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HomeMy WebLinkAbout08-7098• s IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. ROBERT MUSGRAVE, Defendant. No. 0$ - qo% 1Vi i )eXTA CIVIL ACTION - LAW NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 (800) 990-9108 ORIGINAL f IN THE COURT OP ?6MMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, No. V. ROBERT MUSGRAVE, Defendant. CIVIL ACTION - LAW AVISO PARA DEFENDER Conforme a PA RCP Ndm.1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel6fono: (717) 249-3166 (800) 990-9108 I IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. ?-?`-? 1 r? Plaintiff, No. ©F- l o 9i- v. : ROBERT MUSGRAVE, Defendant. CIVIL ACTION - LAW COMPLAINT AND NOW COMES, Church of God Home, Inc. ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following complaint against Robert Musgrave ("Defendant"), and in support thereof, states: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant is an adult individual who currently is a resident at Plaintiff's assisted living facility, located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 3. On or about November 15, 2007, Plaintiff and the Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant with skilled nursing services in exchange for Defendant's promise to pay, inter alia, a specific monetary fee. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 4. Defendant currently owes the Plaintiff $31,329.96, plus costs, interest and attorney's fees, for the care provided to him, and that amount will continue to accrue on a daily basis as long as he remains in Plaintiff's facility. COUNT I - BREACH OF CONTRACT 5. Paragraphs 1 through 4 above are incorporated by reference as though restated in full. 6. At all times material hereto, Plaintiff has been entitled to compensation for the care and services rendered to Defendant, pursuant the terms of the Agreement entered into with Plaintiff. 7. Defendant has breached his contractual obligations by failing to pay Plaintiff for services rendered. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant in the amount of $31,329.96 plus costs, interest and attorney's fees. Dated: I 1 lag 10'? By: Respectfully submitted, SCHUTJER BOGAR LLC Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Anthony T. Lucido Attorney I.D. No. 76583 (717) 909-0353 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff Rx Cze/T'.me NCV-25-2008(TUE) 1d,04 25d1125 11/25/2008 14:24 2541125 CHURCH OF GOD HO - LUWW?IUC? ic::)r 3 CAY'M P. 007 PAGE 07/07 P. OOT/007 The undersigned hereby v9dhes that the statements of fact in the foregoing document are true and correct to the best of my knowledge, information and belief. I unde?ttand that any false statements therein am subject to the penalties contained in 18 Fa. C S. § 4904, relating to unsworn ( cation to authorities. Dated:./ 1-65-c8 ..C Sharon C=mer, Business office Manager Church of God Home, Tnc. ¦ CHURCH OF GOD HOME, INC. ASSISTED LIVING ADMISSION AGREEMENT THIS AGREEMENT made this day of A?gML _, 20ni by and between Church of od Home, nc., a Pennsyl ania non-profit corporation, (called "Facility") and -S [NAME OF RES (calle esident") and INAME OF NS1BL? P SO OR GUARANTOR), if any, of JADDRESSJ, Resident's legal representative and/or the individual who has lawful access to Resident's income and financial resources available to pay for personal care services (called "Responsible Person" or "Guarantor"). The Responsible Person is liable-only up to the amount of the Resident's financial resources. The Guarantor is personally liable for all of the financial obligations of the Resident under this Agreement. The Facility utilizes the terms "personal care" and "assisted living" interchangeably so any reference to "assisted living" has the same meaning as "personal care" and visa versa. Resident has the right to identify a Designated Person who shall be entitled to receive notice in the event of an emergency, termination of service, personal care home closure or other situations as indicated by Resident or as required by law. Resident is not required t ame a Designated erson. Resident elects to name "If A as the Designated Perso M.he Designated Person may also be the Responsible Person or Guarantor if Resident so chooses. Resident, having applied for admission, and, if applicable, Responsible Person or Guarantor, if any, affirm that the information, including all financial information, provided in the Admission Application is true and correct, and acknowledge that the submission of any false information may constitute grounds to terminate this Agreement. Therefore, Facility, Resident, and if applicable, Designated Person and/or Responsible Person or Guarantor, if any, agree to the following terms and conditions: 108664 34 ;i) 2(X)? LATS11A DAVIS MIE & WKENNA. P.C. 1. PROVISION OF SERVICES. M. Basic Services. Facility will provide Resident with: (a) assistance with or supervision in activities of daily living and/or instrumental activities of daily living. The Fee Schedule identifies those activities of daily living and/or instrumental activities of daily living, which are available to Resident as Basic Services and which are included in the Daily Rate. The Fee Schedule is attached hereto as Attachment "A" and is s iect to change from time to time; (b) private semi-private accommodations; (c) blankets, pillows, bed linens, towels, wash cloths, and soap; (d) laundering of linens and towels; (e) three meals each day, except as otherwise medically indicated; (f) furnishings consisting of a bed, chair, storage area for clothing (i.e., chest of drawers and closet), bedside table/shelf, mirror and lamp. Resident, with the approval of Facility, may also supply his/her own furnishings; and (g) certain activity programs and social services. 1.2 Ancillary Services. Facility will provide ancillary services, at the option and upon the request of the Resident, in exchange for additional charges as those charges are reflected in the Fee Schedule attached to this Agreement and incorporated by reference. 1.3 Assisted Living Services Based on Outcome of Support Plan. Facility shall provide Resident with assistance with activities of daily living and/or instrumental activities of daily living consistent with Resident's Support Plan which shall be developed and implemented within thirty (30) days after admission as specified in Section 4.6 of this Agreement. The Support Plan shall be attached to this Agreement and may be subject to change from time to time. Some of the activities of daily living and/or instrumental activities of daily living specified in the Support Plan may not be included in the Daily Rate and Resident may be subject to an additional charge for such Ancillary Services as reflected on the Fee Schedule, which is attached hereto and may be amended from time to time by Facility. ? nxc?M 15 2005 LAT.SHA DAVIS Y01 II: K MicKENNA. P.C. 2. CHARGES. 2.1 Security Deposit. Prior to admission, Resident and/or the individual specified in Section 2.6 of this Agreement shall pay a security deposit in the amount of $,,? 77 Q, 00 [_ p ilfltials]. 2.2 Recurring/ Periodic Charges for Basic Services. Resident and/or the individual specified in Section 2.6 of this Agreement shall pay, in advance, in exchange for the Basic Services the Daily Rate in effect at the time the service is rendered as such rate is reflected on the Fee Schedule, which may be amended from time to time by Facility upon notice to Resident. the time of execution of this Agreement, the Daily Rate is VIV initials], which fee is subject to change from time to time. 2.3 Additional Charges for Ancillary Services and Supplies. Resident and/or the individual specified in Section 2.6 of this Agreement shall be responsible to pay for other services and supplies provided by or through Facility which are not covered by the Daily Rate. Resident and/or the individual specified in Section 2.6 of this Agreement shall pay in exchange for Ancillary Services or Supplies the charges in effect at the time such Ancillary Services or Supplies are rendered, as such charges are reflected on the Fee Schedule. Any items not identified on the Fee Schedule ordered by a physician will be provided at charges established by Facility. 2.4 Charges for Reserving Resident's Assisted Living Room. Resident and/or the individual specified in Section 2.6 of this Agreement shall pay the full Dailv Rate applicable at the time of Resident's absence for reserving Resident's assisted living room for any days or periods of hospitalization, transfer or any other absences from the Facility. Resident's room is automatically reserved unless Resident indicates in writing Resident's intent not to reserve the room. 2.5 Method of Payment for Charges for Long Distance Telephone Calls. Resident and/or the individual specified in Section 2.6 of this Agreement shall pad= the charge as assessed by Facility for all long distance telephone calls. The charges for long distance telephone calls will appear on the monthly statement provided to Resident by the Facility. 2.6 Party Responsible for Pay men. The following individual(s) are responsible for payment, and are requ to pay all applicable charges in accordance with this Agreement: X Resident initials]; Responsible Person initials]; __ Guarantor [ initials]. 109664 36 ', 2005 LAI:SI IA DAVIS YON: ,r MCKBNNA. P.C. 3. PERIODIC BILLINGS AND PAYMENT DUE DATE. 3.1 Monthly Statements and Other Billings. Resident and, if applicable, the Responsible Person and/or Guarantor will receive each month a billing statement reflecting ancillary charges for the previous month and the amount due for Basic Services one month in advance. All bills are due and payable upon receipt. 3.2 Modification of Charges. Facility reserves the right to change from time to time the amount of its charges as reflected in the Fee Schedule or how and when its charges are computed, billed or become due. Facility shall provide thirty (30) days advance written notice of any changes in its Daily Rate or any changes in the prices of Ancillary Services. 3.3 Late Charges and Cost of Collection. Any bills unpaid after the tenth (10111) day of the month of issue are subject to a late charge of one and one-half percent (1.5%) per month, and Resident, and if applicable, Responsible Person or Guarantor are obligated to pay any late charges. In the event Facility initiates any legal actions or proceedings to collect payments due from Resident under this Agreement, Resident, and if applicable, Responsible Person or Guarantor shall be responsible to pay all attorneys' fees and costs incurred by Facility in pursuing the enforcement of Resident's financial obligations under this Agreement. 3.4 Billing Information. Statements shall be sent to• - Q' Resident and/or Responsible Person or Guarantor agrees to notify the Facility within ten (10) days of any change in the billing address. 3.5 Obligations of Resident's Estate and Assignment of Property. Resident and, if applicable, Responsible Person or Guarantor acknowledge the charges for services provided under this Agreement remain due and payable until fully satisfied. In the event of Resident's discharge for any reason, including death, this Agreement shall operate as an assignment, transfer and conveyance to Facility of so much of Resident's property as is equal in value to the amount of any unpaid obligations under this Agreement. This assignment shall be an obligation of Resident's estate and may be enforced against Resident's estate. Resident's estate shall be liable to and shall pay to Facility an amount equivalent to any unpaid obligations of Resident under this Agreement. 4. STANDARDIZED SCREENING, ASSESSMENTS AND MEDICAL EVALUATION. 4.1 Pre-Admission Screening and Medical Evaluation. Admission to Facility is conditioned upon Resident completing to the satisfaction of Facility a pre- 1 UH661 37 i0 2005 L.ATSIIA DAVIS Y0111= A McKENNA. P.C. admission screening, including a mobility assessment, within thirty (30) days prior to admission, which indicates that the needs of Resident can be met by the services provided by Facility. Resident also shall have a medical evaluation and have a licensed physician, physician's assistant or certified registered nurse practitioner complete and sign an acceptable medical evaluation form within sixty (60) clays prior to or within thirty (30) clays after admission. 4.2 Initial Assessment. Resident shall have a written initial assessment, including a mobility assessment, completed by the Administrator or a designee of the Administrator or, subject to Facility approval, completed by a qualified human service agency within fifteen (15) days of admission. 4.3 Cost of Medical Evaluations. Resident is responsible for paying the cost of all medical evaluations and diagnostic tests whenever medical evaluations and diagnostic tests are required. 4.4 Purpose and When Required. The purpose of the screening process, initial assessment and medical evaluation is to provide basic information about the care needed by Resident. Additional assessments, including mobility assessments, are required: (a) annually; (b) if the condition of Resident significantly changes prior to the annual assessment; or (c) at the request of the Department of Public Welfare upon cause to believe that an update or revised assessment is needed. Resident shall have a medical evaluation: (a) annually; or (b) if the medical condition of Resident changes prior to the annual medical evaluation. 108hna 38 -C 2005 1ATSI IA DAVIS Y0I-I1: K McKENNA. P-C. di' ..a 4.5 Results of Screening and,,MC-,,digal Evaluation. In the event that a screening, assessment or medical evaluation indicates that Resident's care needs exceed the capabilities of Facility, Resident shall be transferred or discharged under the terms and conditions set forth in this Agreement. 4.6 Support Plan. Facility shall develop and implement a written Support Plan for Resident within thirty (30) days after admission to Facility. The Support Plan shall describe the care, service or treatment needs of Resident. Resident may participate in the development and implementation of Resident's Support Plan, and may include Resident's Designated Person, if any, in making decisions about the services to be provided to Resident. Resident's Support Plan shall be revised within thirty (30) days upon: (a) completion of the annual assessment; or (b) changes in Resident's needs as indicated on the current assessment. The Support Plan, upon initial completion and any subsequent revisions, shall be attached to this Agreement: The service needs addressed in the Support Plan shall be available to Resident every day during Resident's stay in Facility, unless the Support Plan provides otherwise. 4.7 Level of Care Transfer Determination. The level of care required for Resident is initially determined and periodically reevaluated by Facility. If it is determined by Facility that Resident, due to a change in Resident's condition, requires a higher level of care than Facility provides, Resident and, if applicable, the Designated Person agree to the transfer of Resident to an appropriate, higher level of care facility within Community or a Special Service Facility to meet Resident's care needs in accordance with the terms and conditions specified under Section 10.5 of this Agreement. 5. PERSONAL FUNDS. 5.1 Personal Needs Allowance. The Resident and/or Responsible Person or Guarantor agree(s) to provide such personal funds, clothing and effects as needed, required or desired by the Resident. Resident shall retain the minimum amount of Resident's own funds per month for personal expenditures as required by the Department of Public Welfare, which amount currently is sixty dollars ($60.00). If Responsible Person or Guarantor manages Resident's funds, then Responsible Person or Guarantor shall provide Resident with at least sixty dollars ($60.00) per month for personal expenditures. 108664 39 i' 200-1i_ATSIIA DAVIS YORE R McKENNA. RC 6. SSI PROVISIONS. The following restrictions apply in this Agreement for residents who receive or are eligible for SSI benefits: 6.1 Monthly Charges. SSI Residents shall be obligated to pay monthly charges, but shall not pay more than the SSI Resident's actual current monthly income reduced by a minimum personal needs allowance determined by the Department of Public Welfare. This provision shall not be construed to prohibit Facility from obtaining a third party guaranty for payment of the balance of the monthly charges above the Resident's allowable SSI amount. 6.2 Restrictions on Charges. If Resident is an SSI recipient or eligible for SSI benefits, the Resident shall receive the following items or services as needed: a. Necessary personal hygiene items, such as a comb, toothbrush, toothpaste, soap and shampoo. Cosmetic items are not included. b. Laundry services for personal laundry, bed linens and towels, but not including dry cleaning or other specialized services. C. Assisted living services such as assistance or supervision with dressing, bathing, hygiene, medication prescribed for self-administration, arrangements for special diets if dietary restrictions exist, and weekly housekeeping. 6.3 Restrictions on Supplemental Funds. If Resident is an SSI recipient or eligible for SSI benefits, payment for rent and other services shall not include funds received as lump sum awards, gifts or inheritances, gains from the sale of property or retroactive government benefits. Facility may seek and accept payments from funds received as retroactive awards of SSI benefits, but only to the extent that the retroactive awards cover periods of time during which Resident actually resided in Facility for which full payment has not been received. 7. OBLIGATIONS OF RESPONSIBLE PERSON/ GUARANTOR. 7.1. Non-SS] Recipients. (a) Responsible Person. Responsible Person may be required to enter into and sign a separate "Responsible Person Agreement" to evidence Responsible Person's financial obligations. When applicable, Responsible Person shall be responsible to pay from Resident's financial resources and shall be liable only up to the amount of Resident's resources. 108664 aU • 2005 LATS11A DAVIS voi ir._ s n CKENNA. P.C. (b) Guarantor. Guarantor may be required to enter into and sign a separate "Guaranty and Suretyship Agreement" to evidence Guarantor's financial obligations. When applicable, Guarantor shall be jointly and severally liable for all of Resident's financial obligations under this Agreement and shall guarantee payment in the event Resident does not pay Facility for all charges incurred under this Agreement within thirty (30) days of the payment clue date. 7.2 SSI Reci ients. If Resident enters into an agreement with Guarantor, and Resident enters Facility as an SSI recipient or becomes an SSI recipient during Resident's stay, then Guarantor shall be primarily liable for all unpaid charges incurred under this Agreement, except those charges associated with food, clothing and shelter. In such situations, Guarantor shall enter into and sign a separate "Third-Party Payment Agreement" to evidence Guarantor's financial obligations. 8. RENT REBATE BENEFITS. Resident may apply for any benefits to which Resident may be entitled under the Senior Citizens Rebate and Assistance Act. Facility may not seek or accept in excess of one-half of any rent rebate monies received by Resident under the Senior Citizens Rebate and Assistance Act. 9. FINANCIAL MANAGEMENT. 9.1 Authorization Requirements. Resident has the right to manage his or her own personal funds. Resident may deposit personal funds with Facility, and if Resident so elects, authorize Facility, in writing, to hold and manage Resident's personal funds so deposited. If Resident designates someone other than Facility to manage his or her personal funds, Resident or, if applicable, Designated Person and/or Responsible Person or Guarantor shall notify Facility promptly. Resident may revoke at any time the authorization for Facility to hold and manage his or her personal funds by providing Facility a written notice signed and dated by the Resident or, if applicable, the Designated Person and/or Responsible Person or Guarantor. 9.2 Facility Obligations. If assistance with financial management is offered by Facility and elected by Resident, Facility shall comply with the financial management policies established in the Assisted Living Handbook, which are subject to change from time to time. 109664 41 J F. AWi LATSI IA DAVIS YOHF & Mc'KI;NNA. P.C. 10. TERMINATION, TRANSFER. OR DISCHARGE. 10.1 Facility Initiated. Facility may terminate this Agreement and Resident's stay, and transfer or discharge Resident if: a. It is determined by Resident's physician or Facility's Administrator or a designee that Resident's functional level has advanced or declined so that Resident's needs cannot be met by Facility; or b. Resident is a danger to himself/herself or others; or c. If the Facility chooses to voluntarily close all or a portion of Facility; or d. Violation of Facility's rules, regulations, policies or procedures; or e. Resident has failed to pay after reasonable efforts by Facility to obtain payment; or f. Meeting Resident's needs would require a fundamental alteration in Facility's program or building site, or would create an undue financial or programmatic burden on Facility; or g. Closure of Facility is initiated by the Department of Public Welfare. 10.2 Notice. If Facility initiates a transfer or discharge of Resident, or Facility closes, thirty (30) days prior written notice, except as is provided in Section 10.3, shall be provided to Resident and/or Designated Person, if any, and the referral agency, if any, citing the reasons for the discharge or transfer. Facility will notify Resident and and/or Designated Person, if any, (or if none, a family member or legal representative of the Resident, if known to Facility) at least thirty (30) days in advance of transfer or discharge. 10.3 Waiver of Notice for Facility Initiated Discharge or Transfer. If a delay in discharge or transfer would jeopardize the health or safety of Resident or others in the Facility, as certified by a physician or the Department of Public Welfare, or both; the thirty (30) day notice period may be waived, and Facility shall give only such notice as is reasonable and practicable under the circumstances. 108664 42 i' 2{103 1 I 11A DAVIS Y011F R McKFNNA. P.C. 10.4 Facility Closure. In the event of a partial or complete closure, Facility shall submit to each affected resident at least thirty (30) days before closure, a written statement of the intent to close and the projected date. Copies shall be provided to the Department of Public Welfare; the Resident and his/her Designated Person, if any; any agencies which participated in referral of the Resident to the Facility; and any agencies currently providing services to the Resident. 10.5 Level of Care Transfer to a Nursing Facility. There is no guarantee or assurance that a nursing care bed in the Church of Goes Home's Nursing Facility will be available at such time as Resident may need to transfer to a nursing facility for the provision of a higher level of care than Facility, provides. In order to transfer to the Church of God Home's Nursing Facility, Resident must meet all the criteria for admission, including the financial requirements, and sign a separate admission agreement. In the event that there is no bed available in the nursing facility, or Resident fails to meet the requirements for admission to the nursing facility at such time as Resident needs to be transferred, Resident may be transferred to another nursing facility duly licensed to provide nursing care by the Pennsylvania Department of Health. The expense of such transfer and care, including the cost of transport service, shall be the obligation of the Resident. 10.6 Transfer to Hospital or Other Outside Facility. In the event of illness or deterioration in the physical or mental condition of Resident requiring a higher level of care than provided by Facility, Resident shall be transferred to an appropriate health care provider. The expense of such transfer and care, including the cost of transport service, shall be the obligation of Resident. 10.7 Documentation. The date and reason for the discharge or transfer, and the destination of the Resident, if known, shall be recorded in Resident's record. 10.8 Resident Initiated. Resident may terminate this Agreement upon thirty (30) days written notice to Facility. If Resident leaves Facility for any reason other than a medical emergency or death, Resident must give written notice to Facility at feast thirty (30) days in advance of transfer, discharge or termination of this Agreement. If Resident fails to give thirty (30) days advance written notice to terminate or Resident, after giving notice to terminate, leaves Facility before the expiration of the required thirty (30) day notice period, Resident shall remain responsible for payment of the Daily Rate and other charges then in effect for Resident's stay and care for the entire thirty (30) day notice period, whether or not Resident resided in Facility during that time. 10.9 Withdrawal Against Advice. In the event Resident withdraws from Facility without the consent of Facility and against the advice of his/her attending physician and/or the Medical Director, all of Facility's responsibilities for the care of Resident are terminated. 108661 43 0200 LA,rsi[A DAVIS YOFIE S McKFNNA. P.C. 11. DEATH OF RESIDENT. 11.1. Facility Responsibility. Facility assumes no responsibilities or obligations, which may arise upon the death of Resident except notice to Resident's proper representative. All funeral arrangements and expenses are the obligation of the Resident's Estate and/or those individuals responsible by law. Unless otherwise agreed, Facility will assume no responsibility for life insurance policies or benefits for any deceased resident. Resident's survivors shall be responsible for making application for survivor benefits. 11.2 Transfer. In the event of Resident's death, Facility is authorized to arrange for the transfer of Resident's body to the Funeral Home designated by Resident at the time of admission. Facility shall notify the person(s) designated by Resident in the event of Resident's death. Resident's Estate or those individuals obligated by law are responsible for the payment of all costs associated with the transfer and funeral. 108664 44 -0 2005 L.ATSHA DAVIS YOLIE R WKI NNA. P.C. 12. REFUNDS. 12.1 Refunds of Personal Funds. Any personal funds being managed or held by Facility on behalf of Resident will be refunded within two (2) business days from the date that Resident's room is cleared of Resident's property, subject to deductions for outstanding bills or other amounts due the Facility. In the event of Resident's death, the refund will be made to the duly authorized representative of Resident's Estate, to the Responsible Person or Guarantor designated under this Agreement, or to other persons entitled to property under current law. If Resident is permanently transferred to the Church of God Home's Nursing Facility, then Facility, upon the written request of Resident or, if applicable, upon the written request of the Designated Person, Responsible Person or Guarantor, if any, may continue to hold Resident's personal needs allowance or any funds held in a bank account as opposed to issuing a refund as previously specified under this Section. 12.2 Security Deposit and Advance Payments. The security deposit and any funds paid in advance for Basic Services, subject to deductions for payment of outstanding bills, costs incurred to restore or repair Resident's assisted living room or other amounts due the Facility, will be refunded to Resident within thirty (30) working days after the permanent transfer or discharge of Resident from the Facility, and termination of this Agreement. In the event of Resident's death, Facility shall refund to Resident's Estate or to such parties or persons entitled to the property under current law the security deposit and any unused portion of advance payments for Basic Services made by Resident or Responsible Person and held by Facility after deductions for payment of any outstanding bills, costs incurred to restore or repair Resident's room or other amounts due the Facility, within thirty (30) days from the date that Resident's personal property is removed from Resident's room. 13. FACILITY RULES, REGULATIONS, POLICIES, AND PROCEDURES. 13.1 Source of Rules. Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement, and Facility's rules, regulations, policies and procedures as published in the Assisted Living Handbook or other documents or publications made available by the Facility. Facility reserves the right to amend or change its rules, regulations, policies and procedures. A copy of the Assisted Living Handbook containing an explanation of Facility's rules, regulations, policies and procedures shall be provided to Resident upon admission. The Facility's rules, regulations, policies and procedures shall not be construed as imposing any contractual obligations on Facility or granting any contractual rights to Resident, and are subject to change from time to time. [08604 45 0 200a LAIS[ [A DAVIS Y01 IF R McKENNA. P.C. 13.2 Smoking. The Facility does not permit smoking inside the Facility; however, smoking is permitted outside but only in designated areas. 13.3 Pets. Pets are not permitted. 14. PERSONAL AND OTHER PROPERTY. 14.1 Responsibility for Maintenance and Loss. Resident is responsible for furnishing and maintaining his or her own clothing, jewelry and possessions and other items of property as needed or desired. Facility shall provide Resident with a lock box in which Resident can keep his/her cash or other personal valuables. Facility shall not be responsible for cash or other personal valuables, which are not kept in a lock box. Resident may obtain at his/her own expense, casualty insurance to cover potential damage to or loss of personal property. If damage or loss occurs to Resident's property, the Facility will investigate each incident of loss or damage to determine liability and assess responsibility depending on the facts and circumstances of each incident. The Facility shall be responsible for only such losses or damages as are attributed by the Facility to the negligence or fault of the Facility. 14.2 Dis osition and Storage Upon Resident's Death. Upon the Resident's death, Facility shall contact Resident's authorized representative within twenty-four (24) hours to arrange for an inventory of Resident's personal property. Facility is authorized to transfer Resident's personal property to a duly authorized representative of Resident's Estate or to such parties or persons entitled to the property under current law. The duly authorized representative of Resident's Estate or other persons entitled to property under current law must acknowledge, in writing, the receipt of the personal property transferred to his or her custody by Facility. After Resident's death, Facility may keep Resident's personal property in Resident's assisted living room for a period of time up to thirty (30) days or until the property is claimed by an authorized representative of Resident's Estate or any parties or persons entitled to the property under current law, whichever is sooner. The room rate may continue to be charged until all of the Resident's property is removed from the Resident's assisted living room. After completing an inventory, Facility, in its sole discretion, may move and place Resident's personal property into storage at Facility's expense. If property held in storage is not claimed within thirty (30) days, Facility shall send a notice to the authorized representative via certified mail that if items in storage are not removed within fourteen (14) days, Facility may dispose of Resident's property. 108664 -16 1` ?fHh LATSI IA DAVIS V0111: & McKL•NNA. P.C. 14.3 Disposition and Storage Upon Resident's Transfer or Discharge. If Resident's personal property is not claimed or removed within twenty-four (24) hours of Resident's permanent transfer or discharge, Facility shall move and place Resident's personal property in storage until claimed. In its sole discretion, Facility may permit a longer time for removal of Resident's possessions in exchange for payment at the Daily Pate. If Resident's personal property remains unclaimed for thirty (30) days after permanent transfer or discharge, Facility may dispose of Resident's property. Resident or Resident's Estate shall be obligated to pay all costs of storage or disposition and shall bear the risk of loss or damage to the property. Resident shall be obligated to pay a storage fee for each day of storage as reflected on the Fee Schedule. 14.4 Damage to Room or Facility Property. Resident or Resident's Estate is responsible for any damages caused to Facility property beyond normal wear and tear, and shall pay for the repair and replacement of damaged property, based on such reasonable charges as may be assessed by Facility for such repair or replacement. 15. RESIDENT RECORDS. Resident consents to the release of Resident's personal and medical records maintained by the Facility for treatment, payment and operations as determined reasonably necessary by the Facility. Any such release may be to the Facility's employees, agents and to other health care providers from whom the Resident receives services, to third-party payors of health care services, to any Managed Care Organization ("MCO") in which Resident may be enrolled, or to others deemed reasonably necessary by the Facility for purposes of treatment, payment and operations. Release of records for other purposes shall be done in accordance with applicable law, with a specific authorization from the Resident where required. Authorized agents of the state or federal government, including the Long Term Care Ombudsman, may obtain Resident's records without the written consent or authorization of Resident. 16. ASSISTED LIVING SERVICES AUTHORIZATION. Resident authorizes Facility to provide assisted living services consistent with the terms of this Agreement. 17. ADVANCE DIRECTIVES. If Resident has executed an advance directive in the form of a living will relating to the provision of health care services in the event of terminal or other illnesses or conditions, Resident shall provide a copy of the living will or advance directive to Facility, and a copy of any revisions or changes made to the document during Resident's stay at Facility. 108W 47 k'.-2005 LATSHA DAVIS YoHE K WKENNA. P.C. . - . 18. DURABLE FINANCIAL POWER-OF-ATTORNEY. Resident is strongly encouraged to furnish to Facility, no later than the date of admission, a durable Power-of-Attorney executed by Resident as Principal designating someone other than the Facility or a representative or affiliate of Facility as Agent, for the limited purpose of financial decisions and payment of services. In the event Resident fails to designate an Agent under a Power-of-Attorney, Resident, as specified in Section 19 of this Agreement, shall be responsible to pay for any guardianship proceedings related to the appointment of someone or a legal entity to make decisions on behalf of Resident, if and when Resident lacks capacity to make such decisions as determined by Facility. 19. CAPACITY OF RESIDENT AND GUARDIANSHIP. If Resident is or becomes unable to understand or communicate, and is determined prior to or after admission to be partially or completely incapacitated, then, in the absence of Resident's prior designation of an authorized legal representative, or upon the unwillingness or inability of the legal representative to act, Facility shall have the right to commence a legal proceeding to adjudicate Resident incapacitated and to have a court appoint a guardian for Resident. The cost of the legal proceedings, including attorneys' fees, shall be paid by Resident or Resident's Estate. 20. NOTICE. Wherever written notice is required to be given to Facility under this Agreement, it shall be sufficient if notice is provided by personally delivering it or by first-class mail, return receipt requested, addressed to: Church of God Home, Inc. 801 N. Hanover Street Carlisle, PA 17013 Notice to Resident will be provided by personal delivery to Resident's assisted living room, or where applicable, by first-class mail to Responsible Person or other Designated Person. (RESPONSIBLE PERSON/ DESIGNATED PERSON, if any) I IOXNA 48 t 2005 LATSIIA I)AVIS )'01 [E K McKENNA_ P.C. 21. INDEMNIFICATION. Resident shall indemnify and hold the Facility harmless from and against, and is responsible to pay for, any damages, including attorneys' fees and reasonable costs, including those incident to establishing the right to indemnification for injury to or death of any person or other resident, or for damage to or loss of the property of any person or resident caused by the acts or omissions of Resident, to the fullest extent permitted by law. 22. FACILITY'S GRIEVANCE PROCEDURE. 22.1 Reporting Complaints. If Resident or Designated Person, if any, believe(s) that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident or in any other way, Resident and/or Designated Person may file a complaint with Facility. Resident and/or Designated Person may also file a complaint with the Department of Public Welfare's personal care home regional office, local ombudsman or protective services unit in the area agency on aging, Pennsylvania Protection & Advocacy, Inc., or law enforcement agency. The procedure for filing a complaint with Facility or one of the aforementioned entities is described in the "Notice of Complaint Procedures", which is attached to this Agreement as Attachment "B". The complaint procedures described in Attachment "B" do not impose any contractual obligations on the Facility nor do they grant any private contractual rights to Resident. 22.2 Voluntary Mediation. Mediation is a form of alternative dispute resolution whereby an impartial person facilitates communication between the parties. The goal of mediation is to resolve the dispute promptly, amicably, and without incurring significant time and expense. Mediations are non-binding in nature. This Agreement provides for voluntary mediation whereby the parties may, upon mutual agreement, engage in mediation before resorting to arbitration. If the parties mutually agree to mediate any dispute that may arise between them, then the mediation will be conducted at a site selected by Facility, which shall be at Facility or at a site within a reasonable distance of Facility. The costs of the mediation shall be borne equally by each party, and each party shall be responsible for their own legal fees. If the parties are unable to resolve their dispute through mediation, then the dispute may only be resolved by arbitration as provided in this Agreement. If the parties do not mutually agree to mediate any dispute that may arise between them, then they may proceed directly to arbitration. 108664 49 C, 2(W LAI:SHA DAVIS YNIE K McKENNA. II.C. 22.3 Mandatory, Binding Arbitration. Arbitration is a specific process of dispute resolution utilized instead of the traditional state or federal court system. Instead of a judge and/or jury determining the outcome of a dispute, a neutral third party ("Arbitrator(s)") chosen by the parties to this Agreement renders the decision, which is binding on both parties. Generally an Arbitrator's decision is final and not open to appeal. The Arbitrator will hear both sides of the story and render a decision based on fairness, law, common sense and the rules established by the Arbitration Association selected by the parties. When Arbitration is mandatory, it is the only legal process available to the parties. Mandatory Arbitration has been selected with the goal of reducing the time, formalities and cost of utilizing the court system. (a) Contractual and/or Property Damage Disputes. Unless resolved or settled by mediation, any controversy, dispute, disagreement or claim of any kind or nature, arising from, or relating to this Agreement, or concerning any rights arising from or relating to an alleged breach of this Agreement, with the exception of (1) guardianship proceedings resulting from the alleged incapacity of the Resident, (2) collection actions initiated by the Facility for nonpayment of stay or failure of Responsible Person or Guarantor to fulfill their obligations under this Agreement, the Responsible Person Agreement, Guaranty and Suretyship Agreement or the Third- Party Payment Agreement, which results in a financial loss to the Facility; and (3) disputes involving amounts in controversy of less than Eight Thousand Dollars ($8,000), shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to resolve any disputes or claims that the Resident may have against the Facility. It also means that the Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to resolve any disputes or claims against the Facility. It also means that the Facility is giving up certain rights that it may have to a jury trial or to bring claims in a court against the Resident. Subject to the provisions of Section 22.3(f), the Arbitration shall be administered by ADR (Alternative Dispute Resolution) Options, Inc., in accordance with the ADP. Options Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor relinquish and give up their rights to a jury trial on any matter submitted to arbitration under this Agreement. t08h64 50 t, 2005 LATSI IA DAVIS Y01IE S McKENNA. P.C. 41 - 0 (b) Personal Injury or Medical Malpractice. Unless resolved or settled by mediation, any claim that the Resident may have against the Facility for any personal injuries sustained by the Resident arising from or relating to any alleged medical malpractice, inadequate care, or any other cause or reason while residing in the Facility, shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to bring any claims that the Resident may have against the Facility for personal injuries incurred while residing in the Facility. It also means that the Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to litigate any claims for damages or losses allegedly incurred as a result of personal injuries sustained while residing in the Facility. Subject to the provisions of Section 22.3(f), the Arbitration shall be administered by ADP. Options, Inc., in accordance with the ADR Options Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident, and if applicable, Designated Person and/or Responsible Person or Guarantor acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident, and if applicable, Designated Person and/or Responsible Person or Guarantor relinquish and give up the Resident's right to a jury trial on any claims for damages arising from personal injuries to the Resident which are submitted to arbitration under this Agreement. (c) Exclusion From Mandatory Arbitration. Those disputes which have been excluded from mandatory arbitration (i.e., guardianship proceedings, collection actions initiated by the Facility, and disputes involving amounts in controversy of less than $8,000) may be resolved through the use of the judicial system. In situations involving any of the matters excluded from mandatory arbitration, neither you nor the Facility are required to use the arbitration process. Any legal actions related to those matters may be filed and litigated in any court which may have jurisdiction over the dispute. (d) Right to Le al Counsel. Resident has the right to be represented by legal counsel in any proceedings initiated under this arbitration provision. Because this arbitration provision addresses important legal rights, the Facility encourages and recommends that Resident obtain the advice and assistance of legal counsel to review the legal significance of this mandatory arbitration provision prior to signing this Agreement. (e) Location of Arbitration. The Arbitration will be conducted at a site selected by the Facility, which shall be at the Facility or at a site within a reasonable distance of the Facility. 108664 c 2001 LATS11A DAVIS Y01IIi & MCKENNA. P.C. F - • (f) Time Limitation for Arbitration. Any request for arbitration of a dispute must be requested and submitted to ADR Options, Inc., with notice to the other party, prior to the lapse of t-vvo (2) years from the date on which the event giving rise to the dispute occurred. In the event ADR Options, Inc., is unable or unwilling to serve, then the request for Arbitration must be submitted to Facility within thirty (30) days of receipt of notice of ADR Options, Inc.'s, unwillingness or inability to serve as a neutral arbitrator. Facility shall select an alternative neutral arbitration service within thirty (30) days thereafter and the selected Arbitration Agency's procedural rules shall apply to the arbitration proceeding. The failure to submit a request for Arbitration to ADR Options, Inc., or an alternate neutral arbitration service selected by Facility, within the designated time (i.e., two (2) years) shall operate as a bar to any subsequent request for Arbitration, or for any claim for relief or a remedy, or to any action or legal proceeding of any kind or nature, and the parties will be forever barred from arbitrating or litigating a resolution to any such dispute. Contact information for ADR Options, Inc., is as follows: Two Commerce Square, Suite 1100 2001 Market Street Philadelphia, PA 19103-7044 Phone: (215) 564-1775 / (800) 364-6098 Fax: (215) 564-1822 Website: www,.adroptions.com (g) Limitation of Damages for Arbitration. The costs of the arbitration shall be borne equally by each party, and each party shall be responsible for their own legal fees. (h) Limited Resident Right to Rescind this Mandatory Arbitration Clause (Sections 22.3(a-h) of this Agreement). Resident or, in the event of Resident's incapacity, Resident's authorized representative have the right to rescind this arbitration clause by notifying the Facility in writing within thirty (30) days. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post-marked within 30 days of the execution of this Agreement. The notice may also be hand-delivered to the Administrator within the same 30-day period. The filing of a claim in a court of law within the 30 days provided for above will automatically rescind the arbitration clause without any further action by Resident or Resident's authorized representative. 23. MISCELLANEOUS PROVISIONS. 23.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. 108664 52 •A 2D05 I.A'rSHA DAVIS Y01 IF & MCKENNA. P.C a 46 23.2 Severability. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction and authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. 23.3 Entire Agreement. The Admission Agreement consists of this Agreement, the Admission Application and, if applicable, the Responsible Person Agreement, the Guaranty and Suretyship Agreement or the Third-Party Payment Agreement. This Admission Agreement represents the entire Agreement between the parties, and it supersedes, merges and replaces, all prior negotiations, offers, warranties and previous representations, understandings or agreements, oral or written, between the parties. 23.4 Modifications. Facility reserves the right from time to time to modify unilaterally the terms of this Agreement consistent with law. Facility also reserves the right to request a change in the terms of this Agreement. Facility will give Resident and Resident's Designated Person, if any, thirty (30) days advance written notice of any such modifications or any such proposed modifications. 23.5 Waiver of Provisions. Facility reserves the right to waive any obligation of Resident under the provisions of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by Facility unless such waiver is in writing by Facility. Any such waiver by Facility shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident under this Agreement shall remain in full force and effect. 23.6 Rescission Period. Resident or Designated Person has the right to rescind this Agreement for up to seventy-two (72) hours after the initial dated signature of this Agreement. Resident or Designated Person must notify Facility in writing of the decision to rescind this Agreement. The notice of the rescission must be received by Facility or be post-marked before the lapse of the seventy-two (72) hour rescission period. In the event Resident or Designated Person rescinds this Agreement, Resident shall pay only for services received. 24. ACKNOWLEDGMENTS. 24.1 Fee Schedule. Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor acknowledge(s) the receipt of a copy of the Fee Schedule and the opportunity to ask questions about Facility's charges. The Fee Schedule is attached to this Agreement and incorporated by reference. ) OHfiM 53 +:' 20OS LA'rsHA DAVIS Y01 IF & MCKENNA_ P.C. X , 4W 24.2 Resident Ri hts and Complaint Procedures. Resident and, if applicable, Designated Person acknowledge being informed orally and in writing of Resident's Rights and the right to lodge complaints without intimidation, retaliation or threats of retaliation of Facility or its staff persons against Resident and acknowledge having an opportunity to ask questions about those rights/ complaint procedures. Resident and, if applicable, Designated Person acknowledge receiving a copy of the "Notice of Resident Rights", which is attached to this Addendum as Attachment "C", and a copy of the "Notice of Complaint Procedures", which is attached to this Addendum as Attachment "B". The Resident Rights and Complaint Procedures described in each "Notice" are granted by regulation and are regulatory in nature and origin and they should not be construed as private contractual rights. The "Notice of Resident Rights" and the "Notice of Complaint Procedures" do not impose any contractual obligations on the Facility nor do they grant any private contractual rights to Resident. 24.3 Agreement. Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor acknowledge(s) that they have read and understand the terms of this Agreement, that the terms have been explained to them by a representative of Facility, and that they have had an opportunity to ask questions about this Agreement. A copy of the signed Agreement shall be provided to Resident and a copy shall be included in the Resident's record. 24.4 Assisted Living Handbook. Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor, if any, acknowledge(s) receipt of a copy of the Assisted Living Handbook and the opportunity to ask any questions about Facility's rules, regulations, policies, and procedures. The Facility's Assisted Living Handbook shall not be construed as imposing any contractual obligations on Facility, or granting any contractual rights to Resident, and is subject to change from time to time. 24.5 Personal Care Regulations. Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor, if any, acknowledge having been informed of the location of the Department of Public Welfare Personal Care Home Regulations posted in the Facility. t 08fi ,a 54 i'200 LATSI IA DAVIS YOIIE & McKENNA. RC. r . Y IN WITNESS WHEREOF, the parties, intending to be legally bound, have signed this Agreement on the date written below. ?/11 - & 7 es' ent Date fl-l5S-a7 I onsible erson, if any Date Guarantor, if any Date Designated Person, if any Date Church of God Home, Inc. By /-?=D? 7 Administr o or Designee Date 108664 55 (: 2005 LATSI1A DAVIS Y01 [E- & MIcKI NNA. P.C. n 4 0 " TI odb 7 C ---- .. f 0 SHERIFF'S RETURN - REGULAR CASE NO: 2008-07098 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CHURCH OF GOD HOME INC VS MUSGRAVE ROBERT KENNETH E GOSSERT , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon MUSGRAVE ROBERT the DEFENDANT , at 0015:15 HOURS, on the 17th day of December-, 2008 at 801 NORTH HANOVER STREET CARLISLE, PA 17013 by handing to ROBERT MUSGRAVE DEFENDANT a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 4.50 Affidavit .00 Surcharge 10.00 Postage 42 i 21240 k T". 32.92 Sworn and Subscibed to before me this day of , So Answers: R. Thomas Kline 12/18/2008 SCHUTJER BOGAR LLC By: A. D. T David 1D. Buell prothonotary 2UrkS. Sohonage, Soficitor &nee X Simpson 1S` Deputy prothonotary Irene E. Morrow 2nd Deputy prothonotary Office of the Prothonotary um6erlandCounty, Pennsylvania n98 CIVIL TERM np- 7 AND NOW ORDER OF TERMINATION OF COURT CASES IS 25TH DAY OF OCTOBER, 2011, AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE -THE ABOVE CASE IS HERE Y TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R.C.P 230.2 BY THE COURT, DAVID D. BUELL PROTHONOTARY One Courthouse Square • Su?te 100 • Carfsfe, pA 17013 9 (717 240-6195 0 Fax (717 240-6573