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HomeMy WebLinkAbout08-5907I ?? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. SHARON L. POTTEIGER, Defendant. No. 08 - 690x/ : CIVIL ACTION -EQUITY COMPLAINT 0, tv i l 6P..f YH AND NOW COMES Plaintiff, Church of God Home, Inc. ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within complaint against Sharon Potteiger ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant is an adult individual who currently resides at 478 Wolf Bridge Road, Carlisle, Pennsylvania 17013. 3. On or about July 12, 2007, Defendant made application for the admission of Dorothy Musgrave to Plaintiff's skilled nursing facility. 4. On or about July 12, 2007, Plaintiff and the Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Dorothy Musgrave with skilled nursing services in exchange for Defendant's promise to pay, inter alia, a specific monetary fee from Dorothy Musgrave's assets and, in the event that Dorothy Musgrave became insolvent, to secure Medical Assistance benefits on her behalf in a timely and proper manner, and to cooperate with Plaintiff in providing information about Dorothy Musgrave's finances. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. After her admission to Plaintiffs skilled nursing care facility, Dorothy Musgrave allegedly became insolvent. 6. Subsequently, pursuant to the Agreement, on August 27, 2008, Plaintiff filed an application for Medical Assistance benefits on behalf of Dorothy Musgrave. Plaintiff was compelled to file the application because the Defendant, despite requesting and being provided with an application form, failed to do so. 7. The above-referenced application for Medical Assistance benefits remains pending. However, if Defendant fails to provide the Cumberland County Assistance Office with the information necessary to qualify Dorothy Musgrave for Medical Assistance benefits, the application will be denied, and any appeal of that denial will be unavailing. COUNT I BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 8. The allegations contained in Paragraphs 1 through 7 above are incorporated by reference as though fully set forth herein. 9. Plaintiff has provided and continues to provide skilled nursing services to Dorothy Musgrave in accordance with the terms and conditions of the Agreement. 10. The Defendant breached the Agreement with Plaintiff when she failed to secure Medical Assistance benefits on behalf of Dorothy Musgrave, and the Defendant continues to breach the Agreement with Plaintiff by failing to provide the Cumberland County Assistance Office with the documents required to qualify Dorothy Musgrave for Medical Assistance benefits. 11. The Defendant's breach of the Agreement has irreparably harmed and continues to irreparably harm Plaintiff. 12. Upon information and belief, at all times material hereto, Dorothy Musgrave has been financially unable to fully compensate Plaintiff for the care and services that it has rendered and will continue to render to her in accordance with the terms and conditions of the Agreement. 13. Accordingly, 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: °e By: Respectfully submitted, SCHUTJER BOGAR LLC 3 Anthony T. Lucido Attorney I.D. No. 76583 Misty Bartel Attorney I.D. No. 204190 417 Walnut Street, 4th Floor Harrisburg, PA 17101 (717) 909-0353 Rx Date/Time 5EP-29-2008(MON) 08:29 2541125 09/29/2008 09:48 2541125 CHURCH OF GOD HO The undersigned hereby verifies that the statements of fact in the Complaint are true and correct to the best of my knowledge, information and belief. 1 understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: ?2? I C)O r-A AM , - Sharon Kramer, Business office Manager Church of God Home P. 002 PAGE 02/02 EXHIBIT "A" CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT TABLE OF CONTENTS PAGE 1. PROVISION OF SERVICES . . . . . . . . . . . . . . . . . . 26 2. RECURRING CHARGES . . . . . . . . . . . . . . . . . . .26 _ 3. NON-RECURRING CHARGES . . . . . . . . . . . . . . . . .27 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES . . . . . 27 5. ADMISSION .. .. 28 6. PERIODIC BILLINGS AND PAYMENT DUE DATE 28 7. CHANGES IN CHARGES 28 8. PARTICIPATION- IN MEDICARE/MEDICAID PROGRAMS 28 9. OBLIGATIONS OF RESPONSIBLE PARTY ' . . .29 10. READMISSION - BED/ACCOMMODATION HOLD POLICY . ..:.. 2.9 il. REFUNDS ... 29 12. PERSONAL FINANCES 29 13. TERMINATION, TRANSFER OR DISCHARGE ' . . . . . . . . 30 14. THIRD-PARTY PAYMENTS ... ... .31 15. PERSONAL PROPERTY . . . . . . . . . . . . . . . . . . .. 32 16. RESPONSIBILITIES OF RESIDENT 2 3 17. MISCELLANEOUS PROVISIONS 32 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., ca. d t "Facility," a Pennsylvania non-profit corporation located 8 North Hanover Street arlisle, Cumberland Co Pennsylvania, and called "Resident" and called "Responsible Party". The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and understand that the submission of false information may constitute grounds to terminate this .Agreement. The Resident has applied for admission to the Facility and the Facility has approved the. Application for Admission. Therefore, the Facility, The Resident and Responsible Party agree to the following terms': 1. 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: $ 0??0. ma dollars •per day. Admission and Care Agreement - continued -3-. NON-RECURRM CSARGgS. 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 a 's ion day. The amount of the security deposit is $ etc. 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 a 2p and ALS (Advance Life Support) Unit is $ This fee must be paid prior to admission and i7 1 bebilled annually to the.-Resident. 4. MISCELLANEOUS CHARGLS 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 Resident is responsible to pay -all fees and costs 'for goods or services furnished to or for. the Resident by anyone other than the Facility under this Agreement. The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist,'. therapist, diagnostic or testing laboratory; pharmacist, pharmacy, hospital, or any other person,* facility or entity providing services or goods to or for the Resident, and for all '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 Agreement - continued 5. ADMISSION. The Resident will be admitted, or a bed will be reserved-for Resident, beginning on 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 PAYMMU 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. * CBANMS IN CRAR-GES. 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 •coinputed, 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 O RESPOUS LE 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, un1?ss 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 Home, responsibility to -manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which 'is - provided at the time of your admission, and the Facility's personal .funds management policy. The Facility may deduct, at any time, charges due to. the Facility under this agreement from. the Resident's. personal funds managed by' the Facility. 13. TERMINATION. TRANSFER OR DISC8ARGE. (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 necessary.to meet the Resident's welfare which cannot ..be.met by the Facility; (II) the Resident's health or condition has improved sufficiently that'the Resident no longer needs the services•provided by the Facility; (III) the safety or health of individuals in the Facilityis or otherwise would be endangered; Admission and Care Asreement- 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 Resident's 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 (I), (II) and (III) 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 insui:ance, employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident, the Resident/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 now or hereafter payable 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 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. 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 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 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 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. Party I -D c ..? F f J rv i m _? NJ ,.y -•c IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, No. Ore's76 7 C.i vc I -f "A- V. SHARON L. POTTEIGER, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES Petitioner, Church of God Home, Inc. ("Petitioner"), by and through its attorneys, SCHUDER BOGAR LLC, and files the within Petition against Respondent, Sharon L. Potteiger ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. Petitioner filed a Complaint against Respondent. 2. The Complaint sets forth a claim against Defendant/Respondent relating to Respondent's breach of her contractual duty owed to Petitioner to cooperate fully to secure Medical Assistance benefits on behalf of Dorothy Musgrave ("Ms. Musgrave"), pursuant to the Admission Agreement into which she entered on July 12, 2007. See Exhibit "A" to Complaint. 3. The very nature of Respondent's breach of her contractual duty presents an issue of immediate and irreparable harm to Petitioner, as the Medical Assistance application filed by Petitioner on behalf of Ms. Musgrave will be denied if Defendant fails to provide the Cumberland County Assistance Office with the information necessary to qualify Ms. Musgrave for Medical Assistance benefits - and any appeal of such a denial would be without merit. 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 the same because absent the injunction, the documentation necessary to qualify Ms. Musgrave for Medical Assistance benefits will not be provided and any subsequent appeal of the County Assistance Office's denial of benefits will fail. 6. Petitioner's right to relief is clear. See Complaint attached as Exhibit "A." 7. Petitioner lacks an adequate remedy at law, because at all times material hereto, Ms. Musgrave has been financially unable to fully compensate Petitioner for the services that it has rendered, and continues to render, to her. 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. Dated: ? (t-.,( ;?8- By: Respectfully submitted, SCHUDER BOGAR LLC Anthony T. Lucido Attorney I.D. No. 76583 (717) 909-0353 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff 2 EXHIBIT "A" IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. SHARON L. POTTEIGER, Defendant. No. : CIVIL ACTION - EQUITY COMPLAINT AND NOW COMES Plaintiff, Church of God Home, Inc. ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within complaint against Sharon Potteiger ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant is an adult individual who currently resides at 478 Wolf Bridge Road, Carlisle, Pennsylvania 17013. 3. On or about July 12, 2007, Defendant made application for the admission of Dorothy Musgrave to Plaintiff's skilled nursing facility. 4. On or about July 12, 2007, Plaintiff and the Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Dorothy Musgrave with skilled nursing services in exchange for Defendant's promise to pay, inter alia, a specific monetary fee from Dorothy Musgrave's assets and, in the event that Dorothy Musgrave became insolvent, to secure Medical Assistance benefits on her behalf in a timely and proper manner, and to cooperate with Plaintiff in providing information about Dorothy Musgrave's finances. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. After her admission to Plaintiff's skilled nursing care facility, Dorothy Musgrave allegedly became insolvent. 6. Subsequently, pursuant to the Agreement, on August 27, 2008, Plaintiff filed an application for Medical Assistance benefits on behalf of Dorothy Musgrave. Plaintiff was compelled to file the application because the Defendant, despite requesting and being provided with an application form, failed to do so. 7. The above-referenced application for Medical Assistance benefits remains pending. However, if Defendant fails to provide the Cumberland County Assistance Office with the information necessary to qualify Dorothy Musgrave for Medical Assistance benefits, the application will be denied, and any appeal of that denial will be unavailing. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 8. The allegations contained in Paragraphs 1 through 7 above are incorporated by reference as though fully set forth herein. 9. Plaintiff has provided and continues to provide skilled nursing services to Dorothy Musgrave in accordance with the terms and conditions of the Agreement. 2 10. The Defendant breached the Agreement with Plaintiff when she failed to secure Medical Assistance benefits on behalf of Dorothy Musgrave, and the Defendant continues to breach the Agreement with Plaintiff by failing to provide the Cumberland County Assistance Office with the documents required to qualify Dorothy Musgrave for Medical Assistance benefits. 11. The Defendant's breach of the Agreement has irreparably harmed and continues to irreparably harm Plaintiff. 12. Upon information and belief, at all times material hereto, Dorothy Musgrave has been financially unable to fully compensate Plaintiff for the care and services that it has rendered and will continue to render to her in accordance with the terms and conditions of the Agreement. 13. Accordingly, 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. Respectfully submitted, SCHUTJER BOGAR LLC Dated: ! h'1 °e By. Anthony T. Lucido Attorney I.D. No. 76583 Misty Bartel Attorney I.D. No. 204190 417 Walnut Street, 4th Floor Harrisburg, PA 17101 (717) 909-0353 3 I., Ji-I LJ-LUUUk#IUIIJ uocCy if SUI Its 09/29/2008 09:48 2541125 CHURCH OF GOD HO The undersigned hereby verifies that the statements of fact in the 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 19 Pa. C, S. § 4904, relating to unswonn falsification to authorities. Dated: a=n - r- A - - Sharon Kramer, Business Office Manager Church of God Home P. 002 PAGE 02/02 EXHIBIT "A" CHURCH OF GOD HOME, INC'. ADMISSION AND CARE AGREEMENT ALE OF CONTENTS 1- PROVISION OF SERVICES . 26 2. RECURRING CHARGES . 26 _ 3. NON-RECURRING CHARGES 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES 5. ADMISSION - 28 6. PERIODIC*BILLINGS AND PAYMENT DUE DATE • - .. 28 7. CHANGES IN CHARGES . 28 8. PARTICIPATION. IN 1" MEDICARE/MEDICAID PROGRAMS 28 9. OBLIGATIONS OF RESPONSIBLE PARTY .29 10. READMISSION - BED/ACCOMMODATION HOLD POLICY .: • 29 '11. REFUNDS . 29 12. PERSONAL FINANCES 29 13. TERMINATION, TRANSFER OR DISCHARGE 30 14. THIRD-PARTY PAYMENTS .31 15. PERSONAL PROPERTY , 32 16. RESPONSIBILITIES OF RESIDENT . .32 17. MISCELLANEOUS PROVISIONS . 32 CHORCH 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., ca d "Facility," a Pennsylvania non-profit corporation located North Hanover Stree?arlisle, Cumberland Cam, Pennsylvania, and and- called "Resident" 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.A15plication 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: $ o91(9. ma -dollars .per day. Admission and Care Agreement _ continued following NON-RZCURRIW CM:&gGZS The Resident shall pay the 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 bill d , e after a 's ion day. The amount of the security deposit is $ 2 2 -10 O 4 2 ,e . 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 b M di y e care, until the Medicare benefit concludes.. An applicant who i _ s covered by Medicaid is not required to pay a security deposit. (b) The cost for enrollment in the community e and ALS (Advance Life Support) Unit is $ This fee must be paid ri * p or to admission and lbe?billed annually to the.-Resident. 4. MISCBLI,ANSOUS CHARGES AND OOTSIDB 68RVZCgs, responsible to pay for other services provided by' the Resident which are n t d services/c o covere by the daily rate/charge. A list of such harges is attach d Costs." e to this Agreement on the "Chart of 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,, charges, the Resident is responsible to pay *all fees and costs -for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement . - The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist,'. therapist, diagnostic or test ing: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-Agreement - continued 5. ADMISSION. The Resident will be mitted, or a bed will be reserved *for Resident, beginning on - All pre-admission charges will be billed after a mission, 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 tex-urinated, • even if the Resident does not enter the -Rome 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. ' CEANGES IN C-EMRGES. 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 O RgsgONSTRr fl,?.,,t, 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. RZLDMISSION - Elm fior n DAT Tnv if the Resident leaves the Facility for a period of hoepitalization, 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, 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 rbed.reservation period is fifteen hospitalization, regardless-of level of care, fifteen(15) das for . (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 Resident's . discharge from the Facility or death. dThosef 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 Home, responsibility to -manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which *is. provided - at the time of your admission., and the Facility's personal funds management policy. The Facility may deduct, at any time, charges due to. the Facility under- this agreement from. the Resident's. personal funds managed by' the Facility. 13. TERMINATION. TRkNSIEA_ OR DI3CSARQL. (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 of termination of the Agreement. If advance written notice is not given to the Facility, there will be due to the Facility its daily and other charges then in effect for the Resident's current level of care for the required thirty (30) day notice period. The charge applies whether or not the Resident remains at the Facility during the thirty. (30) day period. (b) By the Facility: The*Facility may terminate the Resident's stay and transfer or discharge the Resident if: (I) the transfer or discharge is necessary.to meet the Resident's welfare which cannot be.met by the Facility; (II) the Resident's health or condition has improved sufficiently that'the Resident no longer needs the services. provided by the Facility; (III) the safety or health of individuals in the Facility is or otherwise would be endangered; Admission and Care Agreement- continued IV. The charges or other amounts due to the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf by Medical Assistance under the 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 (1), (11) and (III) above, or if the Resident has not resided at the Facility at least thirty (30) days, the Facility will give such notice before transfer or discharge asr 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 insurance, supplemental security income insurance, or old-age survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident, the Resident/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 now or hereafter payable 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 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 ofproperty. 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 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 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 terms of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (;0) days notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. .sponsible Party co -rr r? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Petitioner, V. SHARON L. POTTEIGER, Respondent. No. ca - 59o'7 OCT o 7 zoos 0,;v; I UPS CIVIL ACTION - EQUITY ORDER AND NOW, this _ZL L1 day of 2008, a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for 2008, at o'clock a_.m. in Court Room No. 5 , Cumberland County Courthouse. BY THE COURT: ?Jj J. 13 ?d?I+U '?3? ?'urt S3 fJ 4 c i :1 V 0 ! 130 0001 LA/,,- - gp /V 1'Ol ! i ? 3 Hi My a_flH CHURCH OF GOD HOME, INC. IN THE COURT OF COMMON PLEAS OF PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. SHARON L. POTTEIGER, DEFENDANT NO. 08-5907 CIVIL IN RE: PETITION FOR PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 15th day of October, 2008, it appearing that the Defendant did not receive timely notice of the hearing scheduled for today, and Counsel for Plaintiff requesting a continuance, IT IS HEREBY ORDERED AND DIRECTED that the hearing is continued until Friday, November 14, 2008, at 8:30 a.m. in Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. By the Court, Y` M. L. Ebert, Jr., J. Anthony Lucido, Esquire Attorney for Plaintiff Sharon Potteiger, Pro Se /0 - 1,5- 0 51 bas Z c6 WV S 1 130 BQOZ AdVIO- v,jpW)dd L AG 4J", C IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 6-110 7 CASE NO.: 08--2@Wr AFFIDAVIT OF SERVICE Church of God Home, Inc. vs Sharon L. Potteiger Commonwealth of Pennsylvania County of Dauphin ss. I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at 3:30 PM on 10/09/2008,1 served Sharon L. Potteiger at 478 Wolf Bridge Road , Carlisle, PA 17013 in the manner described below: ? Defendant(s) personally served. W1 Adult family member with whom said Defendant(s) reside(s). Relationship is Dennis Potteiger. Spouse. ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. ? Other: a true and correct copy of Complaint; Verification; Order; Petition for Preliminary Injunction issued in the above captioned matter. Description: Sex: Male - Age: 65 - Skin: White - Hair: White - Height: 51811 - Weight: 160 x Sw n to and subscrib dIbefore me on this Timothy Ho day of 11, ie 20d$. Shinkowsk Investigations 316 Fawn Ridge North Harrisburg, PA 171.10 (800) 276-0202 T.T(l V DTTRT.TC' Atty File#: - Our File# 5346 Law Firm: Schutjer Bogar LLC Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102 Telephone: (717) 909-5925 COMMONWEALTH OF PENNSYLVANIA Notarial Seal John F. Shklkowsky, Notaty Public Susquehanna Twp.. Dauphin County My Commission Expires Sept. 28, 2010 Member, Pennsylvania Association of Notaries ` ?; r? ... IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. SHARON L. POTTEIGER, Respondent. No. 08-5907 - Civil Term CIVIL ACTION - EQUITY PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter our appearance as counsel for the Plaintiff in the above-captioned matter: SCHUTJER BOGAR LLC Brandon S. Williams 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Respectfully submitted, Dated: /a SORTU R BOGAR LLC By: __-? Anthony T. Lucido Attorney I.D. No. 76583 (717) 909-0353 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff ORIGINAL 4A 4 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Entry of Appearance was served via first-class, United States mail, postage prepaid, upon the following: Sharon L. Potteiger 478 Wolf Bridge Road Carlisle, PA 17013 to ?,t 08 Date: \/V- WKeslar, Paralegal 2 ct, 7-5 hJ -?C 40 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-5907 -Civil Term SHARON L. POTTEIGER, Respondent. CIVIL ACTION - EQUITY STIPULATION FOR ENTRY OF INTUNCTION Church of God Homes, Inc. ("Petitioner') and Sharon L. Potteiger ("Respondent") stipulate and agree to the following: 1. On or about October 3, 2008, Petitioner filed a Complaint against Respondent. 2. The Complaint sets forth a single claim against Respondent based on her failure to specifically perform the terms of the Admission Agreement ("Agreement") entered into with Petitioner. See Complaint Exhibit "A." Specifically, the Complaint alleges that Respondent failed secure the Medical Assistance benefits on behalf of her mother, Dorothy Musgrave ("Mrs. Musgrave"), pursuant to the Agreement. 3. An application for Medical Assistance benefits was filed on behalf of Mrs. Musgrave and that application currently is pending before the Cumberland County Assistance Office of the Department of Public Welfare. 4. The parties agree to the entry of an Order directing Respondent to provide any and all records within their possession or control as required by the Cumberland County Assistance Office to determine the eligibility of Respondent for Medical 4b Assistance benefits within fifteen (15) days of the date of the Order adopting this Stipulated Injunction. The parties also agree that Respondent will work diligently to secure any and all other documents or verifications required by the Cumberland County Assistance Office to obtain Medical Assistance benefits, and will obtain those documents within thirty (30) days of the date of the Order adopting this Stipulated Injunction. The Order is attached as Exhibit "A." 5. Petitioner agrees to withdraw, without prejudice, its Petition for a. Preliminary Injunction. 6. The parties agree that failure to abide by the terms of this Stipulation and the Order adopting the same constitutes contempt of Court and may result in sanctions imposed by the Court. Respectfully submitted, Dated: // 1 6? By: "Z? - Brandon S. Williams, Attorney for Petitioner Dated: By: Sharon L. otteiger f IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. : SHARON L. POTTEIGER, : Respondent. : No. 08-5907 -Civil Term CIVIL ACTION - EQUITY ORDER AND NOW, this 1"k* day of N64 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, Sharon L. Potteiger shall provide any and all records in her possession that are required by the Cumberland County Assistance Office for the pending application to determine the eligibility of Dorothy Musgrave for Medical Assistance benefits. Sharon L. Potteiger shall also diligently work to secure any and all other documents or verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave, within thirty (30) days. BY THE COURT pJ?-G (Irr c`?a G rTF t ? " ..G w co r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08=5907 Civil Term SHARON L. POTTEIGER, Respondent. CIVIL ACTION - EQUITY RETURN OF SERVICE I HEREBY CERTIFY THAT: I, Catherine Klobucar, served the annexed Stipulated Order upon the following: Sharon Potteiger 478 Wolf Bridge Road Carlisle, PA 17013 Service was made via first-class, United States mail, certified, return receipt requested, on December 5, 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: 1 By: 6ffw'jzs. 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., Petitioner, v. No. 08-5907 - Civil Term SHARON L. POTTEIGER, Respondent. ORDER CIVIL ACTION - EQUITY AND NOW, this N4k, day of 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, Sharon L. Potteiger shall provide any and all records in her possession that are required by the Cumberland County Assistance Office for the pending application to determine the eligibility of Dorothy Musgrave for Medical Assistance benefits. Sharon L. Potteiger shall also diligently work to secure any and all other documents or verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave, within thirty (30) days. BY THE COURT ' ?:.? i.;??! tl y a 3,?t.?y }?1 c?RRif?4' F 'Vgot,,-(I here C.o??<? `?'?,? ¦ 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 hack of the mailpiece, or on the front If space permits. 1. Article Addressed to: S?c'on a?o-H- e_+ge? y?1 ? Wo?F ?r ??ge. Q oad, CaK ??s?e , P ?? no l 3 A Sign X ? Agent j ?-addressee 8. R eived by (Pri ted Name) C. Date f livery D. Is delivery address iffe from item 1? ? Yes If YES, enter delivery address below: ? No i 3. Service Type M(Certifled Mail ? Express Mail ? Registered ? Return Receipt for Merchandise ? Insured Mail ? C.O.D. 4. Restricted Delivery/? (Extra Fee) ? Yes 2. Article Number 7007 3020 0002 0733 7432 (Transfer from service label) Ps Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 c'j ? r?,> ? ? , ??.._ =r' ? c-a r zap r:r -. -? ^;? t:., -;:? ? } , . ?T-? f IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. SHARON L. POTTEIGER, Respondent. No. 08-5907 -Civil Term CIVIL ACTION - EQUITY MOTION FOR CIVIL CONTEMPT AND NOW, COMES, Petitioner, Church of God Home, Inc. ("Petitioner") and files this Motion for Civil Contempt and, in support thereof, avers: 1. On November 14, 2008, this Court entered a Stipulated Order granting Petitioner's request for injunctive relief. A true and correct copy of the Order is attached hereto as Exhibit "A." 2. Pursuant to the Order, Respondent, Sharon Potteiger, responsible party for her mother, Dorothy Musgrave, was obligated to provide verifications required by the Cumberland County Assistance Office. 3. Specifically, Respondent Sharon Potteiger was to "diligently work to secure any and all other documents or verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave, within thirty (30) days." ORIGINAL 4. To date, despite several requests from Petitioner, Respondent Sharon Potteiger has failed to secure all of the documents and verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave. 5. If Respondent Sharon Potteiger does not comply with this Court's Order attached hereto, Dorothy Musgrave will be denied Medical Assistance benefits and Petitioner's ability to secure payment from Medical Assistance for the services provided to Dorothy Musgrave will be lost. WHEREFORE, Petitioner respectfully requests this Court hold a Hearing on this matter, find the Respondent in Contempt, and issue an Order requiring: 1) Respondent to comply with the November 14, 2008 Order by providing the verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave, within five (5) days; or 2) Suffer a sanction in the form of incarceration and a monetary fine in the amount of Fifty ($50.00) Dollars per day, beginning on December 14, 2008, until Respondent has purged herself of her contemptuous action; 2 3) Any additional sanctions the Court deems just and appropriate for Respondent's willful violation of the Court's Order. Respectfully submitted, SCHUTJER BOGAR Dated: 0? By: Anthony T. Lucido V Attorney I.D. No. 76583 (717) 909-0353 Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No. (717) 909-5925 Attorneys for Petitioner 3 EXHIBIT "A" (TO MOTION FOR CIVIL CONTEMPT IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-5907 -Civil Term SHARON L. POTTEIGER, Respondent. CIVIL ACTION - EQUITY ORDER AND NOW, this Wk,_ day of 1\)6U . , 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, Sharon L. Potteiger shall provide any and all records in her possession that are required by the Cumberland County Assistance Office for the pending application to determine the eligibility of Dorothy Musgrave for Medical Assistance benefits. Sharon L. Potteiger shall also diligently work to secure any and all other documents or verifications required by the Cumberland County Assistance Office in order to obtain benefits on behalf of her mother, Dorothy Musgrave, within thirty (30) days. BY THE COURT ?3;yj?=5iu•?ur..., ' c.?s¢?-?2't??.dl??j1????? ?iP?z??e?' ??,s?' Caay?++??61i1?11 T V'? ?i V, vii=XY Y )may ?Y'iY?j; Sj CERTIFICATE OF SERVICE I hereby certify that, on this day, a true and correct copy of the foregoing Motion for Civil Contempt was served via first-class, United States mail, postage prepaid upon the following: Sharon L. Potteiger 478 Wolf Bridge Road Carlisle, PA 17013 Dated: 5- 8 a q By: William Keslar, Paralegal F LED. V THE M9 MAY I I Fil 1: 00 CHURCH OF GOD HOME, INC. IN THE COURT OF COMMON PLEAS OF Petitioner CUMBERLAND COUNTY, PENNSYLVANIA V. SHARON L. POTTEIGER, Respondent NO. 08-5907 CIVIL IN RE: MOTION FOR CONTEMPT ORDER OF COURT AND NOW, this 15th day of May, 2009, upon consideration of the Motion for Contempt filed by the Petitioner, IT IS HEREBY ORDERED AND DIRECTED that a hearing is scheduled for Tuesday, June 16, 2009, at 8:30 a.m. in Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. IT IS FURTHER ORDERED AND DIRECTED that the Petitioner shall serve notice of this hearing on the Respondent. Brandon S. Williams, Esquire Schuter Bogar LLC Attorneys for Petitioner ZSharon Potteiger, Pro Se bas ?-6ptEr rn4t L?.CI.. By the Court, M. L. Ebert, Jr., J. ,UV 70 •E WJ S I AVW 60DZ ndViC)N' - C;- j CHI 10 D?L? 331H I I% IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-5907 -Civil Term SHARON L. POTTEIGER, Respondent. CIVIL ACTION - FQUI_TY AFFIDAVIT OF SERVICE I, William Keslar, being duly sworn according to law, depose and say that I served Sharon. L. Potteiger with the attached Order of Court dated May 15, 2009, in the above-captioned matter, via First-Class, United States mail, postage prepaid, to her residence at 478 Wolf Bridge Road, Carlisle, PA 17013, on the 19th day of May, 2009. Dated: 5 2 0 o Q William Keslar Sworn to and Subscribed before me This 20th day of May, 2009. otary Public My Commission Expires: OF POMYLVANIA NORARIAL MAL BRITTANY A. RMAM N?IRY PUBIJC 3WAURA TDWNW VAMW OM MY MY COMMLSSIOd?I ? AL 23,2OI I ORIGINAL r ti. . ~ JSISAR ER LLC Email: wkeslar@schutjerbogar.com Direct Dial: (717) 909-8985 May 19, 2009 Via Regular Mail Sharon L. Potteiger 478 Wolf Bridge Road Carlisle, PA 17013 Re: Church of God Home v. Sharon L. Potteiger Docket No.: 08-5907 Civil Dear Mrs. Potteiger: Schutjer Bogar LLC 417 Walnut Street 4th Floor Harrisburg; PA 17101 Fax(717)909-5925 www.schutjerbogar.com . Enclosed please find an Order of Court scheduling a hearing regarding the Motion for Civil Contempt for 8:30 a.m. on Tuesday, June 16, 2009, in Courtroom 5 at the Cumberland County Courthouse. Thank you. Sincerely, William Keslar Paralegal Enclosure HARRISBURG, PA • PHILADELPHIA, PA PITTSBURGH, PA COLUMBUS, OH PRINCETON, NJ BALTIMORE, MD • ARLINGTON. VA CHURCH OF GOD HOME, INC. IN THE COURT OF COMMON PLEAS OF Petitioner CUMBERLAND COUNTY, PENNSYLVANIA V. SHARON L. POTTEIGER, Respondent NO. 08-5907 CIVIL IN RE: MOTION FOR CONTEMPT ORDER OF COURT AND NOW, this 15th day of May, 2009, upon consideration of the Motion for Contempt filed by the Petitioner, IT IS HEREBY ORDERED AND DIRECTED that a hearing is scheduled for Tuesday, June 16, 2009, at 8:30 a.m. in Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. IT IS FURTHER ORDERED AND DIRECTED that the Petitioner shall serve notice of this hearing on the Respondent. By the Court, M. L. Ebert, Jr., J. Brandon S. Williams, Esquire Schuter Bogar LLC Attorneys for Petitioner Sharon Potteiger, Pro Se bas OF T 0 Vii Y 22 Pr 2, 06 G IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. No. 08-5907 -Civil SHARON L. POTTEIGER, Respondent. CIVIL ACTION - E PRAECIPE TO WITHDRAW TO THE PROTHONOTARY: Kindly withdraw the Motion for Civil Contempt filed May 11, 2009. Respectfully submitted, Dated: _G '9' C>7 By: SCHUTJER BOGAR LLC Anthony T. Lucido Attorney I.D. No. 76583 (717) 909-0353 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No. (717) 909-5925 Attorneys for Petitioner ORIGINAL CERTIFICATE OF SERVICE I hereby certify that, on this day, a true and correct copy of Praecipe to Withdraw Motion for Civil Contempt was served via States mail, postage prepaid upon the following: Sharon L. Potteiger 478 Wolf Bridge Road Carlisle, PA 17013 Dated: 6o /eq By: William Keslar, foregoing United FIl FD-z`,IFF- ;E OF THE P^OTHIONIOTARY 2009 JUN 11 P14 1: 03 C?G? G J ?l "LINTY FENNS vT Vr6x dIA.