HomeMy WebLinkAbout08-6928PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008- CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by an attorney and filing in writing with
the court, your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so, the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other claim
or relief requested by the plaintiff. You may lose money or property or other rights important to
you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008- b yc4a' CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
COMPLAINT
NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a
Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets
forth the following:
1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Erma A. Moser, is an adult individual with a residence address of 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257.
3. Defendant, Donald Grove is an adult individual with a residence address of 6824
Furnace Road, Waynesboro, Franklin County, Pennsylvania 17268.
4. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
5. On or about February 8, 2008, Donald Grove, sought to have Erma A. Moser
admitted to the Shippensburg Health facility.
6. On or about February 8, 2008, Donald Grove executed an Admission Agreement
on behalf of Erma A. Moser. A true and correct copy of the Admission Agreement is attached
hereto as Exhibit "A" and is incorporated.
7. Pursuant to the Admission Agreement, Erma A. Moser would be responsible to
pay any costs of care which were not covered by a third parry payer.
8. On or about February 8, 2008, Erma A. Moser became a resident of the
Shippensburg Health facility and remains a resident to the date hereof.
9. As of October 31, 2008, Erma A. Moser owed Shippensburg Health the sum of
$51,131.99 for the costs of care provided by Shippensburg Health to her. A true and correct copy
of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is incorporated.
Moreover, the costs and resultant balance owed continue to accrue.
10. Demand has been made upon Erma A. Moser to pay the amount due.
11 Upon information and belief, since February 8, 2008, Donald Grove has been the
representative payee for Erma A. Moser and has been receiving the social security and pension
benefits on behalf of Erma A. Moser.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. ERMA A. MOSER AND DONALD GROVE
12. Plaintiff incorporates by reference paragraphs one through eleven as though set
forth at length.
13. Erma A. Moser has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
14. As a consequence of that breach, Shippensburg Health is owed the sum of
$51,131.39 to October 31, 2008 and the debt continues to accrue.
15. The accrued debt consists of the private pay obligation of Erma A. Moser.
Donald Grove has failed to pay the private pay obligation from the benefits he has received in the
name of Erma A. Moser.
16. The Admission Agreement bound Erma A. Moser to pay for the costs of her care
at the facility and bound Donald Grove to pay the costs of care from the assets and income of
Erma A. Moser.
17. The Admission Agreement provides for the recovery of a penalty for late
payments in the amount of 1.5% per month. These finance charges total $3,529.44 as of October
31, 2008 and continue to accrue.
18. The Admission Agreement provides for the recovery of reasonable attorney fees
and costs incurred by Shippensburg Health to collect a debt due and owing to Shippensburg
Health.
WHEREFORE, Plaintiff requests judgment in its favor and against Erma A. Moser and
Donald Grove for the sum of $54,660.83 plus interest, costs and expenses, late fees and any
additional amount coming due to the date of award and attorney fees and costs.
COUNT II-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. DONALD GROVE
19. Plaintiff incorporates by reference paragraphs one through eighteen as though set
forth at length.
20. During the period of Erma A. Moser's residence at the facility, Donald Grove has
been receiving social security and pension benefits of Erma A. Moser.
21. The proper use of those funds would have been to pay the costs of care accruing
for the care of Erma A. Moser at Shippensburg Health.
22. At the time of receipt of those funds, Donald Grove knew that these funds should
be paid over to Shippensburg Health for the costs of Erma A. Moser's care.
23. Donald Grove gave no consideration for the funds of Erma A. Moser he has
received.
24. Demand has been made upon Donald Grove to tender the funds of Erma A. Moser
to Shippensburg Health and he has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Donald Grove
requiring him to:
a) return the subject matter in specie;
b) pay over the value if Donald Grove has consumed the money in beneficial use;
C) pay its value if Donald Grove has disposed of the funds received; and
d) award costs, expenses and interest.
COUNT III-QUANTUM MERUIT
SHIPPENSBURG HEALTH v. ERMA A. MOSER
25. Plaintiff incorporates by reference paragraphs one through twenty-four as though
set forth at length.
26. During the period of her residency at the facility, Erma A. Moser has enjoyed the
benefit of care and services provided to her by Shippensburg Health.
27. Erma A. Moser has failed and refused to pay for the costs of her care and services
provided by Shippensburg Health.
28. Erma A. Moser has been unjustly enriched by her use and enjoyment of the
services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Erma A. Moser for
the sum of $54,660.83 plus interest, costs and expenses, late fees and any additional amount
coming due to the date of award and attorney fees and costs.
Respectfully submitted,
dBb?'_
EN, B C
V 4
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
da b.d it/shcc/moser/com plaint. pld
VERIFICATION
I verify that the statements made in the foregoing Complaint are true and correct to the
best of my knowledge, information and belief. This verification is signed by David A. Baric,
Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as
documents reviewed by the undersigned as attorney for Plaintiff. This verification will be
substituted and ratified by a verification signed by the Plaintiff who is presently unavailable to
sign said verification. I undersigned that false statements herein are made subject to penalties of
18 Pa.C.S. §4904, relating to unsworn falsificat'ons to authorities.
David A. Baric, Esquire
Dated: 11--c?J-D?
SHIPPENSBURG HEALTH CARE CENTER
ADMISSION AGREEMENT
2v°a'
THIS AGREEMENT, made this day of Ar'grum!3,e
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
"Shippensburg") and &rns 1'?vs?Cr- (hereafter
"Resident"), previously residing at (Street Address and Post Office Box)
and
Ab;u ?xl r? u-r (hereafter
"Legal Representative"), residing at (Street Address and Post Office Box)
?vik?c_y4 PA The Legal
Representative's relationship with the Resident is that of
The staff of Shippensburg will take whatever time is necessary to answer all of
your questions. Please continue to ask questions
until you are sure that you understand.
PROVISION OF SERVICES
NURSING SERVICES: Shippensburg will provide the Resident with routine
:__ ___s_.. ??.......f....i.. ......ww.n,,.?.1a4innc. fhrnra mante eflrtt risar IAymnt
as otherwise medically indicated), blankets, bed linens, towels and wash cloths,
laundering of blankets, linens, towels, and wash cloths, housekeeping services,
and activity programs and social services as established by the facility, as
identified on the Rate Schedule. The Rate Schedule is attached to this
Agreement and is incorporated herein as If set forth In full. The Rate Schedule
sets forth the list of supplies and services included in Shippensburg's daily
rates, those supplies and services which are not covered by the daily rates for
1
Exhibit "A"
which the Resident will be separately charged, and those supplies and services
covered by the Medicare and/or Medicaid programs for enrolled Residents.
Federal and state laws and regulations change regularly and frequently
require changes related to the care and services Shippensburg provide..
Additionally, other financial factors may require Shippensburg to make changes
related to provision of its care and services. On this basis, the Rate Schedule
may be changed, upon notice to the resident.
ANCILLARY SERVICES AND SUPPLIES: Shippensburg will also provide
ancillary services and supplies as set forth in the Rate Schedule, and private
accommodations upon the direction of the Resident's physician. The ancillary
services and supplies are subject to change from time to time at the discretion
of Shippensburg.
OUTSIDE PROVIDERS AND NON-FACILITY SERVICES: Shippensburg
makes available, from time to time, the services of outside providers and non-
facility services. These services will be available under Shippensburg's policies
and procedures, and at the Resident's sole expense unless the charges for
such services are covered by a third party payer. Should the Resident arrange
for the services of outside providers, the providers must be properly licensed or
?. registered under state and federal law, and must comply with all Shippensburg
policies and procedures, Including, but not limited to, providing Shippensburg
with documented proof of their legally required liability Insurance coverage. All
outside providers must be approved in writing by Shippensburg before providing
any services. At Shippensburg's sole discretion, only providers deemed by
Shippensburg to fulfill all of the requirements set forth in federal and state law,
as well as Shippensburg's policies and procedures, may provide services to
Residents.
The Resident recognizes and agrees that all outside providers, including
those designated by Shippensburg, are independent contractors. The Resident
recognizes and agrees that such providers are not associates or agents of
Shippensburg, and that Shippensburg Is not liable for any outside provider's
acts or omissions. The Resident shall be solely responsible for payment of all
charges of any provider who renders care to the Resident in Shippensburg,
unless the charges are covered by a third party payer. Furthermore, the
""slde"rees t6 --VIP firi that any slden#-initiate --approved outside
provider (i.e. private duty nurse, etc.) has worker's compensation insurance
coverage as required by law, as well as liability insurance. To the extent that
the outside provider does not have the legally required worker's compensation
insurance coverage, the Resident will provide and pay for such coverage.
2
{ RESIDENT'S RIGHTS
Shippensburg welcomes all persons in need of its servicos and does not
discriminate on the basis of age, disability, race, color, national origin, ancestry,
religion, or sex. Furthe"rmote, Shippensburg does not discriminate among
persons based on their sources of payment.
Consent for Treatment
SHiPPENSBURG SERVICES: By signing this Agreement, the Resident
consents to Shippensburg providing routine nursing and" otfier health care
services as directed by the attending physician, or when the attending physician
is unavailable, Shippensburg's Medical Director. Shippensburg is not obligated
to provide the Resident with any medications, treatments, special diets or
equipment without specific orders or directions from the Resident's physician or
Shippensburg's. Medical Director. From time to time Shippensburg may.
participate in training programs for persons seeking licensure or certification as
health care workers. In the course of this participation, care may be rendered
to the Resident by such trainees under supervision as required by law.
Consent to routine nursing care provided by Shippensburg shall Include
consent for care by such trainees.
PHYSICIAN SERVICES: The Resident acknowledges that he or she Is under
the medical care of a personal attending physician, and that Shippensburg
provides services based on the general and specific instructions of that
physician, or when unavailable, Shippensburg's Medical Director. The Resident
has a right to select his or her own attending physician. If, however, the
Resident does not select an attending physician, or is unable to select an
attending physician, an attending physician may be designated by
Shippensburg or in accordance with state law. All attending physicians must
meet and conform with all of Shippensburg's policies and procedures, and are
subject to the terms set forth in the Outside Providers and Non-facility Services
section of this Agreement.
RIGHT TO REFUSE TREATMENT: The Resident has the right to refuse
treatment and to revoke consent for treatment. The Resident also has the right
to be informed of the medical consequences of such refusal or revocation of
consent, and to be informed of alternate treatments available. Where, in the
opinion of the attending physician or by judgment of a court of law, the Resident
is determined to be mentally Incompetent to make a decision regarding refusal
3
of treatment, the decision to refuse treatment may be made by a Legal
Representative or other surrogate decision-maker, subject to state and federal
law.
Resident's Personal Property
Shippensburg strongly discourages the keeping of valuable jewelry,
papers, large sums of money, or other items considered of value in
Shippensburg. However, the Resident shall be permitted to retain and use
personal clothing and possessions as space permits, unless to do so would
infringe upon the right of other residents or unless determined medically
inadvisable as documented by the Resident's physician In the Resident's
medical record. Shippensburg shall make reasonable efforts to properly handle
and safeguard the Residents personal property in Shippensburg. The Resident
agrees to inform Shippensburg of all valuable property upon admission. If, at
any time during the Resident's stay, new items of value are added to the
Resident's possessions in Shippensburg, the Resident agrees to so inform
Shippensburg'.s Administrator or designee.
The Resident is responsible for obtaining at his or her own expense any
insurance coverage necessary to cover potential damage to or loss of any of
Resident's personal property. Shippensburg shall not be liable for damage to or
loss of any of Resident's personal property. Should the Resident lose his or her
property, or believe that his or her property has been otherwise removed from
his or her possession, the Resident agrees to follow Shippensburg's procedure
for filing reports of lost or stolen property.
In the event that Resident is transferred or discharged from
Shippensburg, or if the Resident expires, the Resident hereby authorizes
Shippensburg to transfer the Resident's personal property to the Resident's
Legal Representative, or to any duly authorized representative of Resident's
estate. If the Resident's personal property is not claimed or removed JMthin
twenty-four (24) hours of the Resident's transfer or discharge, or expiration, the
Resident authorizes Shippensburg to place his personal property into storage
until claimed. Standard daily storage charges will continue while the Resident's
property remains in Shippensburg.
Should the es ens property a too be claimed VVIthin foutteen (14)
days of the Resident's transfer, discharge, or expiration, the Resident and
Shippensburg hereby agree to a storage and sale arrangement. Under this
arrangement, Shippensburg agrees to bear any and all costs of the storage of
the Resident`s property, not Including any Insurance thereon. However, In
consideration of Shippensburg's storage of the Resident's property, should the
Resident's property fail to be claimed within thirty (30) days of placement by
4
Shippensburg into storage, the Resident hereby agrees that Shippensburg may
dispose of the Resident's property with and at Shippensburg's discretion,
including retaining all proceeds from any sale thereof.
Resident's Records
CONFIDENTIALITY: Information included in the Resident's medical records is
confidential. Unauthorized persons shall not be allowed to review these records
without the Resident's written consent, except as required or permitted by law.
CONSENT TO RELEASE BY Shippensburn: The Resident authorizes
Shippensburg to release all or any part of the Resident's medical or financial
records to any person or entity which has or may have a legal or contractual
obligation to provide the Resident with medical services, or to pay all or a
portion of the costs of care provided to the Resident, including but not limited to
hospital or medical services companies, Insurance companies, workers'
compensation carriers, welfare funds, and/or the Resident's employer. The
Resident also authorizes release of information from medical or financial
records to any medical professional or institution responsible for the Resident's
medical or nursing care when the Resident is transferred or discharged from
Shippensburg. The Resident hereby releases Shippensburg from any liability
for damages or other loss suffered in or incurred by the Resident and arising
out of or directly or Indirectly related to the reliance by the facility upon the
foregoing authorization.
PHOTOGRAPHS; The Resident authorizes Shippensburg to photograph or
videotape the Resident as a means of Identification or for health related
purposes. The photographs or videotapes may also be used to help locate. the
Resident in the event of an unauthorized absence from Shippensburg, but shall
otherwise be kept confidential. If Shippensburg intends to use the photograph
or videotape for purposes other than those noted above, Shippensburg shall get
written permission from the Resident in advance of such use. The Resident
retains the right to refuse the taking of at photograph at any particular time.
RESIDENT'S
RULES AND REGULATIONS: The Resident agrees that Shippensburg may, to
maintain orderly and economical operations, adopt reasonable rules and
regulations to govern the conduct and responsibilities of the Resident. The
?. Resident agrees to follow those rules and regulations. It is understood that
6
these rules and regulations may be amended from time to time as
Shippensburg may require. Any changes to the rules and regulations shall be
given to the Resident in writing.
DIET: The Resident understands that his or her diet is medically prescribed
and, therefore, must be monitored by Shippensburg. the Resident agrees to
consult with Nursing or Dietary staff when food or beverages are brought Into
Shippensburg.
MEDICATIONS: No medications or drugs may be brought upon Shippensburg
premises unless the medications or drugs are labeled according to the
requirements of state and federal law. Packaging of medications must be
compatible with Shippensburg's medication distribution system. No drugs or
medications may' be brought into Shippensburg unless they are delivered
directly to the nurses' station.
CARE OF SHIPPENSBURG'S PROPERTY: To preserve the value of
Shippensburg's property for future residents' use, the Resident agrees to use
due care to avoid damaging Shippensburg's property and premises. The
Resident shall be responsible for the costs of repair or replacement of
Shippensburg's property damaged or destroyed by the Resident. However, the
Resident shall not be responsible for such damage as is to be expected from
ordinary wear and tear.
QME OF THE RESIDENT'S ROOM: Shippensburg encourages the Resident
to have a Shippensburg-like environment, and will attempt to accommodate all
reasonable requests to individualize resident rooms. For safety reasons,
Shippensburg must approve any addition -or rearrangement of furniture, hanging
of pictures, posters, or other similar activities.
INDEMNIFICATION: The Resident hereby agrees to Indemnify and hold
harmless Shippensburg, its officers, directors, agents, and employees from and
against any and all claims, demands or causes of action fbr injury or death to
person or damage to property, Including all costs and attorneys fees Incurred in
defending any claim, demand or cause o action which -is caused by the
Resident and which is not caused by any willful or negligent action of
Shippensburg. This indemnification includes, but is not limited to, all claims,
demands or causes of action stemming from the acts or omissions of the
Resident, including but not limited to Resident's refusal of any nursing cars,
medical or other treatment, or any other item or service deemed necessary by
Shippensburg or any other treating health professional.
6 r
POLICY REGARDING THE IMPLEMENTATION
OF THE PATIENT SELF-DETERMCNATION ACT
The following information is being provided to the Resident as a result of
a federal law which requires certain health care institutions, including
Shippensburg, to disclose to the Resident his or her rights under federal and
state law to make decisions regarding his or her health care.
Shippensburg recognizes and appreciates the dignity and value of each
Resident's life, and the right of each Resident to make decisions regarding his
or her care. Where a Resident is Incompetent, Shippensburg recognizes the
Resident's right to have these decisions mAde on his/her behalf by a substitute
decision-maker in accordance with state law. Shippensburg recognizes the
right of each Resident to utilize those health care advance directives recognized
under state law, and will honor such advance directives developed in
accordance with state law and consistent with the level of care Shippensburg Is
licensed to provide. A health care advance directive is a written document that
states choices for health care and/or names someone to make those, choices.
These choices may include the refusal of certain types of care. A Living Will
and a Durable Power of Attorney for Health Care are examples of such
advance directives.
It can be reviewed and made a part of his -or her medical record It is essWttial
that ShIppensbuig receives a validly executed, original document or documents
to ensure that it is authorized to follow the directives therein.
Questions about Shippensburg's policies regarding health care decision-
making and/or advance directives may be presented to Shippensburg's
Administrator. While questions regarding whether and how to execute health
care advance directives and about their content should be discussed with the
Resident's family, physician and attorney, a health care advance diectlve form.
drafted by the Commonwealth of Pennsylvanla accompanles this Agreement,
No Resident should use an advance directive form without first consulting
the KGS!donrs family, physician, and attorney.
r
7
CAPACITY OF RESIDENT AND GUARDIANSHIP
If the Resident Is or becomes unable to understand or communicate, and
is determined to be Incapacitated by the Resident's physician, In the absence of
the Resident's prior designation of an authorized Legal Representative, or upon
the unwillingness or Inability of the Legal Representative to act, Shippensburg
shall have the right to commence a legal proceeding to adjudicate the Resident
Incapacitated. As a result of such a legal proceeding Shippensburg shall have
a court appoint a legal guardian for the Resident. The cost of the legal
proceedings, Including attorney's fees and costs, if not covered by the
Commonwealth, shall be paid promptly by the Resident or the Resident's
estate.
FINANCIAL ASPECTS OF THE AGREEMENT
Legal Representative
While not legally required, If the Resident Is unable to make decisions for
himself or herself, a Legal Representative should be available to make certain
decisions on behalf of the Resident. For the purposes of this Agreement, the
Resident's Legal Representative Is the person selected by the Resident and
defined under state and federal law as the Resident's responsible person, or as
the person recognized under state law as having the authority to make health
care and/or financial decisions for the Resident. The Legal Representative may
or may not be court appointed, may be an attorney-in-fact acting under a
durable power of attorney for health care, guardian, conservator, next-of-kin, or
other person allowed to act for the Resident under state law. If Legal'
Representative status has been conferred by a court of law or through
appointment by the Resident, verification of such status must be provided to
Shippensburg at the time of Admission. Such verification includes providing
Shippensburg with a certified copy of any court order, or a validly executed
original Power of Attorney or other legal document.
For purposes of this Agreement, LEGAL REPRESENTATIVES ARE
REQUIRED TO SIGN THIS AGREEMENT FOR ADMISSION, AND AGREE TO
DISTRIBUTE TO Shi ensbur , FROM THE RESIDENT'S INCOME OR
RESOURCES, PAYMENT WHEN DUE FOR ITEMSISERVICES PROVIDED
TO THE RESIDENT. Legal Representative is contractually bound by the terms
of this Agreement and may become personally liable for failure to perform their
fiduciary duties under the Agreement. Legal Representatives are also required
to produce financial documentation as proof of the Resident's ability to pay for
charges when due. Wherever this Agreement refers to the Resident's
financfal obligations under this Agreement, the term "Resident" shall be
8
construed to Include the obligations of any'Legal Representative to act on
behalf of Resident.
Financial Arraneements
INCOME AND ASSETS/CHANGES TO INCOME AND ASSETS: It is essential
that the Resident advise Shippensburg of the Resident's income and assets,
and to communicate changes in the. Resident's income or assets to
Shippensburg as quickly as possible. The Resident hereby agrees to notify
Shippensburg ninety (90) days prior to the time when the Resident has reason
to believe that his income and assets will no longer be sufficient to fulfill his
financial obligations under the terms of this Agreement.
Generally, when, private funds are depleted, residents apply for Medical
Assistance. The Medical Assistance application process can be complicated,
and the processing time can be lengthy. Shippensburg is experlenced in the
Medical Assistance Application process, and can be of great assistance to the
Resident in this process. To be of assistance, Shippensburg must have
accurate record of the history and depletion of the Resident's Income and
significant assets. On this basis, please set forth the Resident's income and
assets below:
Social Security:
Account Number:
Income
Monthly Income: 6 a q, b Q
Payee: r rv+ A. 1'V105 er
Pension:
Account Number:
Monthly Income:
l
Financial Institution:
Ct3 5.06
L 1)W A u S
9
r.
Payee: t= tr-Aa A. tX aSec'
Trusts:'
Account Number(s):
Monthly Income:
Financial Institution
Beneficiary(s):
Type of Trust(s):
Other Income to se describe :
10
Payee(s):
Assets
Residence/Real Estate:
Address:
Vehicles :
Year, Make and Model: ! ?-
State of Registration:
Bank Accounts:
Account Number(s): ()n() q15(0 Of] C' ?epj< Inq
"11001 gaylwgs
Financial Institution(s):
i-7 X503 V,reanim Ave.noe,
3Q I - q at t S5 I`1
?. Insurance policies:
19
Account Number(s):
Financial Institution(s):
Beneficiary:
Other Slaniftcant Assets (please describe):
Liabilities
Describe nature and extent:
Has a Will been completed?:
If yes, Executor's Name:
Yes No
12
Executor's Address:
Receipt of Income/Representative Payee. Many Residents find security
in appointing Shippensburg as the "payee" or "Representative Payee" of the
Resident's income, By appointing Shippensburg as the "payee" or the
"Representative Payee", the Resident directs that his or her income be
directed to Shippensburg for the purposes of paying for the Resident's care
and services. Any excess funds accumulated are refunded to the Resident
or the Resident's Legal Representative on or before the tenth (10) day of the
month following the receipt of the benefits. This is not required. However, if
Administrator or_111e Administrator's designee. Shippensburg will assist you
in making these arrangements.
PRIVATE RESIDENTS: A Resident is considered private (or private pay) when
no state-.or federal, program, is paying for the. Resident's room and board, A
private-pay Resident may have private insurance or another third party, which
pays all or some of his or her charges.
• Daily Rate. The Resident agrees to pay Shippensburg's private pay per
diem rate as described in the Rate Schedule, The Resident agrees to pay
Shippensburg In advance for one month's private daily rate. For each
additional month's stay, the Resident agrees to pay Shippensburg in
advance on or before the tenth (10th) day of the month. Any unused
advance payment shall be refunded to the Resident ninety (90) days after
the Resident's discharge If the Resident becomes covered by Medicaid or
Medicare, or leaves Shippensburg before the end.of the month.
• Rate Adjustments. Shippensburg may occasionally need to increase the
daily rate or optional service charges. If this happens, the Resident shall
receive thirty (30) days advance written notice of the rate adjustment.
Shippensburg shall provide notice to the Resident, and If known, the
Resident's Legal Representative. When a notice of a rate adjustment Is
received, the Resident can choose to end this Agreement by providing
written notice to the Administrator. If the Resident fails to leave
Shippensburg prior to the effective date of the rate adjustment, the Resident
shall be considered to have consented to the increase.
• Private Insurance. Even when there is private insurance coverage, the
Resident remains primarily responsible for paying all of Shippensburg's
c,,,hargep. Where the Resident's private insurer is a managed care plan with
which Shippensburg has a contract, Shippensburg agrees to invoice the
13
managed care plan directly for the Resident's care and services. However,
all charges that are not covered by the managed care plan are the
responsibility of the Resident. These non-covered charges include but are
not limited to any coinsurance and/or deductible amounts which the
managed care plan requires the Resident to pay, to the extent allowed
under federal and state laws. Where the Resident's private insurer Is not a
managed care plan with which Shippensburg has a contract, Shippensburg
will invoice the Resident, who is primarily responsible for payment of the
invoice.
MEDICAID RESIDE: A Medicaid Resident is one who receives benefits
from the state Medicaid program for all or a majority of his or her room and
board charges. The services currently covered by Medicaid are set forth in the
attached Rate Schedule, which is subject to change. Shippensburg makes no
guarantee of any kind that the Resident's care will be covered by
Medicare, Medicaid, or any third party Insurance or other reimbursement
source. Shippensburg, its agents and associates are hereby released from
any liability for the Resident's potential claim for any failure to obtain such
coverage.
With respect to applying for and receiving Medical Assistance through the
?. Medicaid Program, Shippensburg will assist the Resident in the application
process. The Resident agrees to the following:
Qualifying for Medicaid Assistance. If the Resident elects coverage
under the Medicaid Program, the Resident agrees to act as quickly as
possible to establish and maintain eligibility for Medicaid. These actions
must Include, but are not limited to, taking any and all steps necessary to
ensure that the Resident's assets and income are within the required limits
and that these assets and income remain within allowable limits for
Medicaid.
• Providing Application Information. The Resident agrees to provide al
financial and other information required for completion of the Medicaid
application accurately and truthfully, as requested by applicable state/county
agencies. Additionally, the Resident agrees to provide this information in
the manner requested by the applicable agencies, and In compliance with
any deadilries set by the appli-ble ageneles- Furthermore, the Resident
agrees to attend any and all interviews necessary for completion of the
Medical Assistance eligibility process, as requested by the applicable
statelcounty agencies. Failure to provide all financial and other information
required for completion and support of the Medicaid application accurately
and truthfully, as requested by applicable state/county agencies, may result
in personal liability for Shippensburg's charges.
14
Keeping Shippensburg Informed. The Resident agrees to keep
Shippensburg informed of the status and progress of the Medicaid
application. The Resident agrees to provide Shippensburg with copies of
any financial and other Information related to the Medicaid application,
including a copy of the completed application.
Transferring Assets. If the Resident transfers assets, this transfer may
disqualify the Resident for Medicaid and/or cause a discontinuance of the
Resident's Medicaid benefits. The Resident acknowledges that this may
result in discharge of the Resident due to non-payment, and personal
liability for Shippensburg's charges.
Legal Representative Controlling Resident's Funds. If the Resident's
Legal Representative has control of or access to the Resident's income
and/or assets, the Legal Representative agrees to use these funds solely for'
the Resident's welfare. This includes, but Is not limited to, making prompt
payment for care and services provided to the Resident as specified and
required by the terms of this Agreement. Failure to use these funds solely
for the Resident's welfare may result in personal liability for Shippensburg's
charges.
• Providing -Financial Information. The Resident certifies that any financial
information regarding the Resident's income and assets required by
Shippensburg and provided by the Resident is complete and accurate.
Daily Rate Payment. The Resident agrees to pay the costs or
Shippensburg's per diem rate as described In the Rate Schedule.
Termination of Coverage. The Resident may remain in Shippensburg fot
as long as he or she is certified eligible for Medicaid coverage, or for as long
as any share of cost owed by the Resident Is paid as due. A Resident who
remains in Shippensburg after Medicaid coverage has been denied and a
final determination has been made must pay Shippensburg charges as a
private resident. In this event, the Resident will pay based on the private
rates, charges, and terms in effect at the time of service. Where the
Resident fails to pay the private rates and charges, the Resident agrees to
seek immediate placement at an alternate facility at the earliest possible
time.
Resident's Share of Cost. The Medicaid program reviews the available
monthly Income of all persons requesting Medicaid. Based on this review,
the Medicaid program requires most Medicaid residents to pay for a
reasonable share of the cost of their care. The amount of the Resident's
share of the cost of their care can change based upon the services the
Resident chooses, and the Medicaid program can adjust the amount of the
Resident's share of the cost of their care based upon changes in the
15
Resident's Income. Payment of that share is the responsibility of the
Resident.
Appeal of Finding of Ineligibility. Where the Resident applies for Medical
Assistance - benefits, the applicable state/county agency may deny the
Resident benefits or some portion of these benefits. Where a denial occurs,
the Resident retains all responsibility for obtaining his or her benefits.
However, the Resident authorizes Shippensburg to assist the Resident in
making any claims and to take all other actions necessary to secure the
Resident's benefits, including, but not limited to, assisting the Resident in
appealing any state/county agency denial, requesting Interim Assistance
benefits, and requesting Reconsideration. The Resident agrees to provide
Shippensburg with all information related to obtaining benefits upon receipt,
Including, but not limited to, notices of denial. This paragraph shall not
create any responsibility on behalf of Shlppensburg to obtain benefits or any
portion of benefits, nor any liability for failure to obtain same. To facilitate
this authorization, but not In lieu thereof, the Resident agrees to properly
execute the AUTHORIZATION FOR REPRESENTATION - MEDICAID
statement attached to this Agreement.
MEDICARE RESIDENTS: A Medicare Resident is one who receives benefits
from the federal Medicare program for his or her Shippensburg care. The
services currently covered by Medicaid are set forth in the attached Rate
Schedule, which Is subject to change. Some additional Items and services may
be also covered by Medicare. Shlppensburg makes no guarantee of any
kind that the Resident's care will be covered by Medicare, Medicaid, or
any third party insurance or other reimbursement source. Shippensburg,
Its agents and associates are hereby released from any liability for the
Resident's potential claim for any failure to obtain such coverage.
• Continuing Payment of Shlppensburg Charges Pending Eligibility.
Where the Resident Is not currently covered by Medicare, the Resident
agrees that while coverage is being pursued the Resident shall pay the
private pay rate as a private pay resident as described within this
Agreement. If the Resident Is unable to pay the private pay rate, the
Resident agrees to pay Shippensburg an amount that Is at least equal to the
Resident's monthly Income from all of the Residents Income sources. This
amount, mini ' is any amount not covered by rMedicare, shall be refunded to
-
the Resident within thirty (30) days of payment by Medicare should the
Resident be found eligible by Medicare.
Once the Resident is determined to be eligible for Medicare, the amount
of the Resfdent's share of cost not covered by Medicare shall be paid to
Shippensburg on or before the tenth (10th) day of each month. Furthermore,
the Resident shall immediately pay to Shippensburg any amount the
Resident is in arrears. If payment of any outstanding amount cannot be
16
made immediately, the Resident shall immediately discuss same with
Shippensburg's Administrator or the Administrator's designee, and shall
make arrangements to bring his or her account into balance within the
shortest possible time.
• Daily Rate Payment. The Resident agrees to pay the costs of
Shippensburg's per diem rate as described in the Rate Schedule for those
supplies and services not paid for by the Medicare program.
• Coinsurance and Deductibles. The Resident is responsible for payment
of any Medicare coinsurance and/or deductibles that are not paid to
Shippensburg by the Medicaid program or private insurance.
Limited Coverage. The Resident understands that Medicare coverage is
established by federal guidelines and not by Shippensburg. Medicare
coverage is limited in that only a specified level of care is covered for a
specified number of days (benefit period). If the Resident no longer meets
Medicare coverage criteria, coverage can be ended before the use of all
allotted days In the current benefit period.
• Expiration of Benefits. Prior to admission, the Resident must be able to
demonstrate the ability to pay Shippensburg (either privately or through
Medicaid) for services rendered after Medicare benefits expire. When
Medicare coverage expires, the Resident may remain in Shippensburg if
private pay or other payment arrangements have been made. If the
Resident wishes to be discharged from Shippensburg upon expiration of
Medicare benefits, he or she must so advise Shippensburg at the time of the
Resident's admission. If the Resident intends to become private pay when
Medicare benefits expire, the Resident agrees to pay in advance for one
month's private daily rate when the Resident changes to private pay status.
No advance payment is required from Medicare Residents who are eligible
for Medicaid coverage.
• Appeals of Denials of Coverage. Where the Resident applies for
Medicare benefits, the applicable intermediary, carrier or government
agency may deny the Resident these benefits or some portion of these
benefits. Where a denial occurs, the Resident retains all responsibility for
obtaining his or her benefits. However, the Resident 'authorizes
Shippensburg to assiAt th Resident in making all claalivis -and to taking all
other actions necessary to secure his or her benefits, including, but not
limited to, appealing any initial or subsequent adverse determinations,
including requests for Reconsideration. The Resident agrees to provide
Shippensburg with all information related to obtaining benefits upon receipt,
including, but not limited to, notices of denial. This paragraph does not
apply to benefits for which Shippensburg has determined the Resident is not
eligible, and does not affect the Resident's right to have a Demand Bill fled.
17
This paragraph shall not create any responsibility on behalf of Shippensburg
to obtain any portion of benefits, nor any liability for failure to obtain same.
To facilitate this authorization, but not In lieu thereof, the Resident hereby
agrees to properly execute the AUTHORIZATION FOR REPRESENTATION
- MEDICARE statement attached to this Agreement.
MANAGED CARE ORGANIZATIONS: Where the Resident enrolls in or
switches the Resident's enrollment to any managed care organization
(hereafter "MCO"), including MCOs that provide Medicare or Medicaid benefits,
the Resident agrees as follows:
The Resident shall advise Shippensburg prior to enrolling in or switching the
Resident's enrollment to any MCO.
The Resident acknowledges that Shippensburg is not responsible for and
has made no representations regarding the actions or decisions of any MCO
with which Shippensburg Is a participating provider, including decisions
relating to a denial of coverage.
Shippensburg will accept payment from the MCO as payment In full only for
those services and supplies covered by the MCO. The Resident is
( responsible for any co-payments or other costs assigned to the Resident
under the managed care plan, or not covered by the MCO under the terms
of the managed care plan. If the Resident utilizes services which the MCO
refuses to pre-authorize, the Resident shall pay Shippensburg for those
services. Further, the Resident shall pay Shippensburg for services for
which the MCO has denied payment because the Resident failed to supply
information to the MCO, or for services which are denied subsequently by
the MCO.
• Shippensburg reserves the right to withdraw as a participating provider in
any MCO at any time and for any reason. In the event that Shippensburg
withdraws as a participating provider, the Resident may convert his or her
coverage to a health plan In which Shippensburg is a participating provider.
Effective the date of Shippensburg's withdrawal from the Resident's MCO,
the Resident is obligated to pay for services and supplies provided to the
Resident as a private pay resident. If possible, Shippensburg will provide
. _ - - -- I 1--_ - Lt- _
Resident's MCO thirty (30) days before Shippensburg's withdrawal.
ASSIGNMENT OF THIRD PARTY PAYMENTS: The Resident irrevocably
authorizes Shippensburg to make claims and to take all other actions to secure
( receipt of third party payments to reimburse Shippensburg for its charges. To
the fullest extent permitted by law, and as security for payment of
18
Shippensburg's charges, the Resident hereby assigns to Shippensburg all of
the Resident's rights to any third party payments now or subsequently payable
to the extent of all charges due under this Agreement. Resident shall promptly
endorse and deliver to Shippensburg any payments received from third parties
to the extent necessary to satisfy the charges under this Agreement. To
facilitate this assignment, but not in lieu thereof, the Resident hereby agrees to
properly execute the ASSIGNMENT OF THIRD PARTY PAYMENTS statement
attached to this Agreement.
FINANCIAL POWER OF. ATTORNEY: The Resident agrees that upon
admission the Resident, If able, will supply Shippensburg with a fully executed
and legally valid original Financial Power of Attorney appointing an individual
chosen at the Resident's sole discretion to be his financial attorney-in-fact
should the Resident become medically incompetent. If not able, the Resident
agrees to work with Shippensburg to pursue guardianship. This Power, of
incomoe ent. If, In the judgment of the Resident, no such Individual Is available,
the Resident agrees to appoint such an individual when one becomes available.
Judgment of the Resident's incompetence shall not require a court adjudication,
but shall require the written order of Resident's physician plus confirmation by a
second examining physician. The Resident's financial attorney-in-fact shall be
granted the authority to make financial decisions for the Resident, including the
unlimited power to pay Shippensburg's charges and invoices from the
Resident's income, and from the proceeds of the attorney-in-fact's sale of the
Resident's assets.
The selection of this attorney-in-fact serves at the complete discretion of
the Resident. However, should the Resident revoke the power of his or her
appointed attorney-in fact, or should the Power of Attorney become Inoperable
for any reason, the Resident hereby agrees to immediately appoint a successor
attorney-in-fact for the financial purposes set forth herein, if such an individual is
available. Upon receiving a duly executed copy or facsimile of this Agreement
noting the Resident's appointed financial attorney-in-fact, Shippensburg may
act hereunder. Revocation of the attomey-lh-fact shall be Ineffective as to
Shippensburg unless and until written or actual notice or knowledge of such
revocation Is received The a-in-fact's power shall continue in full force
and effect and may be relied upon by Shippensburg despite purported
revocation until written notice of revocation is received by Shippensburg.
Financial Power of Attomey forms can be obtained free of charge from
Shippensburg's Social Service Department.
Residents should first consult with his or her family and attorney
before executing any Financial Power of Attorney form.
19
Payment information
DUE DATES AND THE OBLIGATION OF TIMELY PAYMENT: Shippensburg's
charges for services provided shall be billed on a monthly basis to the Resident.
These charges are due and payable by the tenth (10th) day of each month. If
payment Is not received by the fifteenth (15t) day of each month, the account
balance is considered past due, and Shippensburg may add late charges to the
Resident's account. -These late charges shall be assessed on the monthly
balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or
the maximum amount permitted by law. This late charge does not alter any
obligations of Shippensburg or Resident under this Agreement.
The Resident recognizes that Shippensburg does not offer credit or
accept Installment payments. Shippensburg's acceptance of a partial payment
does not limit Shippensburg's rights under this Agreement to full payment for
the care and services provided.
BILLING ADDRESS: All of Shippensburg's Invoices are to be mailed to the
following address for prompt payment (either Resident's address or Legal
Representative's address, when Aapplicable):
Z2ejAM/ j% id`ou r
FAILURE TO PAY: Shippensburg's due date for its payments falls on the
fifteenth (15th) day of each month. If the Resident falls to make a required
payment within twenty-one (21) days.of the due date, Shippensburg may
require the Resident to vacate Shippensburg after appropriate advance notice.
If the Resident is required to vacate Shippensburg for failure to pay,
Shippensburg shall provide advance notice as set forth in Termination section
of this Agreement.
or the actual fee charged by the bank, whichever is greater, will be
any returned check.
dolla
OBLIGATIONS OF RESIDENT'S ESTATE AND ASSIGNMENT OF
PROPERTY: This Agreement shall operate as an assignment, transfer and
conveyance to Shippensburg of as much of the Resident's property as is equal
20
( in value to the amount of any unpaid obligations under this Agreement, and this
assignment shall be an obligation of the Resident's estate and may be enforced
against the Resident's estate. The Resident's estate shall be liable to and shall
pay Shippensburg an amount equivalent to any unpaid obligations of the
Resident under this Agreement. This assignment shall apply whether or not the
Resident is residing in Shippensburg at the time of the Resident's death.
Bed Holds
The Resident may need to be absent from Shippensburg temporarily for
hospitalization or therapeutic leave. The Resident may request that
Shippensburg hold open the Resident's bed during this time. This Is known as
a bed hold. The Resident, and if known, the Resident's Legal Representative
shall be given notice of the bed hold option at the time of hospitalization or
therapeutic leave. A schedule of charges for bed holds is located on the Rate
Schedule attached to this Agreement.
MEDICAID RESIDENTS: If the Resident's care is paid under the Medicaid
Program, Medicaid currently pays for 15 bed hold days. If the Medicaid
Resident's hospitalization or therapeutic leave exceeds the bed-hold period
paid under the Medicaid program, the Resident may request an additional bed
?-' hold period from Shippensburg by agreeing to pay fifty dollars ($50.00) a day
during the additional bed hold period. Otherwise, the Resident shall be
readmitted upon the first availability of a bed in a non-private room as long as
the Resident requires the services provided by Shippensburg and is eligible for
Medicaid benefits.
PRIVATE AND MEDICARE RESIDENTS: Any Private or Medicare Resident
may request a bed hold from Shippensburg. The Resident's private insurance
may or may not pay for bed holds. The Medicare program does not pay for bed
holds. However, if the Medicare Resident is also eligible for Medicaid, and if
proven to the satisfaction of Shippensburg, Medicald pays for 15 bed hold days.
Otherwise, a Private or Medicare Resident- requesting a bed hold must pay
Shippensburg's bed hold rate set forth in the Rate Schedule for the bed being
held during the bed hold period.
Personal Funds
The Resident has a right to manage his or her own personal funds. If the
( Resident wants assistance with management of personal funds, and requests
so In writing through a Resident Fund Authorization form, Shippensburg will
21
hold, safeguard, manage, and account for these funds. A Resident Fund
Authorization form can be obtained from Shippensburg's Administrator or
designee.
Resident personal funds deposited with Shippensburg shall be handled
as follows:
Shippensburg shall deposit funds in excess of fifty dollars ($50.00) in an
interest-bearing account insured by the Federal Deposit Insurance
Corporation (FDIC) that is separate from any Shippensburg operating
accounts. All interest earned on the Resident's funds shall be credited to his
or her account. Shippensburg shall have the option of depositing funds of
less than fifty dollars in a non-interest bearing account, an interest bearing
account, or a petty cash fund. Shippensburg shall inform the Resident as to
how his or her funds are being held. Shlppensburg's policy Is to maintain all
resident funds In a separate account, except for a nominal amount
maintained in a petty cash fund for the Resident's convenience.
• Shippensburg shall have a system that ensures a complete and separate
accounting, based on generally accepted accounting principles, of the..
personal funds deposited with Shippensburg by each Resident or on his or
her behalf. This system shall also ensure that the Resident's funds are not
commingled with Shippensburg's funds or with any other funds besides
those of other residents. In addition to the required quarterly accounting,
Shippensburg shall provide Individual financial records at the written request
of the Resident.
• The personal fund balance a resident receiving Medicaid benefits must
remain within a certain dollar range for the Resident to continue to receive
benefits. Shippensburg shall notify a Medicaid resident if his or her account
balance is within two hundred dollars ($200.00) of the federal Supplemental
Security Income (hereafter "SSI') limit. Shippensburg shall also notify the
Resident If the account balance, in addition to the Resident's known non-
exempt assets, reaches the SSI resource limit. Furthermore, Shippensburg
shall notify the Resident if the account balance, in addition to the Resident's
known non-exempt assets, reaches the resource limits for Medicaid
eligibility. A balance in excess of this limit may cause the Resident to lose
eligibility for Medicaid or SSI.
If a Resident who has personal funds deposited with Shippensburg expires,
Shippensburg shall refund the Resident's personal account balance within
thirty (30) days, and provide a full accounting of these funds to the
Individual, probate jurisdiction administering the Resident's estate, or other
entity as required by state law or regulation. However, any outstanding
balance owed to Shippensburg for the Resident's care and services shall
first be deducted from the Resident's personal account as permitted by law.
22
• Shippensburg shall ensure the security of all resident personal funds
deposited with Shippensburg, and shall not take money from a Medicare
and/or Medicaid resident's personal funds for any item or service for which
payment is covered by Medicare and/or Medicaid.
Funeral Arrannements
Shippensburg assumes no financial responsibility
funeral related expenses associated with a Resident's pas
recognizes the emotional hardship that such an event
Resident's family and loved-ones. To assist during
Shippensburg will convey the Resident's wishes, as
concerning. arrangements to a designated funeral director.
Funeral Arrangements:
Funeral Director:
for the funeral or
sing. Shippensburg
may have on the
this difficult time,
expressed below,
i'Y1 i n h I ?ti o n e rw? I-? d e
os4- 011SO6 bv!?ml
Burial Fund:
Cemetery Lot Location:
Person Assuming
Responsibility for Burial:
BIGHT TO TERMINATE: An explanation of the Resident's rights concerning
termination, transfer, and discharge is contained In the Statement of Resident
Rights, which Is attached to but separate from this Agreement.
23
RESIDENT INITIATED: Notice of resident initiated termination is required for
proper discharge planning. Other than in the case of a medical emergency or
death, the Resident will provide Shippensburg with written notice two (2)
business days before the Resident's termination of this Agreement.
REFUNDS: If a Resident has personal funds deposited with Shippensburg upon
termination of this Agreement, Shippensburg shall refund the Resident's
personal account balance within thirty (30) days, and provide the Resident or
the Resident's estate with a full accounting of these funds. However, any
outstanding balance owed to Shippensburg for the Resident's care and services
shall first be deducted from the Resident's personal account as permitted by
law.
RESIDENT GRIEVANCEICOMPLAINT RESOLUTION
RESIDENT GRIEVANCES: All Residents, family members, and Resident
representatives are urged to bring any grievances concerning Shippensburg to
the attention of the Shippensburg Administrator or the Administrator's designee.
In addition to bringing grievances to the attention of Shippensburg
Administrator or designee, residents may also contact the outside
representative of his or her choice. Outside representatives include the
Governor's Action Line at (800) 932-0784, the Department of Health Hot Line at
(800) 254-8154, the Long Term Care Ombudsman located within the Local
Area Agency on Aging, and the Legal Services Program. The telephone
number of the local Long Term Care Ombudsman and the Legal Services
Program is located within the Resident's Bill of Rights accompanying this
Agreement.
ARBITRATION & ENFORCEMENT OF THIS AGREEMENT
RESIDENT ARBITRATION: Unless otherwise mutually agreed upon in writing,
should grievance procedures fall the Resident and Shippensburg agree that all
disputes arising under this Agreement, with the exception of disputes
concerning non-payment for services rendered, shall be resolved by binding
arbitration before a neutral arbitrator, assigned to the matter in accordance with
the National Health Lawyers AsseeWlen Alternative Disp
Rules of Procedure for Arbitration. Such arbitration shall take place at
Shippensburg at a mutually agreed upon time. Any time a dispute arises, any
party may request the appointment of an arbitrator to resolve the dispute. The
requesting party shall notify the other party in writing a minimum of seven (7)
business days prior to requesting the appointment of the arbitrator. The costs
of the arbitrator and all costs associated with the arbitration, including attorneys
24
fees, costs, and expenses shall be borne by the losing party. The decision of
the arbitrator will be final and binding, and may be entered as a judgment in any
court having competent jurisdiction.
ATTORNEY'S FEES/COLLECTION AGENCY FEES/COSTS: in the event that
Shippensburg institutes and is a,prevailing party in litigation in court against any
party to this Agreement arising from that party's failure to comply with the terms
of the Agreement, Shippensburg shall be entitled to receive from the losing
party reasonable attomeys'/collection agency fees, along with all court and
related costs.
MISCELLANEOUS PROVISIONS
_CLINICAUFINANCIAL INFORMATION: With and at Shippensburg's discretion,
the Resident hereby authorizes Shippensburg to obtain all of the necessary
clinical and/or financial documentation from the Resident's prior or transferring
hospital or nursing facility.
SOLE AG EEMENT: This Agreement, along with any documents attached or
included by reference, is the only agreement between Shippensburg and
parties. Changes to this Agreement are valid only if made in writing and signed
by all parties. If changes in state or federal law make any part of this
Agreement invalid, the remaining terms remain valid and enforceable.
NON-ASSIGNABLE AGREEMENT: The Resident agrees that the right of the
Resident to reside at Shippensburg Is personal and not assignable. The
Resident may not transfer his or her rights under this Agreement to any other
person.
GOVERNING LAK This Agreement shall be governed by and construed by the
laws of the Commonwealth of Pennsylvania, and shall be binding upon and
shall o
heirs, personal representatives, successors and assigns.
SEVERABILITY: The Resident and Shippensburg agree that each separate
obligation contained in this Agreement shall be deemed a separate and
Independent agreement. If any term, condition, clause or provision of this
25
Agreement shall be determined or declared to be void or Invalid in law or
otherwise, then only that term, condition, clause or provision shall be stricken
from this Agreement, and in all other respects this Agreement shall be valid and
continue in full force, effect and operation.
CAPTIONS: The captions used in this Agreement are inserted only for the
purpose of reference. Such captions shall not be deemed to govern, limit,
modify or in any manner affect the scope, meaning or intent of the provisions of
this Agreement. The captions shall be given no legal effect.
WAIVER: A waiver by either party at any time of any of the terms, conditions, or
covenants of this Agreement, or of any default or breach shall not be deemed or
taken as a waiver at any time thereafter of the same or any other term,
condition or covenant herein contained, nor of the strict and prompt
performance thereof.
MODIFICATIONS: Shippensburg reserves the right to unilaterally modify this
Agreement to the extent necessary to conform the Agreement with subsequent
changes in law or regulation. Shippensburg will notify the Resident thirty days
(30) before such modification, If possible.
ACKNOWLEDGMENTS
RATE SCHEDULE: The Resident and the Resident's Legal Representative
hereby acknowledge the receipt of a copy of the Rate Schedule and sufficient
opportunity to ask questions about the Rate Schedule to answer all of their
questions about Shippensburg's charges. The Resident and the Legal
Representative hereby acknowledge that Shippensburg can and will alter the
Rate Schedule from time to time, and that Resident will be subject to those
changes. The Resident and the Resident's Legal Representative hereby agree
to be subject to those changes as provided In this Agreement.
STATEMENT OF RESIDENT'S RIGHTS: The Resident and the Resident's
Legal Representative hereby -acknowledge being Informed orally and of
%.&.FF!ftn oopy of the Residents Rights, as set foFffi in this, AgFeerAePA,
and as further set forth In the accompanying Shippensburg's Statement of
Resident's Rights. Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Resident's rights and have received appropriate responses.
The Resident and the Resident's Legal Representative hereby acknowledge
that the accompanying Statement of Resident's Rights is subject to change
26
from time to time, and shall not be construed as imposing any contractual
obligations on Shippensburg or granting any contractual rights to the Resident.
COMMONWEALTH'S ADMISSIONS NOTICE PACKET: The Resident and the
Resident's Legal Representative hereby acknowledge being informed orally and
of receiving a written copy of the Commonwealth's Admissions Notice Packet,
accompanying this Agreement. Furthermore, the Resident and the Resident's
Legal Representative hereby acknowledge having sufficient opportunity to ask
questions about the Resident's rights 'and have received appropriate responses.
The Resident and the Resident's Legal Representative hereby acknowledge
that the Commonwealth's Admissions Notice Packet Is subject to change from
time to time, and shall not be construed as imposing any contractual obligations
on Shippensburg or granting any contractual rights to the Resident.
PRIVACY ACT STATEMENT - HEALTH PARE RECORDS: The Resident and
the Resident's Legal Representative hereby acknowledge being informed orally
receiving a written copy of the Privacy Act Statement -- Health Care Records, in
compliance with -the Privacy Act of 1974. Furthermore, the Resident and the
Resident's Legal. Representative hereby acknowledge having sufficient
opportunity to ask questions about the Privacy Act Statement and have
received appropriate responses.
HEALTH CARE ADVANCE DIRECTIVES: The Resident and the Resident's
Legal Representative hereby acknowledge being informed orally and In writing
about health care advance directives, including receiving a copy of the
Commonwealth's Medical and Treatment Self-Directive Statement, and of
Shippensburg's policy concerning health care advance directives and medical
treatment decisions. Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about advance directives, the Commonwealth's Medical and
Treatment Self-Directive Statement, and Shippensburg's policy thereon, and
have received appropriate responses to all of their questions.
AGREEMENT: The Resident and the Resident's Legal Representative hereby
acknowledge that they have carefully read and understand the terms of this
representative of Shippensburg. Furthermore, the Resident and the Residents
Legal Representative hereby acknowledge having sufficient opportunity to ask
questions about the Agreement and have received appropriate responses.
27
IN WITNESS WHEREOF, INTENDING TO BE LEGALLY BOUND, the
parties hereto have executed this Agreement the day of
and same shall be
considered binding upon all parties, and shall remain in full force and effect
unless and until cancelled according to the terms of this Agreement,
Resident
Date
Legal Representative
Witness
Date
Date
Date
Date
36
STATEMENT
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Phone: 717-530.8300
Billing Inquiries: 800-555-1212
Statement Date: 10131/08
Donald Grove Resident: ERMAA MOSER
6824 Furnace Road
Waynesboro, PA 17268
Date Service Through Otg Description Amount
BALANCE FORWARD 441807.39
"""* PROJECTED PREBILL CHARGES
10101/08 10101/08 10131108 31 Prebiil Room Charges 6,324.00
TOTAL AMOUNT DUE >>>»»»»» 51,131.39
Exhibit "B" Page
1
-
r
--?
?{'T
x
F
'
(V ? ?
~
? r-
r
V`` ..
?
-5?..
--r
p?.`r T
_...
"? ?
\ ? r 3
?, {?
V? Q_ ?...j °'?:
"??
1?J
PERM SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff,
NO. 2008-6928 CIVIL TERM
V.
ERMA A. MOSER and
DONALD GROVE
Defendant
CIVIL ACTION-LAW
MOTION OF PLAINTIFF FOR ORDER OF SPECIAL SERVICE
AND NOW, comes Plaintiff, Perini Services/South Hampton Manor, L.P. d/b/a
Shippensburg Health ("Shippensburg Health"), by and through its attorneys, O'Brien, Baric &
Scherer, and files the within motion and, in support thereof, sets forth the following:
1. The Plaintiff is Perini Services/South Hampton Manor, L.P. is a Maryland limited
partnership d/b/a Shippensburg Health with a place of business located at 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Shippensburg filed a Complaint in the above caption on November 21, 2008.
Service of the Complaint was made upon the Defendant, Erma A. Moser by the Sheriff of
Cumberland County on December 6, 2008. Service of the Complaint was attempted without
success upon the Defendant, Donald Grove by the Sheriff of Franklin County, Pennsylvania. A
true and correct copy of the Sheriff's return regarding attempted service upon the Defendant,
Donald Grove is appended hereto as Exhibit "A" and is incorporated.
3. Counsel for the Plaintiff has attempted to locate the Defendant, Donald Grove by
searching the internet for a current address and by a postal request through the United States Post
Office. Copies of the internet searches and postal requests are attached hereto as Exhibit "B" and
are incorporated. The postal authorities report that they have no change order on record for the
Defendant, Donald Grove for the Defendant at which the Sheriff's office attempted to make
service.
4. Attached hereto as Exhibit "C" is an Affidavit prepared by undersigned counsel in
connection with his attempts to locate the Defendant, Donald Grove.
WHEREFORE, Plaintiff, Shippensburg Health, respectfully moves this Court to enter a
special order of court to effectuate service of the Complaint upon the Defendant said service to be
made by notice of this action directed to the Defendant, Donald Grove to be published one time
in a newspaper of general circulation in Franklin County in accordance with Pa.R.C.P. 430(b)(1)
and any subsequent service upon Defendant shall be made by regular U.S. Mail postage prepaid
to the Defendant's address of 6824 Furnace Road, Waynesboro, Franklin County, Pennsylvania
17268.
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.d it/orrstownbank/moser/specialservice.mot
VERIFICATION
I verify that the statements made in the foregoing Motion Of Plaintiff For Order Of Special
Service are true and correct to the best of my knowledge, information and belief. This verification
is signed by David A. Baric, Esquire, Attorney for Plaintiff and is based upon the statements
provided by Plaintiff, as well as documents reviewed by the undersigned as attorney for Plaintiff.
This verification will be substituted and ratified by a verification signed by the Plaintiff who is
presently unavailable to sign said verification. I undersigned that false statements herein are made
subject to penalties of 18 Pa.C.S. §4904, relating o orn falsific tions to au ties.
David A. Baric, Esquire
Dated: February 25, 2009
?-et7 1. rJ`I U5: 7. ?n i ^anK 1 1 n L QUnty sner 1 r 1./ X51 - ?HH?
SHERIFF'S OFFICE
• 157 Lincoln Way East, Chainbersburg, Pennsylvania 17201-2233
P.1
SHERIFF SERVICE INSTRUCTIONS FOR SERVICE OF PROCESS
PROCESS RECEIPT, and AFFIDAVIT OF RETURN PLEASE TYPE OR PRINT LEGIBLY,
1, PL,AINTIFFIS/ 2. COURT NUMBER
PERINI SERVICES SOUTH HAMPTON MANOR LP 2008-290T
DEFENDANT/S/ 4. TYPE OF Wtttl OR COMPLAINT:
DONALD GROVE COMPLAINT
SERVE 5. NAME= OF INDIVIDUAL, COMPANY, CORPORATION, E7. to Servo pR Description of property to be Levicd, Attached, or Sold
DONALD GROVE
AT 6 ADDRESS (Strout- Apartment Numbe( , City, Borough, Township, State, and 71p code)
6824 FURNACE" ROAD WAYNESBORO PA 17268
7. INDICATE USUAL SERVICE, COMMON. OF PA DEPUTIZE OTHER
Now, 20_, I, SHERIFF OF FRANKLIN COUN FY, PA., do deputizo the Sheriff of
-
County to execute this Writ and rnako return thereof according to law
`7 his deputation Is bang made at the request and risk of the SHERIFF OF FRANKLIN COUNTY
INFORMATION THAT WILL. ASSIST IN EXPEDITING SERVICE:
HER
8. SPECIAL INSTRUCTIONS OR OT
?
?
mf)Ny' ACtb, a)
'Col)?C ?d17t i
OTC ONL Y APPI iCABLE ON WRI f OR EXECUTION: N,li WAIVER OF WA I CHMAN- Any Deputy Sherds levying upon or attaching any propery under within
nt may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without
liability on the past of such Deputy or the Sheriff to any plaintiff heroin Ivr any toss, destruction or removal of any such proporty before Sheriff sale thereof.
9, SIGNATURE OF ATTORNEY or other ORIGINATOR 10. TELEPHONE NUMBER 11, DATE
OBRIEN BARIC AND SCHERER 249-6873
12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS 6ELOW: (This area most be completed if notice i5 to be mailed)
CUMBERLAND COUNTY SHERIFF'S OFFICE ONE COURTHOUSE SQUARE CARLISLE PA 17013
**x SPACE BELOW FOR USE OF SHERIFF ONLY- DO NOT WRITE BELOW THIS LINE, >r*?****?+
13. 1 acknowledge receipt of the SIGNATURE of AUTHORIZ FCSO D uty or Clerk 14. Date Received 15. Expiration Date
writ or complaint as indicated } RMGCAR7Y ?14 < 1282008 19DEC2008
above,
I hereby CERTIFY and Return that I , have personally served, have le I evidence of service as shown in "Remarks", have
executed as shown in "Romarks", the writ or complaint described on the individual, company corporation, ect. at the
address shown above or on the individual, company, corporation, oct., at the address inserted below by handing a TRUE and ATTESTED COPY
17, I hereby certify and roturn a NOT FOUND because I am unable to locate the individual, company, corporation act,, named above (See Rornarks)
113. Name and title of individual served (It not showy) above) (IF SAME as #5 above, indicate with "SAME')l 19, This was a person of suitable
age and discretion then residing in the
defendard's lace of abode.
20. A00toSs of where served (complete ONLY if different from above) (full street a0d. +city+zip) 21. Date of Service 22.Time AM PM
EST EDST
23. ATTEMPTS Date Miles Depuf Date Miles Dcpuly Date MdcB Deputy Date Miles Deputy
ice C CA" 15, Notary( J
4 %
{ 6-
7 f tistiale
P 28. Surt rgc
r 129. 'Total Costs 30, Cost DUE or REFU DED
•• ,
v
-
, 0
IT1 r+
o
/rlyk. r `
1. REMARKS: !)`
f"
I Q+
32. AFFIRMED and subscribed to before me SO ANSWERS
this clay of 20_, _ 33, Signature of 34, bate
Deputy Sheriff
36. Date
ProthunotarylDoputy/Notary Publkc 35. Signature of Sheriff SHERIFF OF FRANKLIN COUNTY
17. 1 ACKNOWLEDGC RLCEIPI- OF THE Shontt's return } 33. pate Rncoivod
-iynoture OF Authorirod IsSuurg Authority and Title
EXHIBIT "A"
Change of Address or Boxholder Request Format - Process Servers
(Letterhead Oationab
Postmaster Date 01/14/09
Waynesboro, PA 17268
City, State, ZIP Code
REQUEST FOR CHANGE OF ADDRESS OR BOXHOLDER INFORMATION NEEDED FOR SERVICE OF
LEGAL PROCESS
Please furnish the new address or the name and street address (if a boxholder) for the following:
Name: Donald Grove
Address: 6824 Furnace Road, Waynesboro, PA 17268
Note: The name and last known address are required for change of address information. The name, if known, and post
office box address are required for boxholder information.
The following information is provided in accordance with 39 CFR 265.6(d)(5)(ii). There is no fee for providing
boxholder or change of address information.
1. Capacity of requester (e.g., process server, attorney, party representing self): attorney
2. Statute or regulation that empowers me to serve process (not required when requester is an attorney or a party acting
pro se - except a corporation acting pro se must cite statute):
3. The names of all known parties to the litigation: Shippensbur'g Health Care Center,
4. The court in which the case has been or will be heard: Court of Common Pleas & E
5. The docket or other identifying number if one has been issued: 2 0 0 8 - 6 9 2 8 of Franklin Co
6. The capacity in which this individual is to be served (e.g., defendant or witness): defendant
WARNING
THE SUBMISSION OF FALSE INFORMATION TO OBTAIN AND USE CHANGE OF ADDRESS
INFORMATION OR BOXHOLDER INFORMATION FOR ANY PURPOSE OTHER THAN THE SERVICE
OF LEGAL PROCESS IN CONNECTION WITH ACTUAL OR PROSPECTIVE LITIGATION COULD
RESULT IN CRIMINAL PENALTIES INCLUDING A FINE OF UP TO $10,000 OR IMPRISONMENT OF
NOT MORE THAN 5 YEARS, OR BOTH (TITLE 18 U.S.C. SECTION 1001).
a?.
I certi t the above inf ation is tru that the address information is needed and will be used solely for service
of pr ss it con' cti or prospective litigation.
19 West South Street
Signature s Address
David A. Baric, Esquire Carlisle, PA 17013
Printed Name City, State, ZIP Code
POST OFFICE USE ONLY
_ No change of address order on file. NEW ADDRESS OR BOXHOLDER'S NAME PO
?$eo-, ?12 no
'
Moved, left no forwarding address. AND STREET ADDRESS ST
No such address. ?i?
)onald Grove
,*ma Moser
Lnty, PA
t,
EXHIBIT "B"
i
WhitePages.com - Online Directory Assistance Page 1 of 1
White ages. coW04
?,carzh ftndk connect.
VERY GooQ Goof ) AVERAGE = POOR NOT SURE
4W - 5" 30- 3"
Listing Detail
Donald L Grove
6824 Furnace Rd
Waynesboro, PA 17268
(717) 749-0120
,ax,n?stc'- 600 yds:
Yi al EarRiles 0.2o08Micm$oitCGrPorapDn 02000NAVTEQ. ®ANO
het i; Blackberry` Curve'
r. Jy
> Learn More
Copyright* 1996-2009 WhitePages.com. All rights reserved.
Privacy PQlicy , Legal Notice and Terms under which this service is provided to you.
Microsoft MapPoint Terms of Use and Privacy Statement
t,++,..ir«nxnu whitenages.com/virth/map?flrstname=Donald+L&country=US&state=PA&lat=39.824724&na... 2/26/2009
AFFIDAVIT
NOW, comes Affiant, David A. Baric, Esquire, who, being duly sworn, does depose and
state the following:
I am the attorney for Perini Services/South Hampton Manor, L.P. in the matter
docketed to No. 2008-6928 in the Court of Common Pleas of Cumberland County, Pennsylvania.
2. I have caused a search to be made via the internet for addresses or telephone
numbers for the Defendant, Donald Grove. The address I found for the Defendant, Donald
Grove was the address used by the Sheriff's office to attempt service at.
I have filed a request with the United States Postal Service requesting a
forwarding address for the Defendant, Donald Grove. The request was returned to me by the
United States Postal Service indicating that the Defendant's mail is delivered to the address
provided by undersigned counsel.
4. The Sheriff of Franklin County attempted to make personal service of the
Complaint on the Defendant, Donald Grove at his last known address of 6824 Furnace Road,
Waynesboro, Franklin County, Pennsylvania and, in his return of service, notes that the
Defendant was "not found."
Further affiant sayeth not.
21
?
David A. Baric, Esquire
STATE OF Pennsylvania
.: SS.
COUNTY OF Cumberland
AND NOW, this 25th of February, 2009, before me, the undersigned officer, personally
appeared David A. Baric, Esquire, known to me (or satisfactorily proven) to be the person whose
name is subscribed to the within instrument, and acknowledged that he executed same for the
purposes therein contained.
IN WITNESS WHEREOF, I hereunto set
C0&#j0NW?_ ?LTN OF PENNSYLVANIA
NogAr Sad
LjVVVW a. Ur4W, Notary PubOc
wit
Aaodomon of NOWAS
EXH
CERTIFICATE OF SERVICE
I hereby certify that on February A? , 2009, I, David A. Baric, Esquire of O'Brien,
Baric & Scherer, did serve a copy of the Motion Of Plaintiff For Order Of Special Service, by first
class U.S. mail, postage prepaid, to the parties listed below, as follows:
Erma A. Moser
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Donald Grove
6824 Furnace Road
Waynesboro, Pennsylvania 17268
David A. Baric, Esquire
<;:9
?.d3
?
t
AFFIDAVIT
NOW, comes Affiant, David A. Baric, Esquire, who, being duly sworn, does depose and
state the following:
I am the attorney for Perini Services/South Hampton Manor, L.P. in the matter
docketed to No. 2008-6928 in the Court of Common Pleas of Cumberland County, Pennsylvania.
2. I have caused a search to be made via the internet for addresses or telephone
numbers for the Defendant, Donald Grove. The address I found for the Defendant, Donald
Grove was the address used by the Sheriff's office to attempt service at.
I have filed a request with the United States Postal Service requesting a
forwarding address for the Defendant, Donald Grove. The request was returned to me by the
United States Postal Service indicating that the Defendant's mail is delivered to the address
provided by undersigned counsel.
4. The Sheriff of Franklin County attempted to make personal service of the
Complaint on the Defendant, Donald Grove at his last known address of 6824 Furnace Road,
Waynesboro, Franklin County, Pennsylvania and, in his return of service, notes that the
Defendant was "not found."
Further affiant sayeth not. A4 J
/id
David A. Baric, Esquire
STATE OF Pennsylvania
: SS.
COUNTY OF Cumberland
AND NOW, this 25th of February, 2009, before me, the undersigned officer, personally
appeared David A. Baric, Esquire, known to me (or satisfactorily proven) to be the person whose
name is subscribed to the within instrument, and acknowledged that he executed same for the
purposes therein contained.
IN WITNESS WHEREOF, I hereunto set
C WMONWE& OF p 3YLVANIA
Now" sw
dmow S. UWW, Nowy Pubk
cwkbem.
Monnbw. P of
c-? ?,
?_? V,
_.
??r +??,?
,w,+
h) , -?
?
„ ?
`?; -_- -
c;.. °'?
? ,
<:,?
.?
-. ??t
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008-6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
AMENDMENT TO MOTION OF
PLAINTIFF FOR ORDER OF SPECIAL SERVICE
NOW, comes Plaintiff, Perini Services/South Hampton Manor, L.P., by and through its
attorneys, O'BRIEN, BARIC & SCHERER, and files the within Amendment To Motion Of
Plaintiff For Order Of Special Service, in support thereof, sets forth the following:
1. No judge has ruled on any issue in this case.
2. No attorney has entered their appearance of record on behalf of either Defendant
in this case.
WHEREFORE, Plaintiff requests that this Court issue an Order directing special order of
court to effectuate service of the Complaint upon the Defendant said service to be made by notice
of this action directed to the Defendant, Donald Grove to be published one time in a newspaper
of general circulation in Franklin County in accordance with Pa.R.C.P. 430(b)(1) and any
subsequent service upon Defendant shall be made by regular U.S. Mail postage prepaid to the
Defendant's address of 6824 Furnace Road, Waynesboro, Franklin County, Pennsylvania 17268.
Respectfully submitted,
O N, BARI & CHE
f
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
?y
w
PERINI SERVICES/
SOUTH HAMPTON
MANOR, L.P.,
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 08-6928 CIVIL TERM
IN RE: MOTION OF PLAINTIFF
FOR ORDER OF SPECIAL SERVICE
AND NOW, this 19'h day of March, 2009, upon consideration of the Motion of
Plaintiff for Order of Special Service, the motion is granted to the extent that service of
the complaint in the above-captioned matter may be made upon Defendant Donald Grove
by (1) publication once in a newspaper of general circulation in Franklin County,
Pennsylvania, and (2) certified and regular mail addressed to Defendant Grove at 6824
Furnace Road, Waynesboro, Franklin County, Pennsylvania, 17268, said service to be
deemed complete upon mailing.
Any subsequent service upon Defendant shall be made by regular mail to the said
address, service to be deemed complete upon mailing.
BY THE COURT,
esley O Jr., J.
Xvid A Baric, Esq.
19 West South Street
Carlisle, PA 17013
Attorney for Plaintiff
/.? m a Moser
21 Walnut Bottom Road
Shippensburg, PA 17257
Defendant, pro Se
'j 0 :?, wd 61 NVN OR
3H,iL?
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
PRAECIPE TO REINSTATE
TO THE PROTHONOTARY:
Please reinstate the Complaint filed in the above-captioned matter on November 21,
2008.
Respectfully submitted,
O' N, BA SCH
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
da b.dir/shcc/moser/reinstate.pra
71
Y' V
V
Q?K
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008-6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
j AFFIDAVIT OF SERVICE
IN ACCORDANCE WITH COURT ORDER
I hereby certify that service of the Civil Action Complaint was made in accordance with
the Court Order dated March 19, 2009 as indicated below:
By publication as provided by Pa. R. C. P. Rule 430O b in The Record Herald on March
28, 2009. Proof of the said publication is attached hereto.
j By certified mail and U.S. first class mail on March 26, 2009. Proof of said mailing is
I
attached hereto.
y! The undersigned understands that this statement is made subject to the penalties of 18 Pa.
C. S. Section 4904 relating to unsworn falsification to authorities.
r
r
David A. Baric, Esquire
DATE: April 1, 2009
RECORD HERALD PUBLISHING COMPANY
Publishers of
THE RECORD HERALD
Waynesboro, Pennsylvania
PROOF OF PUBLICATION
In compliance with the Newspaper Advertising Act of May 16, 1929, P.L. 1784,
Paragraph 3, Sub-paragraph 25.
Commonwealth of Pennsylvania, County of Franklin, SS:
me, a Notary Public in and for said County and
Sta
who being duly sworn
according to law, deposes and says that he is the VL4"rA? k eA_.
of The Record Herald Publishing Company, a Pennsylvania corporation, and
its agent in this behalf', that the said Company is the publisher of The Record
Herald, established in 1847, a daily newspaper of general circulation, printed
and published and having its place of business at Waynesboro, Franklin County,
Pennsylvania, where it has been established and published continually for more
than six months prior to the publication of the notice hereto attached; that the
printed notice or advertisement hereto attached is a copy of an official adver-
tisement, official notice, legal notice or legal advertisement, exactly as printed
or published in The Record Herald in its regular issue or issues on the following
date or dates:
kA
that neither the affiant nor The Record Herald Publishing Company is interested
in the subject matter of said notice or advertising and that all of the allegations
of this affidavit as to the tk'pe, place and manner of the publication are true.
Sworn to and subscribed before me this day of u// l
COMMONWEALTH OF PENNSYLVAN(A Notary Public
Notarial Seal
Nioole A. Kipe, Notary Public
Waynesboro Boro, Franklin County
My Commission EVires March 22, 2011
Member, Pennm,lvanis Association of Notarles
Nature of "Action: Civil Complaint, claim. for services
provided to Erma A. Moser in the amount of $54,680.83 plus
IrvW" to the dew of a*A4 Noreft, costs' Mid e>glensss
and attorney fees.
NOTICE
It you wish to defend, you must enter a written appeamnce
perssemily or by an attorney arid Me yow-defenaee or
ottjections in writing with the Court. You are waned that It you
fail tD do so, the case may proceed without you and a
judgment-may be entered against you without "further notice
for the relief requested by the Plaintiff. You may lose money
or property or ottW 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 INFOR-
MATION ABOUT AGENCIES THAT MAY OFFER LEGAL
SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE
OR NO FEE.
Cumberland County Bar Association
32 South Bedkx d Street
Car W#,Psnnsytveeda 17013
(7'17) 2493166
DAVID A. BAINC, Esquire
O'dR1EN, BAIUC al SCHlR6R
19 West South Street
Carlisle PA 17013
(717) 24944
Attorney for P11611"M a
i
(Domestic Mail C
For delivery inform
Er
MM
E3
Q" P $ -
+?
ostage
ru Certified Fee ^
` O
`
?
1:3
Return Receipt Fee
ed)
t R
i
AO
a Pos( ry
Y
:
O equ
r
(Endorsemen '
Restricted Delivery Fee n
O (Endorsement Required) 0% s
ro Total Postage & Fees $
rU
M
O
N
Law Offices
r
Robert L. O'Brien
David A. Baric
Michael A. Scherer
March 25, 2009
VIA CERTIFIED MAIL # 7008 2810 0002 2909 5942
AND REGULAR U.S. FIRST CLASS MAIL
Donald L. Grove
6824 Furnace Road
Waynesboro, Pennsylvania 17268
RE: Perini Services/South Hampton Manor, L.P. v.
Erma A. Moser and Donald Grove
No. 2008-6928 Civil Term
Dear Mr. Grove:
(717) 249-6873
Fax: (717) 249-5755
Email: dbaric(a abslaw. com
I am the attorney for the Plaintiff in the above matter. Enclosed for service upon you find
a certified true and correct copy of a Complaint.
You have the right to represented by an attorney in this matter, and. I suggest that you
consult with one if you have any questions or concerns regarding your legal rights.
Very truly yours,
DAB/j1
Enc.
cc: ie Donaldson
(2ile3
dab.dir/shcc/moser/groveAtr
O'BRIEN, BARIC HERER
VIA FACSIMILE: (240) 625-9460
O'BRIEN, BARIC & SCHERER
19 West South Street
Carlisle, Pennsylvania 17013
r
1
David A. Baric, Esquire
FILM-t` FTE
OF TFE T! URY
2909 APR - I PM 3: 31
CLWM:: ,J` dry iD)UN Y
P Wi&tYAA
SHERIFF'S RETURN - REGULAR
CASE NO: 2008-06928 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
PERINI SERVICES/SOUTH HAMPTON
VS
MOSER ERMA A ET AL
MICHAEL BARRICK
0 N
? w
-
17 m f ?may,
rQ -?
, Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the w---thin COMPLAINT & NOTICE
MOSER ERMA A
the
DEFENDANT
, at 0008:59 HOURS, on the 6th day of December , 2009
at 121 WALNUT BOTTOM ROAD
SHIPPENSBURG, PA 17257
ERMA A. MOSER
was served upon
by handing to
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs: So Answers:
Docketing 18.00 , ? ;?
Service 18.90
Affidavit .00
Surcharge 10.00 R. Thomas Kline
.00
46.90 12/19/2008
OBRIEN BARIC SCHERE J?
Sworn and Subscibed to By:
before me this day eput he iff
of A.D.
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2008-06928 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
PERINI SERVICES/SOUTH HAMPTON
VS
MOSER ERMA A ET AL
R. Thomas Kline
n o
t?= b : J rr;
Sheriff or Deputy Sheriff who brQeing
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT
GROVE DONALD
but was unable to locate Him
deputized the sheriff of FRANKLIN
in his bailiwick
serve the within COMPLAINT & NOTICE
to wit:
He therefore
County, Pennsylvania, to
On May 1st , 2009 , this office was-Ao{-inreceipt of the
attached return from FRANKLIN
Sheriff's Costs:
Docketing
Out of County
Surcharge
Franklin
So arjggtj-r.
6.00
q.00
10.00 R
100.00
.00
12-5.00
12/19/2008
OBRIEN BARIC SCHERER
Sworn and subscribe to before me
this day of
A. D.
x-no as Kline
r/ f of Cumberland County
Service unknown, Sheriff's Return from Franklin Co. not received
as of this date. A letter was faxed on 1/22/09 to which no response was
received.
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
PRAECIPE TO ENTER DEFAULT JUDGMENT
PURSUANT TO Pa.R.C.P.1037
TO THE PROTHONOTARY:
Please enter judgment in favor of the Plaintiff, Perini Services/South Hampton Manor,
L.P. and against the Defendants, Erma A. Moser and Donald Grove, for failure to file an answer
to the Complaint of Plaintiff.
True and correct copies of the Notices of Default are appended hereto as Exhibit "A."
True and correct copies of the Certificates of Mailing for the Notice of Default are
appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance
with Pa.R.C.P. 237.1.
Plaintiff requests judgment in the amount of $54,660.83 as set forth in the Complaint
together with addition9l finances charges of $5,596.62 to June 10, 2009 with a per diem of
$25.21, attorney fees and costs of $3,472.00 for a total of $63,729.45.
Respectfully submitted,
O RIEV B C RER
1
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
PERM SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
TO: Donald Grove
6824 Furnace Road
Waynesboro, Pennsylvania 17268
Date of Notice: April 16, 2009
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST
YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR
CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND
OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
awZBARI-I11z?A'R.
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
EXHIBIT "A"
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008-6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
TO: Erma A. Moser
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Date of Notice: May 27, 2009
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST
YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR
CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND
OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES N t j :Lim'=y'4 a
PROVIDE FOR INSURANCE-POSTMASTER
H
.? Fes'
'6A *C scliertr (CO Lil
Irk .
One piece of ordinary mail addressed to:
m JON
GroU '-'
FtArnace, No D
11?a n?sboro ??a?o m
PS Form 3817, January 2001
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES NOT
PROVIDE FOR INSURANCE-POSTMASTER
Receive rqm:
0' n I, & i(U4 SOhw
1 ?? SarNn Sind
One piece of ordinary mail addressed to:
&. A. mo
• S,d?ttlrOl, FA l1Z7
PS Form 3577, January 2001
aZ
o yyyp
o p
•f N
A
m
'
n -C
om
v
o
o. o+v
.»?
JoNf?+
C
O
I (
?
o c
h
to
a c
i
m
EXHIBIT "Brr
?I
CERTIFICATE OF SERVICE
I hereby certify that on June 10 , 2009, I, David A. Baric, Esquire, of O'Brien,
Baric & Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To
Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the parties listed below, as follows:
Erma A. Moser
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Donald Grove
6824 Furnace Road
Waynesboro, Pennsylvania 17268
c
David A. Baric, Esquire
al
'kd
pyvnaWq a-.+?o /m
lei
b nA
*10, 66
4m
di a,
a r?hu019
gip}, 6 %104
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236
TO: Erma A. Moser
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Notice is hereby given to you of entry of a judgment against you in the above matter.
P n
Q
Date: 1p/
CHAD P. BAKER IN THE COURT OF COMMON PLEAS
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
? (
V. DOCKET NO.: Q F%"- 6 / '?-l G? f !?l?v
1800 HIGH STREET CIVIL ACTION -LAW
CORPORATION, CARLISLE
DINER, INC.
Defendant JURY TRIAL DEMANDED
PRAECIPE FOR WRIT OF SUMMONS
TO THE CUMBERLAND COUNTY PROTHONOTARY:
Please issue a Writ of Summons in the above-captioned action.
Writ of Summons shall be issued and forwarded to the Sheriff for service upon:
Angel P. Oliva, President
1800 High Street Corporation
34 Teaberry Drive
Carlisle, PA 17013
Date: x c
Nicholas Giambilis
Carlisle Diner, Inc.
800 West High Street
Carlisle, PA 17013
W Q)FFICE,0F. JOSEPH L. HITCHINGS
Attorney I.D.# 6555
5000 Ritter Road, Suite 202
Mechanicsburg, Pennsylvania 17055
Telephone: (717) 458-8123
Attorney for Plaintiff
WRIT OF SUMMONS
TO THE ABOVE MENTIONED NAMED DEFENDANTS:
YOU ARE NOTIFIED THAT THE ABOVE NAMED PLAINTIFF HAS
COMMENCED AN ACTION AGAINST YOU.
Date: dU-l??l.Q?tc ?2/? .2-66e
Prothonotary
By:6zu?? 2 C04?
Deputy V el
C"J c '
"TJt °t
(? `?( -mac _ -?
rr
t J ,
)
V
r
I
SHERIFF'S RETURN - NOT FOUND
"CASE NO: 2008-06929 P
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
BAKER CHAD P
VS
1800 HIGH STREET CORPORATION
R. Thomas Kline Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
CARLISLE DINER INC C/O NICHOLAS GIAMBILIS but was
unable to locate Them in his bailiwick. He therefore returns the
WRIT OF SUMMONS
NOT FOUND , as to
the within named DEFENDANT , CARLISLE DINER INC
C/O NICHOLAS GIAMBILIS
800 WEST HIGH STREET
CARLISLE, PA 17013
EMPLOYEES AT DINER NEVER HEARD OF NICHOLAS GIAMBILIS (OR ANGEL
P. OLIVA)
Sheriff's Costs:
Docketing 18.00
Service 4.50
Affidavit .00
Surcharge 10.00
Not Found 5.00
3 7 . 5 0
So answer
R. Thomas
Sheriff of Cumbe
LAW OFFICES OF J
12/23/2008
Sworn and Subscribed to before
me this day of
A. D.
ine
land County
SSEPH HITCHING
SHERIFF'S RETURN - NOT SERVED
CASE NO: 2008-06929 P
4 COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
BAKER CHAD P
VS
1800 HIGH STREET CORPORATION
R. Thomas Kline , Sheriff , who being duly sworn
according to law, says, that he made a diligent search and inquiry for
the within named DEFENDANT , to wit:
1800 HIGH STREET CORPORATION C/0 ANGEL P. OLIVA but was
unable to locate Them in his bailiwick. He therefore returns the
WRIT OF SUMMONS
the within named DEFENDANT
C/O ANGEL P. OLIVA
34 TEABERRY DRIVE
CARLISLE, PA 17013
DESPITE SEVERAL ATTEMPTS, PAPER EXPIRED BEFORE SERVICE WAS MADE.
Sheriff's Costs:
Docketing
Service
Postage
Surcharge
Not Served
//bz/o 9 (?,
NOT SERVED , as to
1800 HIGH STREET CORPORATION
6.00
5.40
.42
10.00
5.00
26.82
So answers.. -„- --,-.. T
R. Thomas Kli
Sheriff of Cumberland County
LAW OFFICES OF JOSEPH HITCHING
12/23/2008
Sworn and Subscribed to before me
this day of
A.D.
ROLF E. KROLL, ESQUIRE
Pa. Supreme Court I.D. No. 47,243
MARGOLIS EDELSTEIN
3510 Trindle Road
Camp Hill, Pennsylvania 17011
Telephone: [717] 975-8114 Direct Dial: (717) 760-7502 Attorneys for Defendants:
Fax: [717] 975-812 1800 HIGH STREET CORPORATION,
E-Mail: rkroll@marg4lisedelstein.com and CARLISLE DINER, INC.
CHAD P. BAKER, : IN THE COURT OF COMMON PLEAS
Plaintiff, : CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAWS
V.
DOCKET NO. 08-692$ Civil Term
1800 HIGH STREET CORPORATION, :
CARLISLE DINER, INC.,
Defendant. : JURY TRIAL DEMANDED
MUCIPE TO ENTER APPEARANCE
TO THE PROTHONOTARY OF CUMBERLAND COUNTY, PENNSYLVANIA:
Kindly enter my appearance on behalf of Defendants, 1800 High Street
Corporation and Carlisle biner, Inc., in the above-captioned matter.
Respectfully submitted,
L
Date:
MARGOLIS EDF)LSTEIN
By:
PA. AttornefI.D. No. 47243
Attorney for Defendants,
1800 HIGH STREET CORPORATION
and CARLISLE DINER, INC.
3510 Trindle Road
Camp Hill, PA 17011
(717) 760-7502
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that I served a true and correct copy of the foregoing
ENTRY OF APPEARANCE OF ROLF E. KROLL, ESQ., on all counsel of record by
placing the same in the Vnited States mail at Camp Hill, Pennsylvania, first-class
73
postage prepaid, on the '9 day of , 2009, and addressed as
follows:
Joseph L. Hitchings, Esquire
50WRitter Road, Suite 202
Mechanicsburg, PA 17055
MARGOLIS EDELSTEIN
By:_ Tll? ldlz?
Kellie Ann Nelson, Paralegal
F, LED, - .- OF TFr- pn
TAPY
2009 APR 14 AM 10: 32
PCNN YLV,N' !A
ROLF E. KROLL, ESQUIRE
Pa. Supreme Court I.D. No. 4243
MARGOLIS EnEI STEIN
3510 Trindle Road
Camp Hill, Pennsylvania 17011
Telephone: [717] 975-811 Direct Dial: (717) 760-7502
Fax: [717]975-812
E-Mail: rkrnll(a)marv '7SPelPICta7T vn„
Attorneys for Defendants:
1800 HIGH STREET CORPORATION,
and CARLISLE DINER, INC.
CHAD P. BAKER, : IN THE COURT OF COMMON PLEAS
Plaintiff, : CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAWS
V.
DOCKET NO. 08-6924 Civil Term
1800 HIGH STREET CO"ORATION,
CARLISLE DINER, INC.,'
Defendant. : JURY TRIAL DEMANDED
RULE TO FILE COMPLAINT
TO THE PROTHONOTARY OF CUMBERLAND COUNTY, PENNSYLVANIA:
Please issue Rule -pon Plaintiff to file a Complaint within twenty (20) days
I
from service hereof or suffer judgment non pros.
I
Respectfully submitted,
Date: / 117'16,1 By
3510 Trindle Road
Camp Hill, PA 17011
(717) 760-7502
April 14, 2009, Rule to
Complaint Issued.
S
Curtis R. Long, Protho 4otarvi
Attorney for Defendants,
1800 HIGH STREET CORPORATION
and CARLISLE DINER, INC.
CERTIFICATE QF SERVICE
I HEREBY CERTIFY that I served a true and correct copy of the foregoing RULE
TO FILE COMPLAINT, on all counsel of record by placing the same in the United
States mail at Camp Hill,' Pennsylvania, first-class postage prepaid, on the 9 day
of , 20b9, and addressed as follows:
Joseph L. Hitchings, Esquire
5000''Ritter Road, Suite 202
Mechanicsburg, PA 17055
MARGOLIS EDELSTEIN
By: 0 440-,_
Kellie Ann Nelson, Paralegal
rALEr' -
,J) N,ArIly
2009 APE; 11; Ail 11 : 08
t?vhti+ ;QTY
CHAD P. BAKER IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. DOCKET NO.: 08-6929 Civil Term
1800 HIGH STREET CIVIL ACTION - LAW
CORPORATION, CARLISLE
DINER, INC.
JURY TRIAL DEMANDED
Defendants
PRAECIPE TO REISSUE WRIT OF SUMMONS
TO THE CUMBERLAND COUNTY PROTHONOTARY:
Please Reissue the Writ of Summons for Defendants 1800 High Street Corporation, and
Carlisle Diner, Inc. in the above-captioned action. A copy of the original Writ is attached hereto.
The Reissued Writ of Summons shall be issued and returned to the undersigned for
service upon the Defendant.
Office of Josepk L. Hitchings
Date: , p
7eaeph L. Hitaifings, [*uir
Attorney I.D.# 65551
5000 Ritter Road, Suite 202
Mechanicsburg, Pennsylvania 17055
Telephone: (717) 458-8123
Fax: (717) 790-6019
Attorney for Plaintiff
u
2009 fUT 28 P 12: 4 2
f t i ,.. c.4f Vi,?'a
I O.00 Po AYI-t
co (104
QU43q7
CHAD P. BAKER IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. : DOCKET NO.: 08-6929 Civil Term
1800 HIGH STREET CIVIL ACTION - LAW
CORPORATION, CARLISLE
DINER, INC.
JURY TRIAL DEMANDED
Defendants
NOTICE TO DEFEND
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 OR CANNOT AFFORD ONE, GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE
YOU WITH INFORMATION ABOUT HIRING AN ATTONEY.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFOMRAITON ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED OR NO FEE.
CUMBERLAND COUNTY LAWYER REFERRAL SERVICE
CUMBERLAND COUNTY COURTHOUSE
4TH FLOOR
CARLISLE, PA. 17013
#717-240-6200
CHAD P. BAKER IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. : DOCKET NO.: 08-6929 Civil Term
1800 HIGH STREET CIVIL ACTION - LAW
CORPORATION, CARLISLE
DINER, INC.
JURY TRIAL DEMANDED
Defendants
COMPLAINT
AND NOW, this _ day of 2009, comes the Plaintiff,
Chad P. Baker, by and through its undersigned attorney, Joseph L. Hitchings, Esquire and
avers in support of his Complaint against Defendants, 1800 High Street Corporation and
Carlisle Diner Inc., as follows:
1. Plaintiff, Chad P. Baker, is an adult individual residing at 444 Adams Road,
Carlisle, Cumberland County, Pennsylvania 17013.
2. Defendant, 1800 High Street Corporation, is a corporation, duly organized and
existing under the laws of the Commonwealth of Pennsylvania, with a registered office
address of 34 Teaberry Drive, Carlisle, Cumberland County, Pennsylvania 17013.
3. Defendant, Carlisle Diner, Inc., is a corporation, duly organized and existing
under the laws of the Commonwealth of Pennsylvania, with a registered office address of
800 West High Street, Carlisle, Cumberland County, Pennsylvania 17013.
4. It is believed and therefore averred that Defendant 1800 High Street
Corporation owns the real property and building located at 800 West High Street,
Carlisle, Cumberland County, Pennsylvania, 17013, which houses a diner restaurant
trading as Carlisle Diner
5. It is believed and therefore averred that Defendant Carlisle Diner, Inc., owns
and operates the diner restaurant known as Carlisle Diner, located at 800 West High
Street, Cumberland County, Pennsylvania 17013.
6. On November 23, 2006, at approximately 1:50 a.m. Plaintiff and a group of
friends arrived at the Carlisle Diner to order breakfast.
7. While entering the diner on November 23, 2006, Plaintiff encountered his
future mother and father-in-law, Mr. & Mrs. James Gross, who were leaving the diner.
8. Plaintiff announced to his friends that he was going to use the diner's
restroom and proceeded toward the restroom.
9. While making his way to the restroom, Plaintiff saw two friends of his,
Nathan Lebo and his girlfriend, Natalie, to whom he said hello.
10. The floor area leading up to the men's restroom in the Carlisle Diner is
covered in carpeting; however the floor transitions to tile once inside the men's restroom.
11. When Plaintiff reached the men's restroom, he pushed the door open, and
stepped on the tile restroom floor which was flooded with standing water, and
immediately lost his footing and fell face first onto the tile floor.
12. Plaintiff recalls immediately feeling his face throbbing and when he tried to
get up, his pants, shirt, hands, face and boots were soaked with water.
13. Plaintiff left the restroom and started walking back out to his friends, when
they came up to him to ask if he was ok. Plaintiff was made to sit down and spoke with a
waitress named Ruth, who took information from him and advised this would be reported
to the diner's insurance company.
14. Prior to Plaintiff entering the men's restroom, other patrons of the diner
reported the flooding problem to diner management and/or employees who advised the
situation would be taken care of.
15. After Plaintiff's fall, a diner employee placed a brown sign, believed to be
either a warning or closed sign, on the men's restroom door.
16. After sitting for approximately ten minutes, Plaintiff's friends drove him to
the emergency room at the Carlisle Hospital.
17. While at the hospital, Plaintiff was x-rayed and two CT scans were run on his
head and face. Plaintiff was diagnosed with multiple facial fractures, including a fracture
of the lateral wall of the maxillary sinus, left orbital bone, left zygomatic arch, and a
nondisplaced nasal bone fracture. He was also diagnosed with an acute cerebral
concussion and double vision.
18. Plaintiff subsequently sought treatment from his family doctor, William
Phelan, M.D., who examined the Plaintiff and referred him to an oral surgeon and
optometrist.
COUNTI
Plaintiff v. Defendant, 1800 High Street Corporation
19. The averments of paragraphs 1 through 18 hereof are incorporated by
reference as if the same were more fully set forth at length herein.
20. At all times material hereto, Defendant, 1800 High Street Corporation owned
the building where the Carlisle Diner was located.
21. Defendant, 1800 High Street was negligent in the following ways:
a) Failing to provide a safe environment for patrons of the diner;
b) Failing to warn of existing flooding in the restroom;
c) Failing to take remedial measures to repair or otherwise reduce the risk
of injury to patrons of the diner as a result of the flooding in the restroom;
d) Failing to insure that it's tenant provide a safe environment for patrons
of the diner;
e) Failing to insure that it's tenant warned patrons of the diner of existing
flooding in the restroom;
f) Failing to insure that it's tenant repaired or otherwise reduced the risk of
injury to patrons of the diner as a result of the flooding in the restroom;
22. As a direct and approximate result of the careless and negligent conduct of
Defendant, Plaintiff sustained the following injuries and/or aggravations of pre-existing
conditions, some are all of which may be permanent:
a) fracture of the lateral wall of the maxillary sinus;
b) fracture of the left orbital bone;
c) fracture of the left zygomatic arch;
d) fracture of the nasal bone;
e) acute cerebral concussion;
f) headaches;
g) teeth pain and gum numbness; and
h) vision difficulties.
23. As a direct and approximate result of the careless and negligent conduct of the
Defendant, and the injuries suffered in the accident, the Plaintiff was unable to work for a
period of time resulting in the loss of wages.
24. As a result of the accident and injuries sustained therein, Plaintiff has suffered
serious and permanent injury, which required medical treatment, for which he has
incurred medical bills and expenses and may require further medical treatment in the
future.
25. As a result of the fall and injuries sustained therein, Plaintiff has suffered an
interruption of his daily habits and pursuits to his detriment and loss.
26. All injuries and damages as set forth herein, suffered by Plaintiff, Chad P. Baker,
were proximately caused by the negligence of the Defendant.
WHEREFORE, Plaintiff, Chad P. Baker, demands judgment against the
Defendant, 1800 High Street Corporation, in an amount in excess of fifty thousand
($50,000.00) dollars, plus costs, interest, and delay damages, if applicable.
COUNT II
Plaintiff v Defendant Carlisle Diner, Inc.
27. Paragraphs 1 through 26 hereof are incorporated by referenced as if the same
were more fully set forth at length herein.
28. It is believed and therefore averred that at all times material hereto,
Defendant, Carlisle Diner, Inc., owned and operated the restaurant known as Carlisle
Diner located at 800 West High Street, Cumberland County, Pennsylvania 17013.
29. On November 23, 2006 at 1:50 a.m., Carlisle Diner was open for business
and was serving restaurant patrons.
30. On November 23, 2006, management and employees of Carlisle Diner Inc.,
were aware that a toilet in the men's restroom had overflowed, causing water to flood the
floor of the restroom, resulting in a dangerous condition in the restroom.
31. The management and/or employees of Carlisle Diner attempted to fix the
flooding problem, however their attempts were unsuccessful as standing water was on the
restroom floor when Plaintiff entered the men's restroom.
32. Despite their knowledge of the flooding problem, management and employees
of Carlisle Diner, failed to close the men's restroom or warn patrons of the flooding
problem.
33. Defendant, Carlisle Diner, Inc., was negligent in the following ways:
a) Failing to provide a safe environment for patrons of the diner;
b) Failing to warn of existing flooding in the restroom;
c) Failing to take remedial measures to repair or otherwise reduce the risk
of injury to patrons of the diner as a result of the flooding in the restroom;
d) Failing to close the men's restroom as a result of existing flooding in
the restroom;
f) Allowing a dangerous condition to exist in the men's restroom;
34. As a direct and approximate result of the careless and negligent conduct of
Defendant, Plaintiff sustained the following injuries and/or aggravations of pre-existing
conditions, some are all of which may be permanent:
a) fracture of the lateral wall of the maxillary sinus;
b) fracture of the left orbital bone;
c) fracture of the left zygomatic arch;
d) fracture of the nasal bone;
e) acute cerebral concussion;
f) headaches;
g) teeth pain and gum numbness; and
h) vision difficulties.
35. As a direct and approximate result of the careless and negligent conduct of
the Defendant, and the injuries suffered in the accident, the Plaintiff was unable to work
for a period of time resulting in the loss of wages.
36. As a result of the accident and injuries sustained therein, Plaintiff has
suffered serious and permanent injury, which required medical treatment, for which he
has incurred medical bills and expenses and may require further medical treatment in the
future.
37. As a result of the fall and injuries sustained therein, Plaintiff has suffered
an interruption of his daily habits and pursuits to his detriment and loss.
38. All injuries and damages as set forth herein, suffered by Plaintiff, Chad P.
Baker, were proximately caused by the negligence of the Defendant.
WHEREFORE, Plaintiff, Chad P. Baker, demands judgment against the
Defendant, Carlisle Diner, Inc., in an amount in excess of fifty thousand ($50,000.00)
dollars, plus costs, interest, and delay damages, if applicable.
Respectfully submitted,
Law Office of Joseph L. Hitchings
r
`?-
/A I
ks-i?ph L. Hit i gs, quij
Attorney I.D. No 65551
5000 Ritter Road, Suite 20.
Mechanicsburg, PA 17055
717-458-8123
717-790-6019 Fax
Attorney for Plaintiff
VERIFICATION
I, Chad P. Baker, verify that the statements made in this Complaint are true and
correct to the best of my knowledge information and belief. I understand that false
statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to
unsworn falsification to authorities.
5-13,02
Date
Q.
Cha P. Baker
2L', A Y 13 P'N 2: <; ¢
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/, Civil Action -Law
SOUTH HAMPTON MANOR, L.P.
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE
Defendants
PETITION TO OPEN DEFAULT JUDGMENT PURSUANT TO PA.R.C.P. 237.3
AND LEAVE TO FILE ANSWER
Now come the Defendant, Donald Grove, by and through his attorney Jeffrey S.
Evans, Esquire, and moves the Court as follows:
1. Petitioner Donald Grove is one of the Defendants in the above-captioned
action.
2. Respondent is the Plaintiff in the above-captioned action.
3. On or about November 2008, Respondent initiated this action by filing a
complaint, containing three separate counts.
4. Pursuant to the Affidavit of Service filed in this matter on or about
, the complaint was served on Petitioner via
5. On or about June 10, 2009, Respondent took filed and served upon
Petitioner a Praecipe for the entry of default judgment.
6. Attached hereto, made part hereof is Petitioner's verified answer asserting
meritorious defenses to Counts I and II of the Complaint.
7. Pursuant to Pa.R.C.P. 237.3 the court shall open the judgment if the
proposed answer asserts a meritorious defense and has been filed within Ten (10) days of
the entry of the default judgment.
WHEREFORE, Petitioner requests that this Honorable Court enter an Order
opening the default judgment entered in this matter on June 10, 2009 and granting leave
to Petitioner to file the attached Answer with New Matter.
Respectfully
Donald Grove
2025 Last Main Street
Waynesboro, PA 17268
(717)762-1415
PA Atty. ID No. 55654
VERIFICATION
The undersigned is counsel for the Defendant in the foregoing document and
states that the facts set forth in said document are true and correct, in part according to his
own personal knowledge, and as to the remainder, upon information and belief based
upon conversations with and representations made by Defendant. Defendant is believed
to be outside the jurisdiction of the Court and unavailable and his signature has not been
able to be obtained for this pleading. The undersigned also understands that false
statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to
unsworn falsification to authorities.
Dated: 6 /?'Y d
IN THE COURT°OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERIM SERVICES/, Civil Action -Law
SOUTH HAMPTON MANOR, L.P.
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE
Defendants
ANSWER WITH NEW MATTER
Now comes the Defendant, Donald Grove, by and through his attorney Jeffrey S.
Evans, Esquire, and answers the Complaint of Plaintiff as follows:
1. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
2. Admitted.
3. Admitted.
4. Admitted.
5. Denied. To the contrary Defendant Erma A. Moser sought admission to
Plaintiff's facility with the aid of Defendant, Donald Grove, her son.
6. Denied. To the contrary, Defendant Donald Grove was advised to sign by
members of Plaintiffs staff as Defendant Erma A. Moser's "legal representative" despite
being made aware he was not in fact her power of attorney or designated agent.
7. Admitted.
8. Admitted.
9. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
10. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
11. Denied. To"the contrary, her benefits are direct deposited into her account
at Hagerstown Trust.
COUNT I - BREACH OF CONTRACT
Shippensburg Health v. Erma A. Moser and Donald Grove
12. Defendant hereby incorporates the averments of Paragraphs 1 through 11
of this Answer as if set forth at length.
13. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
14. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
15. Denied. To the contrary Defendant, Donald Grove has not received
benefits in the name of Erma A. Moser and is under no obligation to pay her obligations
under the Admission Agreement.
16. Denied. To the contrary, Defendant was not given the opportunity to
review the Admissions Agreement and did not realize that he was to be made personally
responsible for the payment of any charge accrued as a result of the Erma A. Moser's
residence at Plaintiff's facility.
17. Admitted in part, denied in part. It is admitted that the Admission
Agreement provides for the recovery of a penalty for late payments in the amount of
1.5% per month. It is denied that as of October the finance charges amounted to
$3,529.44 and continue to accrue. To the contrary, Defendant is without sufficient
knowledge or information to form a belief as to the truth of the averments of this
paragraph and therefore same are denied and proof thereof is demanded at trial.
18. Admitted.
COUNT II - MONEY HAD AND RECEIVED
Shippensburg Health v. Donald Grove
19. Defendant hereby incorporates the averments of Paragraphs 1 through 18
of this Answer as if set forth at length.
20. Denied. ` To the contrary, said amounts have been direct deposited to Erma
A. Moser's account at Hagerstown Trust.
21. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
22. Denied. To the contrary, suspected that insurance was covering her stay.
23. Denied. To the contrary the averments of Paragraph 20 are incorporated
herein by reference as if set forth at length. By way of further answer, Defendant has
provided care for Defendant on numerous occasions over the years for which he has
never expected compensation.
24. Denied. To the contrary Defendant, Donald Grove had previously
provided insurance information and is willing to turn over to Plaintiff any amount he has
that belongs to his mother, Defendant Erma A. Moser.
COUNT III - QUANTUM MERUIT
Shippensburg Health v. Erma A Moser
25 - 28. No response is required in that Plaintiff's claim does not involve
Defendant,. Donald Grove.
NEW MATTER
29. At the time of the signing of the Admission Agreement and immediately
prior thereto, Defendant Donald Grove advised representatives of Plaintiff that he was
not Defendant Erma A. Moser's designated power of attorney.
30. Defendant Donald Grove signed the Admission Agreement, at the
insistence of Plaintiff's representatives without the opportunity to review the agreement
or consult counsel for review. Further they insisted that he sign as "legal representative"
of Defendant Erma A. Moser, without explaining the significance of such a designation
nor that he could not appoint himself as such.
31. Defendant Donald Grove believed and therefore avers that the care
Plaintiff would provide Defendant Erma A. Moser would be paid for by her health
insurance carrier.
WHEREFORE, Defendant respectfully requests that this Honorable Court enter
judgment in favor of Defendant, Donald Grove on Counts I and II of Plaintiff's
Complaint.
Respectfully submitted,
4 Je v reifendant
Att o 2025 East Main Street
Waynesboro, PA 17268
(717)762-1415
PA Atty. ID No. 55654
VERIFICATION
The undersigned is counsel for the Defendant in the foregoing document and
states that the facts set forth in said document are true and correct, in part according to his
own personal knowledge, and as to the remainder, upon information and belief based
upon conversations with and representations made by Defendant. Defendant is believed
to be outside the jurisdiction of the Court and unavailable and his signature has not been
able to be obtained for this pleading. The undersigned also understands that false
statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to
unworn falsification to authorities.
Dated:
„-
_ I
1 ?_,I J1 I ..?
PERINI SERVICES/ SOUTH
HAMPTON MANOR, L.P.,
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 08-6928 CIVIL TERM
IN RE: PETITION TO OPEN DEFAULT JUDGMENT
PURSUANT TO PA. R.C.P. 237.3 AND
LEAVE TO FILE ANSWER
ORDER OF COURT
AND NOW, this 2°d day of July, 2009, upon consideration of Defendant's Petition
To Open Default Judgment Pursuant to Pa. R.C.P. 237.3 and Leave To File Answer, it is
ordered that:
1. A Rule is issued upon Plaintiff to show cause why Defendant is not entitled to
the relief requested;
2. Plaintiff shall file an answer to the motion within 21 days of the date of this
order;
3. The petition shall be decided under Pa. R.C.P. 206.7;
4. Depositions shall be completed within 49 days of the date of this order;
5. Argument shall be held on Wednesday, September 16, 2009, at 11:15 a.m., in
Courtroom No. 1, Cumberland County Courthouse, Carlisle, Pennsylvania.
6. Briefs shall be submitted at least seven days prior to argument.
BY THE COURT,
,/llavid A. Baric, Esq.
19 West South Street
Carlisle, PA 17013
Attorney for Plaintiff
Jeffrey S. Evans, Esq.
2025 East Main Street
Waynesboro, PA 17268-1882
Attorney for Defendant
:rc
7/a/o9
FILL t IRIR 'k
OF THE P :'7"?a_ N? O)TAPY
2409 JUL -2 Pfd 12: 0 5
r, ,
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2008-06928 P Amended
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
PERINI SERVICES/SOUTH HAMPTON
VS
MOSER ERMA A ET AL
R. Thomas Kline Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT to wit:
GROVE DONALD
but was unable to locate Him in his bailiwick. He therefore
deputized the sheriff of FRANKLIN County, Pennsylvania, to
serve the within COMPT,ATNT F, T\Tn,rTr''V
On July 6th , 2009 , this office was in receipt of the
attached return from FRANKLIN
Sheriff's Costs: So a
Docketing .00
Out of County .00
Surcharge .00 mas Kl'
.00 She
.00
.00
07/06/2009
O'BRIEN, BARIC & SCHERER
Sworn and subscribe to before me
this day of
A. D.
ine
ff of Cumberland County
n ?
7 C= -rt
7- i
C-
FT,
1 '20
t '
? w
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/,
SOUTH HAMPTON MANOR, L.P.
Plaintiff
ERMA A. MOSER and
DONALD GROVE
Defendants
Civil Action - Law
NO. 2008 - 6928 CIVIL TERM
ORDER OF COURT
AND NOW, this day of , 2009, upon consent of the
parties, through their respective attorneys, IT IS HEREBY ORDERED THAT:
1. The default judgment entered in favor of Plaintiff and against Defendant
Donald Grove on or about June 10, 2009 is hereby opened and Defendant Donald Grove
is granted leave to file the Answer with New Matter attached to his Petition to Open
Default Judgment; and
2. Defendant Donald Grove shall file said Answer with New Matter with the
Prothonotary within ten (10) days of the date of this Order; and
3. The default judgment entered in favor of Plaintiff and against co-
Defendant Erma A. Moser, shall remain in full force and effect.
By the Court,
J.
.' t
CONSENT OF COUNSEL FOR PARTIES
Undersigned counsel for Plaintiff and Defendant Donald Grove, have reviewed
the attached Order and request that the Court nter same obviating the ne or further
proceedings on Defendant Donald Grove's Peti to Open De ult Ju nt.
Date: a7 ?0 ? c .
David A. Baric, Esquire
Attorney for Plaintiff
Date:
Y Je an squire
Att rn or efendant Donald Grove
t,A IA s d itiT7Vl11AR
2909 SEP 10 PIS 3: 48
CUMBEHLA', tD OUN7Y
PFNNSYLVM41A
r-.
SEP 1 12009 1
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/, Civil Action - Law
SOUTH HAMPTON MANOR, L.P.
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE : .
Defendants
ORDER OF COURT
AND NOW, this 1-? day of , 2009, upon consent of the
- 5,,n A -
parties, through their respective attorneys, IT IS HEREBY ORDERED THAT:
1. The default judgment entered in favor of Plaintiff and against Defendant
Donald Grove on or about June 10, 2009 is hereby opened and Defendant Donald Grove
is granted leave to file the Answer with New Matter attached to his Petition to Open
Default Judgment; and
2. Defendant Donald Grove shall file said Answer with New Matter with the
Prothonotary within ten (10) days of the date of this Order; and
3. The default judgment entered in favor of Plaintiff and against co-
Defendant Erma A. Moser, shall remain in full force and effect.
D- +I,- r,,,,,-+
OF THE
2009 SEP 15 AH I I : 3
CUt LL t,
FE°I.fi
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/, Civil Action -Law
SOUTH HAMPTON MANOR, L.P.
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE
Defendants
NOTICE TO PLEAD
To: Perini Services/, South Hampton Manor, L.P., Plaintiff
You are hereby notified to file a written response to the Defendants' Answer and New Matter
within twenty (20) days from service hereof or judgment may be entered against you.
By:_
Jeffrf
2025 EasT-Main Street
Waynesboro, PA 17268
(717)762-1415
Pa. Atty. ID No. 55654
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/, Civil Action -Law
SOUTH HAMPTON MANOR, L.P.
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE
Defendants
ANSWER WITH NEW MATTER
Now comes the Defendant, Donald Grove, by and through his attorney Jeffrey S.
Evans, Esquire, and answers the Complaint of Plaintiff as follows:
1. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
2. Admitted.
3. Admitted.
4. Admitted.
5. Denied. To the contrary Defendant Erma A. Moser sought admission to
Plaintiff's facility with the aid of Defendant, Donald Grove, her son.
6. Denied. To the contrary, Defendant Donald Grove was advised to sign by
members of Plaintiff's staff as Defendant Erma A. Moser's "legal representative" despite
being made aware he was not in fact her power of attorney or designated agent.
7. Admitted.
8. Admitted.
9. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
10. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
11. Denied. To the contrary, her benefits are direct deposited into her account
at Hagerstown Trust.
COUNT I - BREACH OF CONTRACT
Shippensburg Health v. Erma A. Moser and Donald Grove
12. Defendant hereby incorporates the averments of Paragraphs 1 through 11
of this Answer as if set forth at length.
13. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
14. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
15. Denied. To the contrary Defendant, Donald Grove has not received
benefits in the name of Erma A. Moser and is under no obligation to pay her obligations
under the Admission Agreement.
16. Denied. To the contrary, Defendant was not given the opportunity to
review the Admissions Agreement and did not realize that he was to be made personally
responsible for the payment of any charge accrued as a result of the Erma A. Moser's
residence at Plaintiff's facility.
17. Admitted in part, denied in part. It is admitted that the Admission
Agreement provides for the recovery of a penalty for late payments in the amount of
1.5% per month. It is denied that as of October the finance charges amounted to
$3,529.44 and continue to accrue. To the contrary, Defendant is without sufficient
knowledge or information to form a belief as to the truth of the averments of this
paragraph and therefore same are denied and proof thereof is demanded at trial.
18. Admitted.
COUNT II - MONEY HAD AND RECEIVED
Shippensburg Health v. Donald Grove
19. Defendant hereby incorporates the averments of Paragraphs 1 through 18
of this Answer as if set forth at length.
20. Denied. To the contrary, said amounts have been direct deposited to Erma
A. Moser's account at Hagerstown Trust.
21. Denied. Defendant is without sufficient knowledge or information to form
a belief as to the truth of the averments of this paragraph and therefore same are denied
and proof thereof is demanded at trial.
22. Denied. To the contrary, suspected that insurance was covering her stay.
23. Denied. To the contrary the averments of Paragraph 20 are incorporated
herein by reference as if set forth at length. By way of further answer, Defendant has
provided care for Defendant on numerous occasions over the years for which he has
never expected compensation.
24. Denied. To the contrary Defendant, Donald Grove had previously
provided insurance information and is willing to turn over to Plaintiff any amount he has
that belongs to his mother, Defendant Erma A. Moser.
COUNT III - QUANTUM MERUIT
Shippensburg Health v. Erma A Moser
25 - 28. No response is required in that Plaintiff's claim does not involve
Defendant, Donald Grove.
NEW MATTER
29. At the time of the signing of the Admission Agreement and immediately
prior thereto, Defendant Donald Grove advised representatives of Plaintiff that he was
not Defendant Erma A. Moser's designated power of attorney.
30. Defendant Donald Grove signed the Admission Agreement, at the
insistence of Plaintiff's representatives without the opportunity to review the agreement
or consult counsel for review. Further they insisted that he sign as "legal representative"
of Defendant Erma A. Moser, without explaining the significance of such a designation
nor that he could not appoint himself as such.
31. Defendant Donald Grove believed and therefore avers that the care
Plaintiff would provide Defendant Erma A. Moser would be paid for by her health
insurance carrier.
WHEREFORE, Defendant respectfully requests that this Honorable Court enter
judgment in favor of Defendant, Donald Grove on Counts I and II of Plaintiff's
Complaint.
Respectfully submitted,
Waynesboro, PA 17268
(717)762-1415
PA Atty. ID No. 55654
VERIFICATION
I verify that the statements in this document are true and correct to the best of my knowledge,
information and belief, and I understand that false statements herein are made subject to the penalties
of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities.
Dated: 4 ( 'Z2 I O?
Donald Grove, Plaintiff
200;9 SEP 16 Pl E 1: . l
cUPy?'1: -Illy
1,;
Y".?v1 va 1 L 'r"u wlA
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA - CIVIL ACTION EQUITY
PERINI SERVICES/, Civil Action -Law
SOUTH HAMPTON MANOR, L.P. :
Plaintiff
NO. 2008 - 6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE Judge
Defendants
AFFIDAVIT OF SERVICE
STATE OF PENNSYLVANIA
COUNTY OF FRANKLIN
Personally appeared before me, a Notary Public, in and for said State and County, Jeffrey S.
Evans, Esquire, who, being duly sworn according to law, deposes and says that on September 17,
2009, he did serve a Notice to Plead an Answer to New Matter, dated September 16, 2009, on
Attorney David A. Baric, by faxing and mailing a true and attested copy of the same to him, at his
address, 19 West South Street, Carlisle, Pennsylvania 17013, by regular first-class mail postage
prepaid at the post office in Waynesboro, Pennsylvania.
By
Jeffrey v Es re
Atto n nt
Sworn to and subscribed to before
me this % V""-day of 2009.
Notary Public
NOTARIAL SEAL
DAWN E. MONK NOTARY PUBLIC
WASHINGTON TOWNSHIP, FRANKLIN COUNTY
MY COMMISSION EXPIRES JUNE 5, 2011
^t_FILEr.,-t'? ,ACC [
2009 SEP 21 PH 12:1 3
cul
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
REPLY TO NEW MATTER
29. Denied. To the contrary, Donald Grove did not make such representations to
Plaintiff.
30. Denied. To the contrary, Donald Grove had an opportunity to review the
agreement and to review the document with counsel of his choosing. Moreover, Plaintiff
discussed the obligations of Donald Grove pursuant to the Admission Agreement at the time of
his execution of the document.
31. After reasonable investigation, plaintiff is without knowledge or information
sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
WHEREFORE, Plaintiff requests judgment be entered in its favor in accordance with the
averments of the Complaint.
Respectfully submitted,
O' , BA.RIC S
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.dir/shcc/moser/newmatter.rep
VERIFICATION
I verify that the statements made in the foregoing Reply To New Matter are true and
correct to the best of my knowledge, information and belief. This verification is signed by David
A. Baric, Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff,
as well as documents reviewed by the undersigned as attorney for Plaintiff. This verification will
be substituted and ratified by a verification signed by the Plaintiff who is presently unavailable to
sign said verification. I undersigned that false statements herein are made subject to penalties of
18 Pa.C.S. §4904, relating to unworn falsifica ' ns to authorities.
David A. Baric, Esquire
Dated: September 23, 2009
CERTIFICATE OF SERVICE
I hereby certify that on September A , 2009, I, David A. Baric, Esquire of O'Brien,
Baric & Scherer, did serve a copy of the Reply To New Matter, by first class U.S. mail, postage
prepaid, to the party listed below, as follows:
Jeffrey S. Evans, Esquire
2025 East Main Street
Waynesboro, Pennsylvania 17268
David A. Baric, Esquire
FILED-
OF THE RR? - F CINIO TARY
2009 SEA' 29 P: 22
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
ERMA A. MOSER and
DONALD GROVE,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
PRAECIPE TO ATTACH SUBSTITUTE VERIFICATION
Please attach the following Substitute Verification to the Reply To New Matter filed in
this matter on September 29, 2009.
Respectfully submitted,
O'BRIEN, BARIC & S RER
David A. Baric, Esquire
Date: September 30, 2009 I.D. #44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
09/24/2009 10:54 7172495755 OBS PAGE 02
R
y CK,ION
I, Deb Black, verify that the statements made in the foregoing Reply To New Matter are true
and correct to the best of my knowledge, information and belief.
I hereby ratify the verification previously supplied by my attorney, David A. Baric, Esquire
and execute this verification as a substituted verification.
I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.
§4944 relating to unworn falsifications to authorities.
DE-
fate: 9
Deb Black
Business Office Coordinator
CERTIFICATE OF SERVICE
I hereby certify that on October 1, 2009, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of a Praecipe To Attach Substitute Verification, by first class U.S. mail,
postage prepaid, to the party listed below, as follows:
Jeffrey S. Evans, Esquire
2025 East Main Street
Waynesboro, Pennsylvania 17268
David A. Baric, Esquire
RLO-OFFICE
OF THE PRIOD4MURY
2009 OCT -I PM 3= 09
3.,..5UNIN
YENNSYLVmm
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2008-6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE, ri
Defendants C_
1
PRAECIPE TO DISCONTINUE
TO THE PROTHONOTARY: -
Kindly mark the above-captioned action as having been settled and discontinued without
prejudice.
Date: February 18, 2010
Respectfully submitted,
BARIC SCHERER
AA?' z( I I
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, PA 17013
(717) 249-6873
Attorney for Plaintiff
r
CERTIFICATE OF SERVICE
I hereby certify that on February 18, 2010, I, David A. Baric, Esquire of Baric Scherer, did
serve a copy of a Praecipe To Discontinue, by first class U.S. mail, postage prepaid, to the party
listed below, as follows:
Jeffrey S. Evans, Esquire
2025 East Main Street
Waynesboro, Pennsylvania 17268
David A. Baric, Esquire
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2008-6928 CIVIL TERM
ERMA A. MOSER and
DONALD GROVE,
Defendants
ca Qz)
PRAECIPE TO SATISFY JUDGMENT T7. `' ''7
C? i77'7`t
TO THE PROTHONOTARY:
Kindly mark the judgment entered in the above-captioned matter on June 14 2009 is
satisfied. - `'
co r
Respectfully submitted,
C SCHE R
David A. Baric, Esquire
I.D. # 44853
Date: February 18, 2010 19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
/A7/7
I?(x7* d ?77-77
CERTIFICATE OF SERVICE
I hereby certify that on February 18, 2010, I, David A. Baric, Esquire of Baric Scherer, did
serve a copy of the Praecipe To Satisfy Judgment, by first class U.S. mail, postage prepaid, to the
party listed below, as follows:
Jeffrey S. Evans, Esquire
2025 East Main Street
Waynesboro, Pennsylvania 17268
David A. Baric, Esquire