 Giles' mother in accordance with the terms and conditions of the Agreement. 12. Defendant Giles 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 Giles 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 Giles' 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. Clepper 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: By: r f?f l Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff 4 EXHIBIT "A" CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this day of , by and between The Church of God Home, Inc., called the "Facility," a Pennsylvania non-profit corporation located at 801 North Hanover Street, Carlisle, Cumbers County, Pennsylvania, D 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. PROVISION 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: $ 07j40.Oeldollars per day. Admission and care Agreement - continued -3r. NON-RECIIRRING 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 admission day. The amount of the security deposit is $ _/ '` No interest will be paid on the security deposit. A security 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 ce and ALS (Advance Life Support) Unit is $ a This fee must be paid prior to admission and w4 l be•billed annually to the Resident. a MISCELLAN'EOIIS CEARGES AND OUTSIDE SERVICES. 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 OWN 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 APPLICABLE GOVERNMENT RULES AND POLICIES OF THE FACILITY ARE MET. in addition to the Facility's charges, the Residexit 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 drugs, 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 P_greement - continued ?5. ADMISSION. The Resident will be aa? fitted, or a bed will be reserved for Resident, beginning on N'-f3-07 All 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 Home for whatever reason, including illness, injury, incapacity or death. 6. PERIODIC 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 charges above the- daily rate. These miscellaneous charges will 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. CHANGES IN CHARGES. 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 /MEDICAID" 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 XIX 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 -9-. OBLIGATIONS OF RESPONSIBLE 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 - BED 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 is 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 f or 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 will.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 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain 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. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charoe nurse regarding resident's personal property. If nametag labels are needed for clothing items, please leave them at the nursing station. 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 assigned. 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 part of this Agreement. d. The Facility reserves the right to modify unilaterally the tens of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty {;p} days notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. Resident/Responsible Party s ent Name 9 V Facility Rept se tative Date -07 EXHIBIT "B" VD CAU 599 MEDICAID +ESTMINSTER DRIVE DISCONTINUE !LISLE PA 17013-9599 NOTICE ,O RETURN ADDRESS CSLD pp33 JEAN E CLEPPER CHURCH OF GOD HOME 801 N HANOVER ST CARLISLE PA Notice ID: 8p45A1 Ce 21 0090854 0 PAN 80 WORKER K PEARSON TELEPHONE: (717) 240-2100 17013 MAIL DATE: 01 /23/2008 NOT: 042 OPT: OTYPE- D IF YOU DD ROT UNDERSTARO OUR DECISIDR OR RAVE ANY OUESTIORs, PLEASE CORrXT YOUR WORKER IMMEDIATELY You are not eligible for Medicaid or Lonp Term Care services. You have not provided the following requested verification: MASi;MA103; Options Assessment; Haa7th insurance preimiums; PA4 Release; Power of Attorney Paperwork,- Gross VA income information; 10120107 bank balances; verification of all resources sold 10!20/07rceshrvaTuenofwatlilifeeinsurance three years; vehicle registration; to burial ; burial reserve: deed to all Drooerty and current amarketdvalue: deedptotMobile home and current market value; Unpaid medical bills; shelter and utility exoenses; tax returns and 1099 forms for the oast three years: COMPLETED 600L APPLICATION FOR LONG TERM CARE SERVICES. REGULATIONS:55 PA Code 125.84 (e) If you disagree with our decision, you have the right to appeal_ attached form fora com lets ex alnatiort of our ri ht tea sal and to a fair See h@ar afng ip you are , currently receiving benefits and your oral request for a -hearing is received in the F40IARLISLE IDPENN LEGAL SERVICES County Assistance Office or your written request is postmarked or received an or -405 LOUTHER STREET before 02/p5/2008 your assistance wi(l continue pendln PA 17013 except when the change Is due to State or Federal law, 9 the hearing decision, r .rr. Notice ID: 80458154 JEAN E CLEPPER CHURCH OF GOD HOME 861 N HANOVER ST "COi irQliECf)gp={DF".?? ~ ' CARLISLE PA 17013-°-e? =G77s: 21 0090854 0 PAN 80 CONTINUED ON REVERSE SIDE PA/MA 162 12103 i PAGE 1 OF 1 1 i. i CUMBERLAND CAO rAEA R: K PEARSON P.O. BOX 599 L• 02/05/2008 33 WESTMIN STER DRIVE ONE: CARLISLE PA 17013-0599 ATE (717) 240-2700 01 /231200A VERTFTg&TIoN The undersigned hereby verifies that the statemr• nts of fact in the foregoing Complaint arc true and correct to the best of my knowledge, information and belief. 1 understand that any false statements therein are subject to the penalties containod in 18 Pa. CSA. § 4904, relating to unswom falsification, to authoritim- Dated: 4?0 Cramer, SR g/AR Specialist Church of God Home, Inc. n ^a 'r 723 (1) 6' Cyt1 ?: - ^-- ?7 t a __ O IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08-1584 Civil Term CHARITY GILES, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Petitioner, Church of God Home, Inc. ("Petitioner"), by and through its attorneys, SCHurJER BOGAR LLC, and files the following Petition against Respondent, Charity Giles ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. 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 jean Clepper, 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: -5) da Respectfully submitted, SCHUTIER BOGAR LLC By: 4 - VL Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No. (717) 909-5925 Attorneys for Plaintiff 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Petition for Preliminary Injunction was sent to Shinkowsky Investigations, Inc. to personally serve the following: Charity Giles 225 Red Tank Road Boiling Springs, PA 17007 Dated: By: t '&bs.(?? Catherine Klobucar, Paralegal E IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08- 158q awa-T-a", CHARITY GILES, Defendant 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 ?iQ? RECORD Telephone: (717) 249-31A TWOlOllyWhOrW, I h'" Unto W my hand (800) 990-9108 ?Wd ft 1W 01 S* CWn at Carlisle, Pa. .i doog C?(DPV EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. CHARITY GILES, Defendant. CIVIL ACTION - EQUITY AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en ]as 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 peed perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. CHARITY GILES, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW COMES, Plaintiff, Church of God Home, Inc. ("Plaintiff Church of God"), by and through its attorneys, SCHUr1ER BOGAR LLC, and files the within Complaint against Defendant, Charity Giles ("Defendant Giles"), 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 Giles is an adult individual who resides at P.O. Box 251, Boiling Springs, Pennsylvania, 17007. 3. On or about August 13, 2007, Defendant Giles made application on behalf of her mother, Jean Clepper ("Ms. Clepper"), for admission to Plaintiff Church of God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17103. 4. On or about August 13, 2007, Plaintiff Church of God and Defendant Giles entered into a written Admission and Care Agreement ("Agreement"). Pursuant to the Agreement, Plaintiff Church of God agreed to provide Defendant Giles' mother with skilled nursing care and services in exchange for Defendant Giles' 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 "[c]ooperation 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. Clepper's admission to Plaintiff Church of God's skilled nursing facility, Ms. Clepper allegedly became insolvent. 6. On or about December 20, 2007, 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 January 23, 2008, because Defendant Giles did not provide verification to the Cumberland County Assistance Office to determine Ms. Clepper'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. 2 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant Giles 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. 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 Giles' mother in accordance with the terms and conditions of the Agreement. 12. Defendant Giles 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 Giles 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 Giles' 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. Clepper 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, SCHUTIER BQGAR LLC Dated: B #, Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff 4 E CHURCH OF GOD ROME, INC. ADMISS IO1\t AND CARE AGREEMENT THIS ?AGREEMENT is made on this day of + by and between The Church of God Home, Inc., called the "Facility," a Pennsylvania non-profit corporation located at 801 North Hanover Street, Carlisle, Cumbers County, Pennsylvania, , oa ?atAj 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. PROVISION 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. RECIIRRING CRARGES. In exchange for the above services, the Resident shall pay the following recurring charges: (a) For skilled nursing care: $ c21 .O dollars _per day. Admission and Care Agreement - continued -a% NDN-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 admission day. The amount of the security deposit is No interest will be paid on the security deposit. A security 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 *wil ce and ALS (Advance Life Support) Unit is $ This fee must be paid prior to admission and billed annually to the.Resident. a_ MISCELLANEOUS CHARGES AND OUTSIDE SERVICES. 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 an 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 EIS/HER OWN 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 APPLICABLE GOB 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 furni shed 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 drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or se--v.-ices for the Resident. SUCH FEES AND COSTS ARE NOT INCLUDED IN THE HOME ` S DAILY RATE / CHP.RGE . Admission and Cue P_greement - continued fitted, or a bed will 5. PgMIBSION. The Resident will be ad be reserved for Resident, beginning on - l3 -O 7 All 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 Home for whatever reason, including illness, injury, incapacity or death. G. PERIODIC 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 charges above the daily rate. These miscellaneous charges will 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. CHANGES IN CHARGES. 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. . B. PARTICIPATION IN nMEDICARE/MEDICPIDn 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 XIX 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 -9-. OBLIGATIONS OF RESPONSIBLE 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 - BED 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 -is 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 will-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 his/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 dome, 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. TERMINATION, TRANSFER OR DISCHARGE. (a) By the Resident: -The Resident may terminate this Agreement upon thirty (30) 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 necessaryto 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 A«reement- continued IV_ The charges or other amounts due to the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Residents behalf by Medical Assistance under the Medical Assistance 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. describe in subparagraph (l)_ (I1) and (11I) above. or if the Resident has not resided at the Facility for at least thirty (30) days. the Facility will give such notice before transfer or discharge as is practicable under the circumstances- 14. THIRD PARTY PAYMENTS- 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 instuance, 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 tbird-parties for the stay and care of the Resident. the Resident/Responsible Party shall. at all times, cooperate fully with the Facility and each third-party payments. 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 maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law. the Resident hereby assigns novv or hereafter payable to the extent of all charges due to the endorse and true 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/ Responsible Party is and will be responsible to furnish and maintain 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. Ail non-clothing items of value must be recorded on the residents personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse regarding resident's personal property. If nametag labels are needed for clothing items. please leave them at the nursing station. 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 taws 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 assigned. 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 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. Residem/Responsible Party Name 1/1 l ? Facility Rept se tative Date E MEDICAID Notice )D- AD 80458154 _0 599 DISCONTINUE WESTMINSTER DRIVE NOTICE co^ w??co -°Illb??CftT'- `GGx PS "; ,&ISLE PA 17013-9599 ,O RETURN ADDRESS CSLD 0033 21 0090854 0 PAN 80 JEAN E CLEPPER CHURCH OF GOD HOME _.801 N HANOVER ST CARLISLE PA 17013 K PEARSON TELEPHONE: (717) 240-2700 MAIL DATE 01 /231 2008 NOT. 042 OPT. OCYPE-- D IF YOU DO NOT UNDERSTAND OUR DECISION OR 94.1 ANY QUESTIONS, PLEASE CONTACT YOUR WAXER DUEDIATELY. t You are not eligible for Medicaid or Lonq Term Care services. You have not provided the following requested verification: MA51;MA103: Options Assessment: Health insurance preimiums; PA4 Release; Power of Attorney paperwork; Gross VA income information; 10120107 bank balances; verification of all resources sold transferred or given away in the past three years; vehicle registration; 10120107 cash value of all life insurance policies; deed to burial plot; burial reserve: deed to all property and current market value: deed to mobile home and current market value; unpaid medical bills' shelter and utility expenses: tax returns and 1099 forms for the past three vears: COMPLETED 66OL APPLICATION FOR LONG TERM CARE SERVICES- REGULATIONS:55 PA Code 125.84 (e) APPEAL?AND FAIR HEARIPIG. If you disagree with our declsion, you have the right to appeal. See at7inthe MIDPERN 7LE SERVICES for a complete expalnation of your right to appeal and to a fair hearing 491-405 LDUTHER STREET currently receiving benefits and your oral request for a hearing is recCARLISLE PA 17013 County Assistance Office or your written request is postmarked or recbefore 02/0512008 your assistance will continue pending the heariexcept when the change is due to State or Federal taw. JEAN E CLEPPER CHURCH OF GOD HOME 801 N HANOVER ST CARLISLE PA 17013 CAO • ADDRSSS CUMBERLAND CAO P.D. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-6599 Notice ID_ 80458154 21 0090854 0 PAN 80 WORKER: K PEARSON APPEAU D210512008 TELEPHONE: (717) 240-2766 MAIL DATE: 0112312BO8 NOT- 042 OPT: OTYPE D i PAGE 1 OF 1 PANIA162A CONTINUED ON REVERSE SIDE PAIMA 167 12103 VERMQkTION 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 unswom falsification to authorities. Dated: / Sharon Cramer, SR ' ' g/AR SpcecislisIlt Church of Gad Home, inc_ is ? C,> ?- ?;-?, r ?:, --r? ., ,--? L ?.? - r ?; ,?,,,,,.? ?, ::f.:: °4 S ._ L... - .? ??4 Y1 .. . '?? ?.. ._. F5?1 MAR 181D08 /Y IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08-1584 Civil Term CHARITY GILES, Defendant. CIVIL ACTION - EQUITY ORDER AND NOW, this I B-0 , day of 11? , 2008, a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for CL44 J 3 2008, at ?_:36_ o'clock -P-.m. in Court Room No. ,. Cumberland County Courthouse. p 4a . p ?cw 53,46 - GOal/F ?!ra^ no 6 8 • h Wd 81 8VW 80@Z hdV1Cti ? :a i;dd 3HI JO 3014-40-{3311 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08-1584 Civil Term CHARITY GILES, Defendant CIVIL ACTION - EQUITY RETURN OF SERVICE I HEREBY CERTIFY THAT: I, Catherine Klobucar, served the annexed Order and a copy of the Petition for Preliminary Injunction upon the following: Charity Giles 225 Red Tank Road P.O. Box 251 Boiling Springs, Pa 17007 Service was made via overnight delivery on March 24, 2008. A copy of the UPS Delivery Notification is attached hereto as Exhibit "A." Service was also made via first-class, United States mail, certified, return receipt requested, on March 24, 2008. A copy of the receipt evidencing service is attached hereto as Exhibit "B." I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service is true and correct. Dated: 01 A 7101 01 By: 0Ak&k4_" Catherine Klobucar SCHUTJER BOGAR LLC 417 Walnut Street, 4th Floor Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08-1584 Civil Term CHARITY GILES, Defendant. : CIVIL ACTION - EQUITY ORDER AND NOW, this _ /84k , day of 2008, a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for &a,- - 2008, at o'clock in Court Room No. Cumberland County Courthouse. BY THE COURT: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V_ CHARITY GILES, Defendant No. 08-1584 Civil Term C) CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION CTs J7 AND NOW, COMES, Petitioner, Church of God Home, Inc- ("Petitioner"), by and through its attorneys, SCHU7IER BOGAR LLC, and files the following Petition against Respondent, Charity Giles ("Respondent"), pursuant to Pa_ R_CP. § 1531, and, in support thereof, avers: 1. 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 Jean Clepper, 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. 0 ;1 z C (O PV 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. 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. Respectfully submitted, SCBUT)ER BOGAR LLC Dated: By: Bradley A. Schutjer Attorney LD_ No_ 75954 (717) 909-5921 Allison M. 0'11oro Attorney 1_D_ No_ 200568 (717) 909-5924 417 Walnut Street, 4, Floor Harrisburg, PA 17101 Fax No. (717) 909-5925 Attorneys for Plaintiff 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Petition for Preliminary InJunction was sent to Shinkowsky Investigations, Inc. to personally serve the following: Charity Giles 225 Red Tank Road Boiling Springs, PA 17007 Dated: 1 E? By ?iL?IJ ,- - Catherine Klobucar, Paralegal E IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CI-IURCI-i OF GOD HOME, INC_, Plaintiff, V_ No_ D8- 153q ?IV !der n, CHARITY GILES, Defendant. CIVIL ACTION - EQUITY NOTICE TO DEFEN D 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 attornev 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 import ant 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 _ 1-HIS 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 ABOUTT AGENCIES THAT MAY OFFER I_FGAI. SFRVICFS TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE_ Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 IME R FROM RECORD Telephone: (717) 249-3169 Y i lOlt t{?1E1 C ?,, i uo Onto set -y hod (800) 990-9108 and the ,seW t? said Gtutt at Carlisle,- Pa. rv (?OFV EN LA CORTE DE ALEGATOS COMON DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V- No. CHARITY (,J1_ ES, Defendant. CIVIL ACTION - EQUITY A VI S O PA RA DEFENDER Conforme a PA RCP Num. 1018_I LISTED HA SIDO DEMAN DADO%A EN CORTE. Si usted desea defenderse (j( las demandas que se presentan mas adelante en ]as siguientes paginas, debe tomar action dentro de Jos proximos veienie (20) dias despues de la notification 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, ]as demandas presentadas aqui en contra suya. Se le advierte de Sue si usted falla de tomar action Como se describe anteriormente, el caso puede proceder sin usted y un fallo por ctialgmer suma de dinero reclamada en la demanda o cualquier otra reclamation o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso ad)-clonal- Usted peed perder dinero o propiedad u otros derechos importarrtes para usted_ LISTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE_ SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA_ ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUL ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BA]O COSTO A PERSONAS QUE CUALIFICAN_ Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 TeIHono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, v- No_ CHARITY GILES, Defer d an l _ CIVIL ACTION - EQUITY COMPi_,A1NT AND NOW COMES, Plaintiff, Church of God Home, Inc- ("Plaintiff Church of God"), by and through its attorneys, SCHU7IER BOGAR LLC, and files the within Complaint against Defendant, Charity Giles ("Defendant Giles"), and in support thereof, provides as follows= I- Plaintiff Church of God is a Pennsylvania corporation with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17103- 2. Defendant Giles is an adult individual who resides at P_O_ Box 251, Boiling Springs, Pennsylvania, 1170107- 3- On or about August 13, 2007, Defendant Giles made application on behalf of her mother, Jean Clepper ("Ms_ Clepper"), for admission to Plaintiff Church of God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17103_ 4. On or about August 13, 2007, Plaintiff Church of God and Defendant Giles entered into a written Admission and Care Agreement ("Agreement")_ Pursuant to the Agreement, Plaintiff Church of God agreed to provide Defendant Giles' mother with skilled nursing care and services in exchange for Defendant Giles' promise to pay a specific monetary fee from her mother's resources and io cooperate fully with Plaintiff Church of God upon becoming eligible for the receipt of IN/ledical Assistance benefits, such "[c]ooperation includes, when requested, providing information, [and] signing and delivering documents. _ .. _" A t-r-.:e and correct copy ^f th; A?eem ert is attached b` hereto as Exhibit "A_" 5. Subsequent to Ms. Clepper's admission to Plaintiff Church of God's skilled nursing facility, Ms. Clepper allegedly became insolvent. 6. On or about December 20, 2007, 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 January 23, 2008, because Defendant Giles did not provide verification to the Cumberland County Assistance Office to determine Ms. Clepper'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- 2 4- if the documents requested by the Cumberland County Assistance Olhce are not provided by Defendant Giles 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- COUNTI BREACH OF CONTRACT/SPECIFIC PERFORMANCE f() 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 Giles' mother in accordance with the terms and conditions of the Agreement. 12. Defendant Giles breached the Agreement with Plaintiff Church of God \Alhen she failed to make timely and proper application for Medical Assistance benefits for her mother, and Defendant Giles continues to breach the Agreement with Plaintiff Church of C,od 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 Giles' 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. Clepper 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 r\ gr eem en t 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 wfluch orders specific performance of the Agreement between theParties- Respectfully submitted, SCIiUT;EF. BOGRR LL( Dated_ By. ; Bradley A. Schutjer Attorney I.D_ No. 75954 (717) 909-5921 Allison M_ O'Horo Attorney I.D. No_ 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for PIaintiff EXHIBIT "A" CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this day of , by and between. The Church of God Home, Inc-, called the "Facility," a Pennsylvania non-profit corporation located at B01 North Hanover Street, Carlisle, Cumbers County, Pennsylvania, ? ' r7 and callea "Resident" and J called "Responsible Party"- -The Resident and the Responsible PaT-ty reaffirm that the i;-iformation provided in the Pre-Admission Questionnaire is true and correct and understand that the submissioii of false information may constitute grounds to terminate this Agreement. The Resident has anrl1ed far admission to the Facility and the Facility haE approved the Application for Admission- Therefore, the Facility, The Resident and Responsible Pasty agree to the follow=--rag 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 crash cloths- (d) Three meals each day, except as otherwise medically indicated. (e) Activity programs and social services- 2- RECDRRTNG CHARGES. In exchange for the above services, the Resident shall pay the follokina recurring charges: (a) For skilled nursing care : $ V/(2- 00 dollars _per day. Acinussicir rya Czre k(Treement - coocinued _ NON-RECURRING =-RGES. The Resident shall pav the f of l owing non-recurring charge-: (a) P_ security deposit in the amount of thirty-one (31) times the current daily rate for the level of care recuired by the resident, will be billed aster admission day- The amount of the security deposit i S S fir - ' No interest will be paid on the security deposit- A security deposit will not be charged to residents who are receiving benefits for room and hoard provided by Medicare, until the Medicare benefit concludes- An applicant who is covered by Medicaid is not requ=ired to pay a security deposit. (b) The cost for enrollment in the community a ce and ALS (Advance Life Support) -Unit is $ This fee gmst he paid prior to admission and w` 1 be hilted annually to the Resident- a " MISCELLANEOUS CHARGES AND OUTSIDE SERVICES- 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 cost s - " The services of a licensed physician and dentist, 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- TEE RESIDENT HAS THE RIGHT TO SELECT EIS/HER OWN PHYSICIAN OR ANY OTHFR SERVICE PROVIDER SO LONG AS THE PI3YSICI.AN OR OTHER SERVICE PRUd I DER IS PROPERLY LICENSED OR REGISTERED UNDER THE LAW, AND THAT ALL APPLICABLE 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 Day applies to all fees for costs of services provided for the Resident by any physician., dentist, optometrist, therapist, diagnosti c 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 drugs, 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 TIC HOD'S DAILY RATE/ CHARGE - Admission and Car° Pcreemenr - ccnrinvee 5_ ADMISSION. The Resident will be admitted, or a bed will be reserved for Resident , beu?-nning on - t3 --0 7 A-11 pre-admission charges will he billed art=r 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 rar-e for the reserved bed will continue to accr-ne and be payable until the reservation is terminated, even if the Resident does not enter the Home for whatever reason, including il-"ness, injury, incapacity or death- 6 _ PERIODIC HILLINCS AA'D PnYTEENT DUE DATE- (a) On the first of each month, Resident will be billed the current daily rate or Resident's current level of care times the number of days in the month- The hill is due and payable upan _ecelpt. (b) Miscellaneous charges (refer to "Chart of Costs" attached to this Agreement) such as hair care, personal laundz--y, incontinency, supplies, etc., are.additional charges above the daily rate- These miscellaneous charges will be added to, and included with, your mont-hly bi11. (c) Pharmacy charges will he 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_ CHANGES IN CBA.RGES_ 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. - B. PARTICIPATION ITI "MKDICARE/NF-DICP-ID" PROGRAMS. The Facility participates in the Medicare grogram 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 XIX 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 atd CzTe Agreement - continued g-_ OBLIGATIONS- OF RESPONSIBLE PARITY _ The Responsible Party is responsible for services and supplies t-hat awe 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 - HED ROLD POLICY. 7--f the Resident leaves the Facility for a period of hospitaliz.etion, therapeutic leave, a,- 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, than 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 is receiving medical cssistance 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 tinder 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 (3D) 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 hospitalisation 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 Horne- 11- REF[TNDS_ The security deposit for private pay residents, after deduct_ons for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (3D) 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 will 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 Faci1_ty hold and manage the Resident's personal funds- If the Resident Pdm;s&ian arc CETe Rareeap_nt - cnnti=Ed desigzrat es 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 ii_m6s unless such aesignation is made- The Resident may revoke, at any time, the designation of she Facility as the manager of his/her personal funds by provid'nq the Facility a written notice signed and dated by the Resident OT Responsible Party- if the Resident transfers to the Bome, responsibility to _manace the Resident's personal funds, the Facility will de so in accordance wiEh 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 anv time, charges due to the Facility under tbis EiareeTne_TTt from the Resident's personal funds managed by the I3- TEP-1,MITATION, TRANSFER OR T1ISCTAROE_ (a) By the Resident: The Resident may terminate this Agreement upon thirty (30) 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 (3o) 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-Lo 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 A.Ieement- continued lV . The charges or other amounts due to the Facility under this Acreement have not been paid to the Facility or treated as paid to the Facility on the Residents behalf by Medical Assistance under the Medical Assistance Program or by Federal Medicare benefits under Title XVIII of the Federal Social Security Act, or V The Facility ceases to operate- The Facility penerally v,.-111 noniv the Resident and Responsible Party or if none- a family member or fecal representative of the Residem. if known to the Facility, at least thirty (30) days in advance of such a transfer or discharge. However_ in any case- describe in subparapraph (1)_ (II) and (1111) above. or if the Resident has not resided at the Facility for at least thirty (30) davs. the Facility wiil Qive such notice before transfer or discharge as is practicable under the c ircunrstances 14 TEIRD PARTY PAYMENTS- 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 tinder the Pennsvlvania Medical Assistance Program, Medicare benefits- supplementary medical or other health insurance, supplemernal security income insurance- or old-age survivors. or disability insurance under or pursuant to the Federal Social Sectinty Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident. the Reside nt!Responsiblc Party shrill- at all times- cooperate fully with the Facility and each third-pane payments- Cooperation includes, when requested- providinp information. signing and deliverino documents- and having the Facility desionated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other -ovemmental assistance- reimbursement or benefits to the extent of all charoes due the Facility- The Resident irrevocably authorizes the facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent perrrriued by lain- the Resident hereby assicns now or hereafter pavable to the extent of all charges due to the endorse and turn over to the Facility any payments received from third-parties to the extent necessary to satisfy the charges tinder this Apreement_ Admission and Care Agreement- continued 15_ PERSONAL PROPERTY- The Resident( Responsible Party is and will be responsible to furnish and maintain clothing- }ewelrv- personal possessions- and other items of property- The facility may Iimit 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. All non-clothing items of value must be recorded on the residents personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident-s room. You are requested to see the charge nurse reparding residents personal property. If nantetag labels are needed for clothing items. please leave Them at the nursing station. I6_ RESP ONSI 13:1 LI TIES OF RESIDENT- The Resident shall comph, fulh, with all -ovenimental laws and reaulations_ The provisions of this Agreement and the facility's elisinig policies, rules and reenlations which may, from time to lime_ be altered or amended. 1 TIJISCE%I ANEMUS PROOVISIONS 11 a. The Resident and Responsible Party acknowledge That they are adith individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by the taws of the ComrnonweaIth of Pennsylvania and shall be binding upon and itntre to The benefit of each of the undersigned parties and their respective heirs- personal representatives, successors and assigned- c_ The various provisions of this Agreement shall be severable one from another- If any provision of this Agreement is found by competent le-2a) authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been 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- Resident/Responsible Party (7 _?4 s entName FacilitARepi ?se tanve Date EXHIBIT "B" DISCGNT1NIL) E fVOTfCE tt+5[_ tea. ?70?3-0554 d RETtlRrvr s DG4lE 5 CSLD 0033 JEAN E CtEPPER CHURCH OF GOO HOME 805 N HANOVER Si CARtISLE PA 17013 H0r45 1 s4_ PACF - OF I ,CD-/ ftE?OPQ""_`BS Sl? `CP7 GC'`=_ PS--`?J' 21 0090854 ' 0 PAN BO WORKER K PEARSON TELEPHONE (717} 2402700 MAIL DATE 01 (2312008 NOT- D420PT. OCYPE 0 it rcxr W Hui UNDERSTAND OUR DFCl-UM DR Half oy ERIESF fOHS, Pr a" CoirACT YOUR WrdtfR 1N.vFOIATEL) You are not er,n:ble for Medicaid or Lonn Term Care services. You have not pr(3vlded TbE ioli?,lr}n reauEsted verification- MASI'IiA103: ODtions Assessment= Health In5uranCE preimlums: PA4 Release; Power of Attorney paperwork; Gross VA income Information: 10)26107 bank baTances: verification of all resources sold 'transferred o, given array in the past three years, vehicle registration; ce5h a?ee of all life tr.surance policies: treed to burial plot; h;,rial reseeve. teed to all Brooerty and current market value: deed to mobile home and current market value: unpaid medical bills: shelter and utility exoenses ias returns and ,099 forms for the cast three vears_ COMPLETED 600L APPtICAI]ON FOR ICNG IERM CARE SERVICES. REGULM IGNS 55 PA. Code 125.84 (e) It you disagree with our derision, you have the right to appeal- See attached form for a complete expalnatton of your right to appeal and to a fair hearfnq. If you are currently teceiving benefits and your oral request for a hearing Is received in the County Assistance Office or your written request is postmarked or received on or f before 0210512008 your assistance will continue pending the hearing declsion, except when the change Is due to State or Federal law- JEAN E CIEPPER CHURCH OF GOD HOME 861 N HANOVER S CARLISLE PA 17013 MIDPENN LEGAL SERVICES 401-405 LOUTHER SIREEI CARLISLE PA 17013 Notice I0: 80458154 CUMBERLAND CPA- - P-0_ BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17813-0599 i?CfS'_7 RECtlij6__}'r,tTl$l_ _Cl4? _;.TiG :IFS' 21 909BB54 D PAN BO WORKER: K PEARSON APPEAL-- - 0216512008 TELEPHONE (717) 240-2708 MAIL DATE Ot 12312808 NOT- 642 OPT: OTYPE D PA ht. 167, C.ONIINUED ON REVERSE SIDE P-A 1i,? l:to: vERiFICLD ON `Flee undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and corrcct to the hest of my knowledge, information and belief. I understand that any false st?temertF tizerer are -,object to the penalties contained in 18 Pa- CS-A, § 4904, relating to unswom falsification to authorities. Dated. / Sharon Gamer, SR - g/t1K SpeciaEi?`t Chuck of Gocf fiomc-, Inc. E vj r3: t racm'ng lmorm.atloIl Delivery Notification Dear Customer, This is in response to your request for delivery information concerning the shipment listed below. Tracking Number: Reference Number(s): Service: Shipped/Billed On: Delivered On: Delivered To: Location: 1 Z Y99 V53 01 9599 3 CG H-012 NEXT DAY AIR 03/21/2008 03/24/2008 11:52 A.M. 225 RED TANK RD BOILING SPRINGS, FRONT DOOR 358 PA, US 17007 Thank you for giving us this opportunity to serve you. Sincerely, UPS Tracking results provided by UPS: 03/26/2008 8:43 A.M. ET rage .t https://wwwapps.ups.com/WebTracking/processPOD?I ineData=HARRISBURG %5EFS %... 3/26/2008 EXHIBIT "B" ¦ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: A Sign lure 9, AL 1R x .#? B. Received by( PAnted Name prb r C-Awfmj 7-. 6. D. Is delivery address different 1? yues g if YES, enter delivery address Clo ?/ vI Q ?) ( X Z PS I L? *\j Cr SQSS ?G (N Ur)? 3 SeMce Type cem ed mail O Express Mail X--,! 0 Registered 0 Return Receipt for Merchandise 0 Insured Mail 0 C.O.D. 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number 7007 0220 0000 2164 5284 (ranter from service kw __-- PS Form 3811, February 2004 Domestic Return Receipt trn595-02-W15Q {? hJ ,7 ?? CJ ` : n ?4° ? ;, ? ?.._ - `? ? ) ,..? 4 w.: . ' l t? _i ? • , l'? ?? ?? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-1584 CHARITY GILES, Respondent. CIVIL ACTION - EQUITY ORDER AND NOW, this day of Yy ` 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, Charity Giles shall provide any and all records within her possession that are required by the Cumberland County Assistance Office to determine Jean Clepper's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits for Jean Clepper. J f? ? N v 443 r cz? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-1584 CHARITY GILES, Respondent. CIVIL ACTION - EQUITY STIPULATED AGREEMENT Church of God Home, Inc. ("Petitioner') and Charity Giles ("Respondent") stipulate and agree to the following: 1. On or about March 10, 2008, Petitioner filed a Complaint against Respondent, the daughter of one of Petitioner's residents, Jean Clepper ("mother") 2. The Complaint sets forth a single claim against Respondent based on her failure to specifically perform the terms of the written Admission and Care Agreement ("Agreement") entered into with Petitioner. See Complaint Exhibit "A." Specifically, the Complaint alleges that Respondent failed to assist her mother in the application for Medical Assistance by failing to provide documentation needed by the Cumberland County Assistance Office. 3. An application for Medical Assistance benefits was filed on behalf of Respondent's mother on or about December 20, 2007, and was denied by the Cumberland County Assistance Office on January 23, 2008. 4. An appeal of the aforementioned denial is currently pending before the Cumberland County Assistance Office of the Department of Public Welfare. 5. The parties agree to the entry of an Order directing Respondent to provide any and all records within her possession as required by the Cumberland County • Y-01-'08 16;52 FROM- T-042 P003/004 F-057 Assistance Office to determine the eligibility of Respondent' s mother for Medical Assistance benefits within fifteen (15) days of the date of the Order and to diligently woxk to secure any and all other documents necessary to obtain benefits on Respondent's mother's behalf. That Order is attached as Exhibit "A," 6. Petitioner agrees to withdraw, without prejudice, its Petition for a Preliminary Injunction. Respectfully submitted, Dated: d By: Allison M. O'fioro Attorney for Petitioner Dated: -I -dY By: ( ,, I " j, \ . C ? ? - Charity G' s 2 EXHIBIT "A" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CHARITY GILES, Respondent. ORDER AND NOW, this day of No. 08-1584 CIVIL ACTION - EQUITY 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, Charity Giles shall provide any and all records within her possession that are required by the Cumberland County Assistance Office to determine jean Clepper's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits for Jean Clepper. BY THE COURT J. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 08-1584 Civil Term AFFIDAVIT OF SERVICE Church of God Home, Inc. vs. Charity Giles Commonwealth of Pennsylvania County of Dauphin so. I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at 8:40 PM on 04/02/2008, I served Charity Giles at 225 Red Tank Road, Boiling Springs, PA 17007 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. ? Other: an officer of said Defendant's company. a true and correct copy of Notice to Defend, Complaint, Petition for Preliminary Injunction, Certificate of Service, Brief in Support of Petition for Preliminary Injunction, Certificate of Service issued in the above captioned matter. Description: Sex: Female - Age: 50 - Skin: White - Hair: Brown - Height: 5' 6" - Weight: 180 X sworWIf to and subscri ed b fore me on this Timot y Ho r20D Shinkowsky Investigations 316 Fawn Ridge North Harrisburg, PA 17110 (800) 276-0202 N ARY PUBLIC CO p O EALTH OF PENNSYLVANIA Atty File#: - Our File# 3357 Notarial Seal (ohn F. Shinkowsky, Notary Public Susquehanna Twp., Dauphin County My Commission Expires Sept. 28. ,2010010 Law Firm: Schutjer BogiAteennsylvania Association of Notaries Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102 Telephone: (717) 909-5925 C? rv - tv C-% --C IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CHARITY GILES, Respondent. RETURN OF SERVICE I HEREBY CERTIFY THAT: No. 08-1584 CIVIL ACTION - EQUITY I, Catherine Klobucar, served the annexed Stipulated Order upon the following: Charity Giles 225 Red Tank Road Boiling Springs, PA 17007 Service was made via first-class, United States mail, certified, return receipt requested, on April 18, 2008. A copy of the receipt evidencing service is attached hereto. I declare under penalty of perjury under the laws of the United States of America that the foregoing information contained in the Return of Service is true and correct. Dated: L} j a By: " A 1-) Catherine Klobucar SCHUTJER BOGAR LLC 417 Walnut Street, 4th Floor Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-1584 CHARITY GILES, Respondent. CIVIL ACTION - EQUITY ORDER AND NOW, this /?-'>_ day of OgA-'VL 2008, in consideration of the parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that: Within fifteen (15) days of the date of this Order, Charity Giles shall provide any and all records within her possession that are required by the Cumberland County Assistance Office to determine Jean Clepper's eligibility for Medical Assistance benefits and diligently work to secure any and all other documents necessary to obtain benefits for Jean Clepper. BY THE COURT MUE: COPY .s 3 +?! ?4iw';?J",i.?/?J 4,A x • a _ J",`?tY? ? ,.i?a+?rh ? ??; ?'y !? ?i?t2a<? V . , _ ¦ Complete items 1, 2, and 3. Also complete" item 4 if Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: OVN?ir leS ??? Spr ucv; pA 1 C0 X ( ;A*"s r , B. Received by (Printed N V. C. Ute of D. Is delivery address dMerent Tro if YES, enter delivery address 3 Se Type ?Cerflfied mail ? Egress Mail ? isterad ? Return Receipt for Merchandise ? Insured Mail ? C.O.D. 4. Restricted Delivery? Pft Fee) p Yes 2. Article Number 7007 0220 0000 2164 5642 (Transfer from service kw PS Form 3811, February 2004 Domestic Return Receipt 102e95-o2-*1540 ;_! -,5 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. No. 08-1584 Civil Term CHARITY GILES, Defendant CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW, DISCONTINUE AND END To the Prothonotary: Kindly mark the above-captioned action withdrawn, discontinued and ended. Respectfully submitted, Dated: Aslog SCHUTJER BOGAR LLC By: Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5290 Allison M. O'Horo Attorney I.D. No. 200568 (717) 909-5924 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw, Discontinue and End was served via first-class, United States mail, postage prepaid, upon the following: Charity Giles 225 Red Tank Road Boiling Springs, PA 17007 Dated: b m By: OCatherine Klobucar, Paralegal oil CC` Ifni,