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HomeMy WebLinkAbout08-2372 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. D8- A31a Oivi ( TerwA LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 ORIGINAL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad a otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. 4 d'? o? 37,7- ett?iy T. LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Lottie Stine ("Defendant"), and in support thereof, provides as follows: Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17015. 2. Defendant is an adult individual who currently resides at 4100 E. Beachwood Lane, Harrisburg, Pennsylvania 17112. 3. On or about October 25, 2007, Defendant made application for the admission of her sister, Toni Filler ("sister"), to Plaintiff's skilled nursing facility. 4. On or about October 25, 2007, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's sister with skilled nursing care and services in exchange for her promise to pay a specific monetary fee from her sister's income or resources and, in the event that she were to become insolvent, to secure Medical Assistance benefits in a timely and proper manner. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. After Defendant's sister became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that she needed to apply for Medical Assistance benefits for her sister, and an application for Medical Assistance benefits was subsequently filed. 6. The application for Medical Assistance benefits was denied on December 21, 2007, because the information needed by the Cumberland County Assistance Office to determine Defendant's sister's eligibility for Medical Assistance benefits was not provided to the Cumberland County Assistance Office. A true and correct copy of the PA-162 is attached hereto as Exhibit "B." 7. At all times material hereto, Defendant has not cooperated with the Medical Assistance application process and has not provided information and documentation necessary for that process. 8. An appeal of the December 21, 2007 denial of the application for Medical Assistance benefits is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant 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 REACH OF CONTRACT/ SPECIFIC PERFORMANCE 10. The allegations contained in Paragraphs 1 through 9 are incorporated herein by reference as if fully set forth at length. 11. Plaintiff has provided, and continues to provide, skilled nursing care and services to Defendant's sister in accordance with the Agreement, attached hereto as Exhibit "A." 12. Defendant breached her Agreement with Plaintiff when she failed to secure Medical Assistance benefits for her sister, and Defendant continues to breach her Agreement with Plaintiff by failing to provide those documents needed by the Cumberland County Assistance Office to determine her sister's eligibility for Medical Assistance benefits. 13. Plaintiff lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Defendant's sister has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to her and continues to render to her. 14. Defendant's breach of her Agreement with Plaintiff has irreparably harmed and continues to cause Plaintiff irreparable harm. 15. Only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Dated: $ if ) Respectfully submitted, SCHUTJER BOGAR LLC 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 Plaintiff EXHIBIT "A" Hy Date/'l'ime MAK-24-2[JH iMUV IIJ: Z9 Mar 24 2008 10:25RM CFIRLISE MAIN 717L49U641 7172490647 P 2 ADMISSION AGREEMENT PARTIES, ADMISSION DATE, AND DEPOSIT The following are parties to this Agreement: A. Center (We, Us, Our): ManorCare Carlisle B. Patient (You, Your): Toni Filler C. Responsible Party, if applicable (You. Your): Doris Glass Admission Date: 10/25i2007 Deposit Amount: S 0 2. CENTER'S RESPONSIBILITIES We will: Pennsylvania A. Provide You with a basic room, board, common facilities, housekeeping, laundered bed linens, ;eneral nursing care, personal assessment, social services, and other services. B. Apply Your deposit, if any, to Your first one or two months of Your stay at Center, C. Refund any amounts owed to You within 30 days or within the time frame required by state law after Your discharge or transfer. RESIDENT'S RIGHTS AND RESPONSIBILITIES 3.1 You have the right to: A. Choose Your own personal physician as long as the physician is properly licensed and complies with Our policies and procedures. B. Choose Your own pharmacy as long as the pharmacy complies with Our policies and procedures and operates in compliance with state and federal laws. In order for You to receive prescription drug coverage under Medicare Part D, the pharmacy must have a contract with the Part D plan You select. 3.2 You will: A. Pay Us: 1. the room and board rate for all days that You reside at the Center including the day of admission. Unless you are covered under Medicaid or an insurance plan that prohibits it, We may bill You for a late fee if You do not leave the Center before 12:00 p.m_ on the day of Your discharge. The late fee will reflect any charges accrued by You while in the Center after 12:00 p.m. on the day of Your discharge. If We change the room and board rate, We will notify you in writing 30 days before the change. (Room and Board Rates are listed in Attachment A). 2. all additional ancillary charges accrued by You while in the Center. (Ancillary Charges are described on Attachment B) 3. any co-insurance, deductibles or reimbursement You receive for non-covered services if You are eligible for any insurance or governmental program including Medicare, Medicaid, or Veteran's Administration. 4. Any additional or denied charges that are not covered by Your insurance company's benefit or third party payer 5. upon receipt of the bill. If We hire a collection agency or attorney to collect payment on Your account, You will pay for these collection costs. Y V"-24-4' UU8;nON; I U : 2 9 Mar 24 2008 10:215RM CRRLISE MAIN 71724unha 7172490647 B. Pay other providers, including Your attending physician, directly for care they provide to You. C. Notify Us of Your coverage under any insurance plans or government programs. D. Notify Us in writing within 5 days if Your coverage under any insurance plans or government programs changes while You are at the Center. E. Assign Us the right to bill and receive money directly from Your insurance or government payor. You authorize Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services and iLs agents and to third party payors any information needed to determine Your benefits and Our right to receive payment. F. Pay for any damage You cause to any person or property on Center grounds. G. Abide by our policies and procedures. 4. RESPONSIBLE PARTY'S RESPONSIBILITIES You will: N . 'J IJ 3 p.3 A. Have legal access to the Patient's income or resources and deliver any documents supporting such authority to the Center. B, Pay for all charges that Patient incurs while at the Center from the Patient's income or resources. C. Notify Us immediately and in writing if the Patient's financial resources are depleted. D. Secure Medicaid in a timely and proper manner. E. Cooperate with Us by providing information about the Patient's finances. F. Transfer and accept the Patient when it is medically appropriate to discharge the Patient from the Center. G. Abide by Our policies and procedures. H. Not misappropriate the Patient's income or resources or use them for the benefit of someone other than the Patient. 1. Be personally liable for the payment of all charges if You fail to fulfill Your other responsibilities under this Agreement. 5. CONSENT You consent to allow Us to: A. Use and disclose your health information for purposes of treatment, payment, or health care operations. B, Treat You to maintain Your well-being. C. Photograph you for identification purposes. 6. TERM AND TERMINATION 6.1 Term This Agreement begins on the day You are admitted to the Center and ends on the day You are discharged from the Center unless you are readmitted within 15 days of Your discharge date. If You are re-admitted within 15 days of being discharged from the Center, this Agreement will continue in effect as of the date of Your re-admission. x a'.e im^ M,':K-24-2UUVMU1'; 1U, 29 Thar 24 2008 10.25RM CRRLISE MRIN 6.2 Termination A. By You: 717249°6'% U UU1 7172490647 p.4 You may terminate this Agreement: 1, immediately if you leave the Center because of emergency; or 2. by providing 7 days written notice of Your intent to leave the Center. B, By Us: We may terminate this Agreement and discharge You from the Center by notifying You in writing. Where legally required, We will notify you at least 30 days prior to Your transfer or discharge. In cases where the safety or health of You or other individuals in the Center may be endangered, or if other legal reasons exist, we will notify You as soon as practicable before transfer or discharge. We can terminate the Agreement for any of the following reasons: 1. Your needs cannot be met in the Center; 2. Your health has sufficiently improved so that You no longer need Our services: 3. The safety of other individuals in the Center is endangered; 4. The health of other individuals in the Center is endangered; 5. After appropriate notice, You have failed to pay for your stay at the Center; or 6. We cease to operate the Center. 7. ACKNOWLEDGMENTS You acknowledge that You have received the following attachments A. Room and Board Rate - Attachment A B. Ancillary Charges - Attachment B C. Notice of Information Practices and Receipt of Notice of Information Practices - Attachments C-I and C-2 D. Resident's Personal Trust Fund Agreement - Attachment D F,. SNF Medicare Determination Form - Attachment E F. Medicare Secondary Payor Questionnaire - Attachment F G. Summary of Limited Treatment Policy - Attachment G H. Medicare and Medicaid Information 1. Patient Information Handbook J. Center Supplement K. Resident Rights By signing the Admission Agreement, You acknowledge that you have been given and have read this Agreement in its entirety, and all its attachments, You agree that all information submitted as part of Your admission to the Center is true and correct. You acknowledge that the Center relies on the accuracy of all information submitted by You or on Your behalf in determining whether to admit You to the Center, 1)a'.r in- b1AN,-Z4-ZUU8;.t1U?'; IU lu Mar 24 2008 10:25AM CARLISE MAIN I--- By signing below, the parties agree to the terms of this Admission Agreement: Patient Date 40 CeAt-e'r-Re resentative Date f applicable: "J Responsible Party Date -1 h lo?? -02 ^-? Responsible Party's Telephone Number 717249Jb47 7172490647 p.5 4 EXHIBIT "B" N Ca'e/'; IIn 24-2IJ U8;,?10 K; IL:J9 Mar 24 2008 10:82RM CRRLISE MEAN NOTICE TO APPLICANT 71114°U5V P.U'u '7172490647 P.18 ICUMBERLAND CAO JJ VVt7 r mirva I cn tinivc f PO BOX 589 I - CARLISLE PA 1 701 3-0599 00 BENEFIT = H ? ASSISTANCE After ft first check which may be a special amount you will receive $ CHECK ? Twice a Month O Once 'a Month ? in ft Mall fl At the Bank © MEDICAL , ? You have a patient pay liability 0( $ D te ? Eff ti ASSISTANCE a ec ve for the period beginning and ending ? FOOD You wiz race" $ for the month(s) of men you will receive food stamps in the amount of S STAMPS a rnontti from to ? In the Mail O At the Bank NURSNG MOM CAFE ? Level of care authorized you are epected to pay S a month 6oward your care. SOCIAL OT HER SERVICES NMI NO. NAME NAME 01 Toni Filler X - op ,on anon Code SR 56 P71 Coae 201. i As a condition of eligibility for Medicaid and Long Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person (s) and item (s) by the date requested: Proof of gross monthly income for Toni and Jeffrey Filler; Statements for all 90 into f f $2676 it accounts as of 111130007; Titl . depos o e or registration to al I vehicles; MA 51 completed with Options Determination; MA 103; proof o checking account. CC RECORD NUMBER CAT CTR DIG GIST 21 I 0103818 PAN _ Judy Peiper 12/21(07 _ 240-2720 Worker's Signature Mailing Date Telephone-Number: r 7 Toni Filler C/o Manor Care 940 Walnut Bottom Road Carlisle PA 17015 _ J 13 CLIENT APPEAL COPY LEGAL SERVICES INC. 8 IRVINE ROW CARLISLE, PA 17013-0000 (717) 243-9400 ? CASE RECORD COPY PAIFS 152 POT VERIFICATION 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 IS Pa. C.S.A. 9 4904, relating to unsworn falsification to authorities. Dated: Ll Amy Marsh, siness Office Manager Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle O -? Q C a LL? 7 4:3 .2:7 lam- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, : V. No. .S 72 Civil T?'k LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AGAINST RESPONDENT LOTTIE STINE AND NOW COMES Petitioner, Manor Healthcare Corp. d/b/a ManorCare Carlisle ("Petitioner"), by and through its attorneys, SCHUTIER BOAR LLC, and files the within Petition against Respondent, Lottie Stine ("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 when she failed to secure Medical Assistance benefits on behalf of her sister, Toni Filler ("sister"), per the Admission Agreement into which she entered on October 25, 2007. See Exhibit "A" to Complaint. ORIGINAL 3. The very nature of Respondent's breach of the Agreement, i.e., failing to secure Medical Assistance benefits for her sister by providing to the Cumberland County Assistance Office the information necessary to qualify her sister for Medical Assistance benefits, presents an issue of immediate and irreparable harm to Petitioner, as the application for Medical Assistance benefits currently pending has been denied due to the lack of necessary documentary evidence to qualify her sister for Medical Assistance benefits. See Notice to Applicant, i.e., PA-162, attached as Exhibit "B" to Complaint. 4. The requested injunction would restore the parties to the status quo as it existed immediately prior to the breach of Respondent's contractual duty. 5. Greater injury would result from the denial of the requested injunction than from the granting of same because absent the injunction, without the documentation necessary to qualify Respondent's sister for Medical Assistance benefits, the appeal of the Cumberland County Assistance Office's denial of Respondent's sister's Medical Assistance application will fail due to the lack of necessary documentary evidence to qualify her for Medical Assistance benefits, and further appeal to the Commonwealth Court would be without merit. 6. Petitioner's right to relief is clear. See Complaint attached hereto as Exhibit "A." 7. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent's sister has been financially unable to fully compensate Petitioner for the care and services that it rendered to her in accordance with the terms and conditions of the Agreement. 8. 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, SCHUTJER BOGAR LLC Dated: -i ?q Y 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 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Lottie Stine 4100 E. Beachwood Lane Harrisburg, PA 12112 Dated: L4 B ? Y: ? Catherine Klobucar, Paralegal EXHIBIT "A" IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a : MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medic, de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, v objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad a otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. LOTTIE STINE, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Lottie Stine ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17015. 2. Defendant is an adult individual who currently resides at 4100 E. Beachwood Lane, Harrisburg, Pennsylvania 17112. 3. On or about October 25, 2007, Defendant made application for the admission of her sister, Toni Filler ("sister"), to Plaintiff's skilled nursing facility. 4. On or about October 25, 2007, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's sister with skilled nursing care and services in exchange for her promise to pay a specific monetary fee from her sister's income or resources and, in the event that she were to become insolvent, to secure Medical Assistance benefits in a timely and proper manner. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. After Defendant's sister became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that she needed to apply for Medical Assistance benefits for her sister, and an application for Medical Assistance benefits was subsequently filed. 6. The application for Medical Assistance benefits was denied on December 21, 2007, because the information needed by the Cumberland County Assistance Office to determine Defendant's sister's eligibility for Medical Assistance benefits was not provided to the Cumberland County Assistance Office. A true and correct copy of the PA-162 is attached hereto as Exhibit "B." 7. At all times material hereto, Defendant has not cooperated with the Medical Assistance application process and has not provided information and documentation necessary for that process. 8. An appeal of the December 21, 2007 denial of the application for Medical Assistance benefits is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 9. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant 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. The allegations contained in Paragraphs 1 through 9 are incorporated herein by reference as if fully set forth at length. 11. Plaintiff has provided, and continues to provide, skilled nursing care and services to Defendant's sister in accordance with the Agreement, attached hereto as Exhibit "A." 12. Defendant breached her Agreement with Plaintiff when she failed to secure Medical Assistance benefits for her sister, and Defendant continues to breach her Agreement with Plaintiff by failing to provide those documents needed by the Cumberland County Assistance Office to determine her sister's eligibility for Medical Assistance benefits. 13. Plaintiff lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Defendant's sister has been financially unable to fully compensate Plaintiff for the care and services that it has rendered to her and continues to render to her. 14. Defendant's breach of her Agreement with Plaintiff has irreparably harmed and continues to cause Plaintiff irreparable harm. 15. Only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Dated: $ Respectfully submitted, SCHUTJER BOGAR LLC By ?r 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 EXHIBIT "A° Nx :z.± -2'1 -2L',J0.29 71=14`;-547 Mar 24 2008 10:25AM CARLISE MAIN 7172490647 p.2 ADMISSION AGREEMENT I. PARTIES, ADMISSION DATE, AND DEPOSIT The following are parties to this Agreement: A. Center (We, Us, Our): ManorCare Carlisle B. Patient (You, Your): Toni Filler C. Responsible Party, if applicable (You, Your): Doris Glass Admission Date: 10/25i2007 Deposit Amount: S 0 2. CENTER'S RESPONSIBILITIES We will: Pennsylvania A, Provide You with a basic room, board, common facilities, housekeeping, laundered bed linens, general nursing care, personal assessment, social services, and other services. B. Apply Your deposit, if any, to Your first one or two months of Your stay at Center. C. Refund any amounts owed to You within 30 days or within the time frame required by state law after Your discharge or transfer. 3. RESIDENT'S RIGHTS AND RESPONSIBILITIES 3.1 You have the right to: A. Choose Your own personal physician as long as the physician is properly licensed and complies with Our policies and procedures. B. Choose Your own pharmacy as long as the pharmacy complies Nvith Our policies and procedures and operates in compliance with state and federal laws. In order for You to receive prescription drug coverage under Medicare Part D, the pharmacy must have a contract with the Part D plan You select. 3.2 You will: A. Pay Us: 1. the room and board rate for all days that You reside at the Center including the day of admission. Unless you are covered under Medicaid or an insurance plan that prohibits it, We may bill You for a late fee if You do not leave the Center before 12:00 p.m. on the day of Your discharge. The late fee will reflect any charges accrued by You while in the Center after 12:00 p.m. on the day of Your discharge. If We change the room and board rate, We will notify you in writing 30 days before the change. (Room and Board Rates are listed in Attachment A). 2. all additional ancillary charges accrued by You while in the Center. (Ancillary Charges are described on Attachment B) 3. any co-insurance, deductibles or reimbursement You receive for non-covered services if You are eligible for any insurance or governmental program including Medicare, Medicaid, or Veteran's Administration. 4. Any additional or denied charges that are not covered by Your insurance company's benefit or third party payer 5, upon receipt of the bill. If We hire a collection agency or attorney to collect payment on Your account, You will pay for these collection costs, Hx Date%'1'1 1C MA! -26-20U8IMUN) I U: 29 71'7 2 49U64? P UU? Mar- 24 2008 10:25AM CARLISE MAIN 7172490647 p.3 B. Pay other providers, including Your attending physician, directly for care they provide to You. C. Notify Us of Your coverage under any insurance plans or government programs. D. Notify Us in writing within 5 days if Your coverage under any insurance plans or government programs changes while You are at the Center. E. Assign Us the right to bill and receive money directly from Your insurance or government payor. You authorize Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services and its agents and to third parry payors any information needed to determine Your benefits and Our right to receive payment, F. Pay for any damage You cause to any person or property on Center grounds. G. Abide by our policies and procedures. 4. RESPONSIBLE PARTY'S RESPONSIBILITIES You will: A. Have legal access to the Patient's income or resources and deliver any documents supporting such authority to the Center. B. Pay for all charges that Patient incurs while at the Center from the Patient's income or resources. C. Notify Us immediately and in writing if the Patient's financial resources are depleted. D. Secure Medicaid in a timely and proper manner. H. Cooperate with Us by providing information about the Patient's finances. F. Transfer and accept the Patient when it is medically appropriate to discharge the Patient from the Center. G. Abide by Our policies and procedures. H. Not misappropriate the Patient's income or resources or use them for the benefit of someone other than the Patient. 1. Be personally liable for the payment of all charges if You fail to fulfill Your other responsibilities under this Agreement. 5. CONSENT You consent to allow Us to: A. Use and disclose your health information for purposes of treatment, payment, or health care operations. B. Treat You to maintain Your well-being. C. Photograph you for identification purposes. 6. TERM AND TERMINATION 6.1 Term This Agreement begins on the day You are admitted to the Center and ends on the day You are discharged from the Center unless you are readmitted within 15 days of Your discharge date. If You are re-admitted within 15 days of being discharged from the Center, this Agreement will continue in effect as of the date of Your re-admission. Hx Uate/'time MAH-24-2UU8(10N) 10:29 Mar 24 2008 10:25AM CRRLISE MAIN 6.2 Termination A. By You: 717249 n547 is 7172490647 p.4 You may terminate this Agreement; 1. immediately if you leave the Center because of emergency; or 2. by providing 7 days written notice of Your intent to leave the Center_ B, By Us: We may terminate this Agreement and discharge You from the Center by notifying You in writing. Where legally required, We will notify you at least 30 days prior to Your transfer or discharge. In cases where the safety or health of You or other individuals in the Center may be endangered, or if other legal reasons exist, we will notify You as soon as practicable before transfer or discharge. We can terminate the Agreement for any of the following reasons: 1. Your needs cannot be met in the Center; 2. Your health has sufficiently improved so that You no longer need Our services; 3. The safety of other individuals in the Center is endangered; 4. The health of other individuals in the Center is endangered; 5. After appropriate notice, You have failed to pay for your stay at the Center; or 6. We cease to operate the Center. ACKNOWLEDGMENTS You acknowledge that You have received the following attachments: A. Room and Board Rate - Attachment A B. Ancillary Charges - Attachment B C. Notice of Information Practices and Receipt of Notice of Information Practices - Attachments C-I and C-2 D. Resident's Personal Trust Fund Agreement - Attachment D E. SNF Medicare Determination Form - Attachment E F. Medicare Secondary Payer Questionnaire - Attachment F G. Summary of Limited Treatment Policy - Attachment G H. Medicare and Medicaid Information 1. Patient Information Handbook J. Center Supplement K. Resident Rights By signing the Admission Agreement, You acknowledge that you have been given and have read this Agreement in its entirety, and all its attachments. You agree that all information submitted as part of Your admission to the Center is true and correct. You acknowledge that the Center relies on the accuracy of all information submitted by You or on Your behalf in determining whether to admit You to the Center. Hx Uate/1'i'ne MAk-24-2UUSl?0N) 10:2 u 71724 Mar 24 2008 10:25AM CARLISE MAIN 7172490647 By signing below, the parties agree to the terms of this Admission Agreement: Patient 140 Center Re resentative pplicable: Responsible Party Date Date Date 1ri Responsible Party's Telephone Number Y. p.5 4 EXHIBIT "B" ux ,te .9e 1111'',-L4-2UUB',119N U U° Mar 24 2008 10:32AM CARLISE MRIN NOTICE TO APPLICANT 7(724';LIF17 P ' 1 y 7172490647 F.18 CUMBERLAND CAO 33 WESTMINSTER DRIVE PO BOX 599 CARLISLE, PA 17013-0599 o civcrii ? ASSISTANCE CHECK -- - -- Afler the first check which may be a special amount you will receive $ O Twice a Month O Once a Month ? In the Map 17 At the Bank 21 MEDICAL ASSISTANCE , ? You have a patient pay liability of $ for the period beginning and ending O Effective Date ? FOOD STAMPS 21 NURSING HOME CARE You w+lt receive $ for the month(s) of then you wilt receive food stamps in the amount of $ a month from to ? In the Mail ? At the Bank Level of care authored you are expected to pay S a month toward your care. ? SERVICES ? OTHER LINE NAM E JERVICF Nn NAIVE SFRVCF NO, 01 Toni Filler _ x , ? ? e ason Code c oeizoi.i As a condition of al gibtlity for Medicaid and Long Tenn Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person (s) and item (s) by the date requested: Proof of gro ss monthly income for Toni and Jeffrey Filler; Statements for all accounts as of 1 1 /132007; Tine or registration to al l vehicles; MA 51 completed with Options Deterrhination; MA 103; proof of deposit of $2676.90 into checking account. CO RECORD NUMBER CAT CTR DIG DIST 21 0103818 PAN (- Toni Filler c/o Manor Care 940 Walnut Bottom Road Carlisle PA 17015 _ J ? CLIENT APPEAL COPY Judy Peiper 12/21107 240-2720 Worker's Slgnaa,re MaRing Date Telephone Number 7 LEGAL SERVICES INC, 8 IRVINE ROW CARLISLE, PA 17013-0000 (717) 243-9400 0 CASE RECORD COPY PAIFS 162 :TOT, VERIFICATION 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. 9 4904, relating to unsworn falsification to authorities. Dated:_ ?/ b (? f -h A I i, Amy Marsh, IDUsiness Office Manager Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle r.a :.. -TI A , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. LOTTIE STINE, Defendant. ORDER APR 16 zooa My 3 No. 02 -c237a aivit Z'er*L CIVIL ACTION - EQUITY AND NOW, this day of 2008, a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for 7 2008, at 7.'30 X30 o'clock A-.m. in Court Room No. Cumberland County Courthouse. J Irv I D ? t f u S'3,' JPO - S o Julb 1 I AUVzL ' (_i -r{ ?U MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES-CARLISLE, Plaintiff V. LOTTIE STINE, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-2372 CIVIL TERM CIVIL ACTION - EQUITY ORDER OF COURT AND NOW, this 7th day of May, 2008, after hearing, by agreement of the parties, Ms. Lottie Stine is directed to sign Exhibit A attached to the complaint. She is further directed to cooperate fully with ManorCare Nursing Home and to provide them with any and all financial information she has in her possession with regard to her sister, Toni Filler. The Defendant is directed to file whatever paperwork is necessary to have Plaintiff ManorCare named as the representative payee on Ms. Filler's Social Security benefits and any other pension payments. Provided, however, that Plaintiff ManorCare shall first pay the amounts due on any outstanding mortgages from said Social Security and pension payments before it applies the remainder to its bill for services. By -,thb , Court ,.:iuwatu Kirk S. Sohonage, Esquire For the Plaintiff ?/Ms. Lottie Stine 4100 Beechwood Lane, Apartment E Harrisburg, PA 17112 Defendant, Pro se srs E. Guido, J. s i3 09 l/ - 'I 81 :6 HV 81 AN SOoZ