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HomeMy WebLinkAbout09-1159 Steven M. Montresor smontres@ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA UNITED CHURCH OF CHRIST HOMES, INC. d/b/a SARAH A. TODD MEMORIAL HOME 1000 West South Street Carlisle, PA 17013 ?Plaintiff, NO. ?• //.S?l!' L?G?' V. TRICIA ROBERTS 63 East North Street Carlisle, PA 17013 TERM, 2009 CIVIL ACTION - LAW AND EQUITY and FRANCES ROBERTS 65 East North Street Carlisle, PA 17013 Defendants. 128481 NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyers Reference Service Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (800) 990-9108 (717) 249-3166 128481 Steven M. Montresor smontres@ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA UNITED CHURCH OF CHRIST HOMES, INC. d/b/a SARAH A. TODD MEMORIAL HOME 1000 West South Street Carlisle, PA 17013 Plaintiff, NO. Q q- //SQ V. TRICIA ROBERTS 63 East North Street Carlisle, PA 17013 TERM, 2009 CIVIL ACTION - LAW AND EQUITY and FRANCES ROBERTS 65 East North Street Carlisle, PA 17013 Defendants. 128481 COMPLAINT AND NOW COMES, Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home, by and through its attorneys, Latsha Davis Yohe & McKenna, P.C., and files the within Complaint against Defendants, Tricia Roberts and Frances Roberts, and in support thereof, avers as follows: Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home (hereinafter "Sarah Todd"), is a Pennsylvania non-profit corporation with offices located at 30 North 31 st Street, Camp Hill, Pennsylvania 17011. 2. Sarah Todd owns and operates a long-term care skilled nursing facility located at 1000 West South Street, Carlisle, Pennsylvania 17013. Sarah Todd provides living accommodations and skilled nursing care (hereinafter "Nursing Care Services"). 4. Defendant Tricia Roberts is an adult individual currently residing at 63 East North Street, Carlisle, Pennsylvania 17013. Defendant Frances Roberts is an adult individual currently residing at 65 East North Street, Carlisle, Pennsylvania 17013. 6. Tricia Roberts' mother, Frances Roberts, is a former resident of Sarah Todd. 7. Frances Roberts appointed Tricia Roberts as her Agent pursuant to a Durable General Power of Attorney dated March 27, 2008. A true and correct copy of the Power of Attorney is attached hereto as Exhibit "A" and made a part hereof. 8. Frances Roberts was admitted to Sarah Todd on or about May 29, 2008. 9. On or about May 29, 2008, Sarah Todd and Tricia Roberts, on behalf of Frances Roberts, entered into a Nursing Home Admission Agreement (hereinafter "Admission 128481 2 Agreement"), whereby Sarah Todd agreed to provide Frances Roberts with Nursing Care Services. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and made a part hereof. 10. Tricia Roberts is designated as "Responsible Person" under the Admission Agreement. 11. On or about May 29, 2008, Sarah Todd and Tricia Roberts, as Frances Roberts' Responsible Person, entered into a Responsible Person Agreement. A true and correct copy of the Responsible Person Agreement is attached hereto as Exhibit "C" and made a part hereof. 12. On or about July 24, 2008, Sarah Todd submitted a Medical Assistance application to the Cumberland County Assistance Office ("CAO") on behalf of Frances Roberts. 13. On August 22, 2008, Tricia Roberts, as Agent for her mother, sold Frances Roberts' property located at 67 East North Street, Carlisle, Pennsylvania 17013, which property has an assessed total value of $67,480.00, to a Gary Leach for $45,000.00. 14. The CAO denied the Medical Assistance application on September 3, 2008 due to Tricia Roberts' failure to provide certain documentation requested by the CAO. A true and correct copy of the "Medicaid Not Eligible Notice" is attached hereto as Exhibit "D" and made a part hereof. 15. The documentation requested by the CAO included: a. Verification of the disposition of the funds received from the sale of Frances Roberts' home on August 22, 2008; b. Verification that Frances Roberts' available resources were below the $8,000 limit; and 128481 Verification of the cash value of a certain annuity or statement of irrevocability from the annuity company. 16. On or about November 12, 2008, Sarah Todd submitted a second Medical Assistance application to the CAO on behalf of Frances Roberts. 17. The CAO denied the second Medical Assistance application on December 30, 2008, due to Tricia Roberts' failure to provide certain documentation requested by the CAO. A true and correct copy of the "Medicaid Not Eligible Notice" is attached hereto as Exhibit "E" and made a part hereof. 18. The documentation requested by the CAO included: a. Verification of statements for all of Frances Roberts' bank accounts, annuities, Keoghs, IRAs, stocks and bonds as of August 1, 2008; b. Verification of the proceeds received in the sale of Frances Roberts' home, disposition of funds received after the sale of the home; Verification of all resources of Frances Roberts sold, transferred or given away in the past 36 months; and d. Verification of why Frances Roberts received $45,000 for her home that was listed as having a fair market value of $57,000. 19. Tricia Roberts, as Frances Roberts' Agent and Responsible Person, had both a fiduciary and a contractual duty to use Frances Roberts' assets and/or resources to compensate Sarah Todd for the Nursing Care Services which it provided to Frances Roberts and to keep her account current. 20. At all times relevant, Sarah Todd provided Nursing Care Services to Frances Roberts in accordance with the Admission Agreement. 128481 4 21. Tricia Roberts has failed to use Frances Roberts' assets and/or resources to pay Sarah Todd for the Nursing Care Services which Frances Roberts received at Sarah Todd. 22. Frances Roberts was discharged from Sarah Todd on November 8, 2008. 23. A balance in the amount of $30,796.69, plus interest is currently due and owing to Sarah Todd for the Nursing Care Services that it provided to Frances Roberts. A true and correct copy of the A/R Account Detail is attached hereto as Exhibit "F" and made a part hereof. COUNT I - BREACH OF CONTRACT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts and Frances Roberts 24. Paragraphs 1 through 23 above are incorporated herein by reference as if fully set forth at length. 25. Tricia Roberts, as Frances Roberts' Responsible Person, entered into the Responsible Person Agreement with Sarah Todd as more fully set forth above. See Exhibit "C". 26. The Responsible Person Agreement obligates Tricia Roberts to provide payment from Frances Roberts' income and resources and to apply Frances Roberts' income and resources to the costs and charges incurred during her stay. 27. From May 29, 2008 through November 8, 2008, Sarah Todd provided Nursing Care Services to Frances Roberts pursuant to the aforementioned Admission Agreement. 28. Frances Roberts had a contractual obligation to make payments to Sarah Todd. 29. Tricia Roberts had a contractual obligation, as Frances Roberts' Responsible Person, to make payments on Frances Roberts' account from Frances Roberts' assets and/or resources. 128481 30. Frances Roberts has an overdue balance in her account with Sarah Todd, which is currently in the amount of $30,796.69, plus interest. 31. The failure of Frances Roberts to pay the outstanding balance on her account with Sarah Todd constitutes a breach of the Admission Agreement. 32. The failure of Tricia Roberts to pay the outstanding balance on Frances Roberts' account with Sarah Todd constitutes a breach of the Responsible Person Agreement. 33. According to Section 3.2 of the Admission Agreement, Sarah Todd may recover attorney's fees and costs of collection, which total $2,605.50 as of January 31, 2009. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $33,402.19 together with interest, attorney's fees and costs of collection. COUNT II - INJUNCTIVE RELIEF United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 34. Paragraphs 1 through 33 above are incorporated herein by reference as if fully set forth at length. 35. The Responsible Person Agreement obligates Tricia Roberts, as the Responsible Person, to take any and all actions necessary and appropriate to initiate, make and conclude an application for Medical Assistance benefits on Frances Roberts' behalf, "including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals." See Exhibit "C", ¶ 3. 36. Tricia Roberts did not comply with this contractual obligation. 128481 6 37. The failure of Tricia Roberts to comply with her contractual obligation to assist in the Medical Assistance application process constitutes a breach of the Responsible Person Agreement. 38. The breach of the Responsible Person Agreement resulted in the CAO denying Medical Assistance benefits. See Exhibits "D" and "E". 39. Sarah Todd has no other means of securing the documents necessary to be turned over to the CAO in order for it to make a determination on Frances Roberts' benefits. 40. As Agent and Responsible Person, Tricia Roberts is the only person with such access to Frances Roberts' documentation. WHEREFORE, Plaintiff requests that the Court enter an order compelling Tricia Roberts to take all steps necessary to turn over to the CAO any and all the information identified in the CAO's Medicaid Not Eligible Notice dated December 30, 2008. COUNT III - QUANTUM MERUIT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts and Frances Roberts 41. Paragraphs 1 through 40 above are incorporated herein by reference as if fully set forth at length. 42. Sarah Todd has demanded payment in full for the Nursing Care Services which it provided to Frances Roberts, and has not received payment for the same. 43. Sarah Todd is entitled to receive payment in full for the reasonable value of the Nursing Care Services it provided to Frances Roberts. 128481 7 44. Frances Roberts has been unjustly enriched and enhanced by the receipt of Nursing Care Services which have been rendered by Sarah Todd to her in the amount of $30,796.69 plus interest. 45. To the extent Tricia Roberts has retained Frances Roberts' assets and/or resources and has failed to pay for the care and services rendered by Sarah Todd to Frances Roberts, Tricia Roberts has been unjustly enriched. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $30,796.69, together with any other relief the Court deems just and equitable. COUNT IV - CONVERSION United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 46. Paragraphs 1 through 45 above are incorporated herein by reference as if fully set forth at length. 47. Upon information and belief, Tricia Roberts converted, misappropriated and deprived Frances Roberts of her right in, use and/or possession of her property as more fully set forth above. 48. To the extent Tricia Roberts' conversion, misappropriation and deprivation of Frances Roberts' right in, use and/or possession of the aforementioned property was for the purpose of hindering or delaying their transfer to Sarah Todd, these actions were beyond Tricia Roberts' authority as Frances Roberts' Agent. 49. As a result of the foregoing unlawful actions of Tricia Roberts, Sarah Todd has incurred damages in the amount of $30,796.69 plus interest. 128481 8 WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest. COUNT V - FRAUDULENT TRANSFER United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 50. Paragraphs 1 through 49 above are incorporated herein by reference as if fully set forth at length. 51. Upon information and belief, Tricia Roberts transferred Frances Roberts' assets and/or resources without receiving reasonably equivalent value and/or for the purpose of hindering and delaying their transfer to Sarah Todd. 52. Upon information and belief, Tricia Roberts accepted the transfer(s) of Frances Roberts' assets and/or resources with full knowledge that the transfer was not for reasonably equivalent value and/or that the purpose of the transfer was to avoid paying Sarah Todd for the Nursing Care Services that it has rendered to Frances Roberts. WHEREFORE, Plaintiff demands judgment in its favor. and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest. COUNT VI - FILIAL SUPPORT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 53. Paragraphs 1 through 52 above are incorporated herein by reference as if fully set forth at length. 128481 9 54. Upon information and belief, Tricia Roberts, as Frances Roberts' Agent, transferred Frances Roberts' assets to herself or otherwise misappropriated said assets. 55. Upon information and belief, the above-referenced transfer and/or misappropriation of assets rendered Frances Roberts indigent and unable to pay the outstanding balance owed on her account. 56. Tricia Roberts is Frances Roberts' daughter. 57. As a result of Tricia Roberts' transfer or misappropriation of her mother's assets, Tricia Roberts has the ability to satisfy her mother's debt to Sarah Todd. 58. Pursuant to 23 Pa.C.S. § 4603, Tricia Roberts has a statutory obligation to care for, maintain or financially assist her mother. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest, together with an Order directing Defendant, Tricia Roberts, to take all steps necessary to turn over to the CAO any and all the information identified in the CAD's Medicaid Not Eligible Notice dated December 30, 2008. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.C. Dated: ? .? By: Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home 128481 10 , ?, ?) --? /Ir -'r.:r-- NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA. C. S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. March 18, 2008 9\._ FRANCES R. ROBERTS DURAfU GE"MAL P0E11tof -A=Q l N ff KNOW ALL MEN BY THESE PRESENTS, that I, FRANCES R. ROBERTS, of Carlisle, Pennsylvania, do by these presents make, constitute and appoint STEPHANIE E. LEACH, and/ or TRICIA P. ROBERTS, jointly or independently (hereinafter referred to as "my agent"), my true and lawful agent under a power of attorney, for me and in my name and on my behalf generally, to do and perform all matters and things, including, without limiting the generality of the foregoing, to transact all business, to make, execute, acknowledge, endorse and deliver all deeds of conveyance, certificates of stock, bonds, car titles, releases of lien or satisfaction of bonds and mortgages, contracts, orders, releases, checks, notes and endorsements, transfers and assignments of any such contracts, specifically including but in no way limited to the execution in my name of checks or orders of any nature for the withdrawal of funds standing to my credit in any type of account in any bank, building and loan association or other financial institution, and also to deposit in any accounts in my name in any such institutions any money, funds, checks or drafts, payable or belonging to me; to enter my safe deposit boxes in any and all banking institutions and to establish new safe deposit boxes and to add to and to remove any of the contents thereof; to borrow money and to mortgage, pledge or hypothecate any property, real or personal, now or hereafter owned by me as security therefore; to buy, sell possess, insure, manage, maintain, improve, lease, mortgage, pledge, encumber, convey and otherwise dispose of, or take any other action with respect to, any property, real or personal, now or hereafter owned by me, on such terms and conditions as my agent may consider appropriate, and in the event of sale of any of my real estate, to execute the sales agreement and the deed in my name and to make settlement and receive the proceeds; and to prepare, execute and file any tax returns, governmental reports and other instruments of whatever kind, and likewise to execute any and all writings, assurances, instruments or documents which may be requisite or proper to effectuate any matter or thing appertaining or belonging to me. I hereby authorize my agent to contract with and arrange for my entrance to any hospital, nursing home, health center, convalescent home, residential care facility or similar institution, to authorize medical, therapeutic and surgical procedures for me and to pay all bills in connection therewith. GIVING AND GRANTING unto my agent full authority and power to do and perform any and all other acts necessary or incident to the performance and execution of the powers herein expressly granted, with power to do and perform all acts authorized hereby as fully to all intents and purposes and with the same validity as I might or could so if personally present, hereby ratifying and confirming whatsoever all that my agent shall lawfully do or cause to be done by virtue hereof. AND, I hereby declare that any act or thing lawfully done hereunder by my agent shall be binding on myself and my heirs, legal and personal representatives and assigns. AND, if incapacity proceedings for my estate or person are hereafter commenced. I hereby nominate my agent to be appointed the guardian of my estate or person by any court having jurisdiction in accordance with the provisions of Section 5604 (c ) (2) of the Probate, Estates and Fiduciaries Code. This Power of Attorney shall continue in force and may be accepted and relied upon by anyone or any entity to whom it is presented despite my purported revocation of it or my death, until actual written notice of any such event is received by such person or entity. In the event of my incapacity from whatever cause, this Power of Attorney shall not thereby be revoked but shall thereupon become irrevocable and may be accepted and relied upon by anyone or any entity to whom it is presented despite such incapacity, subject only to it becoming void and of no further effect only upon receipt by such person or entity either of (1) written evidence of the appointment of a guardian (or similar fiduciary) of my estate following adjudication of incapacity, or ' (2) written notice of my death. This Power of Attorney shall not be affected by my subsequent disability or incapacity. This power of attorney shall rescind and revoke any other powers of attorney previously made by me. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 18t?' day of March 2008. WITNESSED BY: delte ? NCES R. ROBERTS (SEAL) COMMONWEALTH OF PENNSYLVANIA : :SS: COUNTY OF CUMBERLAND On this, the 18TH day of March 2008, before me, the undersigned officer, personally appeared FRANCES R. ROBERTS, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that she executed same for the purposes therein contained. r COMMONWEALTH OF P24NSYL.VAIZA / NOTARIAL SEAL Harold S. Irwin 1u, Esq, Notary Public Carlisle, Cumberland County Notary Public My commission exlmes February 06, 2011 ACKNOWLEDO???rT g?? A6E T 1, STEPHANIE E. LEACH, and 1, TRICIA P. ROBERTS, have read the attached Power of Attorney executed by FRANCES R. ROBERTS and am the person identified as the Agent for the PRINCIPAL. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney or in 20 PA. C. S. when I act as Agent: I shall exercise the powers for the benefit of the PRINCIPAL. I shall keep the assets of the PRINCIPAL separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the PRINCIPAL. March 2008._.::_... STEPH NIE . LEACH March ?? . 2008 ?A'tt c'& ?1 'G TRICIA P. ROBERTS COMMONWEALTH OF PENNSYLVANIA : COUNTY OF CUMBERLAND :SS: On this, the z7 day of March 2008, before me, the undersi ned officer 9 ,personally appeared STEPHANIE E. LEACH and TRICIA P. ROBERTS, known to me or satisfactorily proven to be the persons whose names are subscribed to the within acknowledgment and acknowledged that they executed same for the purposes therein contained. WITNESS my hand and seal the day and year COMMONWEALTH OF PENNSYLVANIA v \-A NOTAIUALSEAL Notary Public Harold S. Irwin iii, Esq, Notary Public Carlisle, Caunbaland County MY Moission expires Febnw 06, 2011 x k?j-f B UNITED CHURCH OF CHRIST HOMES NURSING HOME ADMISSION AGREEMENT This Agreement is made by and between a Pennsylvania non-profit nursing home, (hereinafter called "Facility") and Resident and his/her legal representative and/or the individual who has access to Resident's income ' and financial resources available to pay for nursing care (hereinafter called "'Responsible for the provision of nursing services for Jqtscit") (hereinafter called "Resident"). Resident and Responsible Person affirm that the information provided in the Admission Application is true and correct to the best of their knowledge, and acknowledge that the submission of any false information may constitute grounds to terminate this Agreement. Therefore, the Facility, Resident and Responsible Person, intending to be legally bound, agree to the following terms and conditions: 1. PROVISION OF SERVICES. 1.1 Nursing Services. Beginning on the designated admission date, the Facility will provide Resident with (a) the routine nursing services described in the Schedule of Charges, attached to this Agreement and incorporated by reference; (b) private or semi-private accommodations, as applicable; (c) three meals each day, except as otherwise medically indicated; (d) blankets, bed linens, towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services; and (g) activity programs and social services as established by the Facility. 1.2 Acillarv Services and Supplies. The Facility will provide ancillary services and supplies as identified on the Schedule of Charges, and such other ancillary services and supplies at the option and upon the request of the Resident, or upon the direction of Resident's treating physician or the Facility's Medical Director. The ancillary services and supplies identified on the Schedule of Charges are subject to change from time to time at the discretion of the Facility. 1.3 Services of Other Providers. The services of outside providers such as a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, rehabilitation therapies and diagnostic services, laboratory, x-ray, podiatry, optometry, medications, ambulance services and hearing aid repair are available from time to time at the Facility. These services are available under guidelines and procedures established by the Facility and may be utilized by Resident at his or her own expense. 1723 Nursing Agreement 12-15-04; 5-06 1.4 Role of Ajkgn? Mikan- and Medical Director. The Resident shall select a qualified physician, from a list of Facility credentialed physicians, who will provide medical care during the Resident's stay at the Facility and who shall comply with the Facility's rules, regulations, policies and procedures. The Facility is not permitted to provide Resident with any medicines, treatments, special diets or equipmert without specific orders or directions from Resident's attending physician. In the event Resident's personal physician is unavailable, the Facility's Medical Director may issue appropriate orders. Resident is responsible to pay for all services or equipment ordered by Resident's attending physician or the Facility's Medical Director for Resident's care. 2. CHARGES. 2.1 Recurringn'eriodic Char es for Routi a Nursaxi ; Services. Resident shall pay the Daily Routine Service Charge, specified in the Schedule of Charges in effect at the time the service is rendered, for routine nursing services provided to Resident. The Daily Routine Service Charge may be changed from time-to- time in accordance with the provisions of Section 3.3. Charges for a resident whose payor source is other than Medicare Part A or Medicaid will begin on the designated admission date or actual admission, whichever is earlier; charges for a resident whose payor source is Medicare Part A or Medicaid will begin no earlier than the date of admission. 2.2 A ,..o a for 'c arL `es. Resident shall pay for other services and supplies provided by or through the Facility which are not covered by the Daily Routine Service Charge as set forth in the Schedule of Charges in effect at the time such ancillary services or supplies are rendered. Any items ordered by a physician, which are not identified on the Schedule of Charges, will be provided at charges identified by the Facility. The charges for ancillary services and supplies are subject to change from time to time. 2.3 C es f 'de #Rd -F In addition to the Facility's charges, Resident shall pay all fees and costs for goods or services furnished to or for Resident by anyone other than the Facility as described in Subsection 1.3 (Services of Other Providers) unless otherwise covered in full by Medicare or Medicaid or another third-party payor. Resident or Responsible Person is obligated to pay such fees and costs whether the goods and services are furnished by a person or provider made available by the Facility, or by a person or provider selected by Resident, and whether the goods or services are provided at the Facility or elsewhere. These fees and costs are not included in the Daily Routine Service Charge. Fees for professional services rendered by a physician are not included in the Daily Routine Service Charge and will be charged directly to the Resident by the physician. 3. PERIODIC BILLINGS AND PAYMENT DUE DATE. 3.1 Monthly Statements and Other Billings. If permitted, prepayment for one month of the basic monthly rate is required at the time of admission. The Facility will mail Resident or Responsible Person on or about the tenth (10th) calendar day of the month a billing statement reflecting charges for nursing services for the upcoming month and charges for ancillary services and supplies which were incurred in the prior month. Statements are due and payable upon receipt of the Monthly Statement. 3.2 Late Charges and Cost of Collection. Any monthly statements not paid within thirty (30) days of the date of the statement are subject to a late charge of one and one-quarter percent (1.25%) per month (annual rate of fifteen percent (15%)), and Resident or Responsible Person is obligated to pay any late charges. In the event the Facility initiates any legal actions or proceedings to collect payments due from Resident under this Agreement, Resident or Responsible Person shall be responsible to pay all attorney's fees and costs incurred by the Facility in pursuing the enforcement of Resident's financial obligations under this Agreement. 3.3 Modification of Charges. The Facility reserves the right to change the Schedule of Charges reflecting the amount of any of its charges or how and when charges are computed, billed or become due. The Facility shall provide thirty (30) days advance written notice of any such changes. 3.4 Obligations of Resident's Estate and Assignment of Property. Resident and Responsible Person 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 the 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 the Facility an amount equivalent to any unpaid obligations of Resident under this Agreement. 4. OBLIGATIONS OF RESPONSIBLE PERSON. 4.1 General Obligations. Resident has the right to identify a Responsible Person (usually the Agent in the Resident's Power of Attorney or Guardian), who shall be entitled to receive notice in the event of transfer or discharge or material changes ' the R ident' c on, and changes to this Agreement. Resident elects to name of 1723 Nursing Agreement 12-15-04 . 3 [address], as the Responsible Person. The Resident's selected Responsible Person shall sign this Agreement and the Responsible Person Agreement in recognition of this designation with the intent to be legally bound by all provisions in this Agreement and the Responsible Person Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of the Resident imposed by this Agreement and the Responsible Person Agreement in accordance with the law governing fiduciary duties. The Facility may petition a court to appoint a Guardian and take other legal action if the Facility reasonably believes that the Resident's needs are not being properly met or the duties imposed by this Agreement or the Responsible Person Agreement are not being fulfilled by the Responsible Person. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. 4.2 Potential Liability. The Responsible Person's duties, obligations and responsibilities are set forth in the Responsible Person Agreement, which is incorporated by reference herein in its entirety. By signing this Agreement, Responsible Person acknowledges he/she has read the Responsible Person Agreement, understands the terms therein, and that he/she shall be bound by all term set forth in the Responsible Person Agreement. 5. MEDICARWWDICAID PROGRAMS. 5.1 Part cznaab'.a in Pro?S. The Facility currently participates in the Pennsylvania Medical Assistance program („Medicaid") and the federal Medicare program. The Facility reserves the right to withdraw from the Medicaid or Medicare programs at any time in accordance with law. 5.2 Actions of Mec'd a Medicare ea The Pennsylvania Department of Public Welfare ("DPW") is responsible for administering benefits under the Medicaid program. The Centers for Medicare and Medicaid Services ("CMS"), of the United States Department of Health and Human Services, is responsible for administering the Medicare program through an intermediary. Resident acknowledges that the Facility is not responsible for, and has made no representations regarding, the actions or decisions of DPW, CMS or the Medicare intermediary in administering the programs. 5.3 Medicaid Deese, ts. (a) Ob turns of Resident is obligated to make full and complete disclosure regarding all financial resources and income during the application process. Failure to identify all resources and income, or the submission of false information, may result.in the tem-tination of this Agreement. Resident is obligated to notify the ` Facility when Resident's resources available to satisfy the Resident's financial obligations under this Agreement have been reduced to Fifteen Thousand Dollars ($15,000). Resident is obligated to apply for Medicaid benefits at such time as Resident's resources will no longer be sufficient to pay all the Facility charges for Resident's care and stay or when directed to do so, by the Facility. In the event Resident applies for Medicaid benefits, Resident shall continue to pay and apply all of Resident's available resources toward the fulfillment of Resident's financial obligations under this Agreement while the Medicaid application is pending an eligibility determination by DPW. (b) 1 Patient Pay Amount. For residents approved for Medicaid benefits, the Facility will accept payment from the Commonwealth of Pennsylvania and, if applicable, the Resident's Patient Pay Amount as determined by DPW as payment in full only for those services covered by the Medicaid program. Resident remains obligated to pay such Patient Pay Amount, less any qualified medical expense deductions, on a monthly basis. Services not covered by Medicaid are identified in the Schedule of Charges and Resident remains obligated to pay for such services. In the event Resident applies for Medical Assistance benefits, Resident or Responsible Person, to the extent permitted by law, shall arrange for assignment to the Facility of any payment on behalf of Resident in an amount equivalent to the Patient Pay Amount as determined by DPW. (c) Determination of Eligibility. Resident and Responsible Person are -obligated to cooperate fully in any Medicaid eligibility determination or redetermination process. In the event that Resident's eligibility for Medicaid benefits is denied, interrupted or terminated due to the failure of Resident or Responsible Person to cooperate in the Medical Assistance application, redetermination or appeal process, the Resident and Responsible Person shall be liable for the Daily Routine Service Charge plus charges for ancillary services and supplies during any non-payment, and the Facility may terminate this Agreement. (d) Authorization to Appeal (Medicaid). In the event of Resident's incapacity and in situations where Resident's resources are depleted or appear to be depleted to the extent that Resident can no longer pay privately for nursing care, and it appears that Resident has become or will become eligible for Medicaid benefits to cover the cost of Resident's continued stay in the Facility; and if there is no other legal representative of Resident known to the Facility or other friend or relative known to the Facility who is authorized and/or is available or willing to act on Resident's behalf, after the Facility has made a good faith effort to identify such persons; then Resident hereby authorizes the Facility to request, file and/or apply for Medicaid benefits on behalf of Resident for the limited purpose of assisting Resident to secure payment through the Medical Assistance program for Resident's continued stay in the Facility. In the event the application for Medicaid benefits filed on behalf of the Resident is denied, or in the event Medicaid benefits are granted and subsequently 1723 Nursing Agreement 12-15-04 5 discontinued, Resident hereby authorizes the Facility to file on Resident's behalf an appeal of any such denial of Medicaid eligibility or discontinuance of Medicaid benefits, and to take such actions to secure Resident's Medicaid benefits as the Facility deems reasonably necessary or appropriate and consistent with law. Resident warrants and represents that the financial information disclosed in the Admission Application is true and accurate and may be relied on by the Facility in pursuing Medicaid benefits on behalf of Resident. (e), Authorization to File a U Mdshiy Waiver with DPW on Behalf of &esident. If DPW's application of the "transfer of assets" or "look-back period requirements for Medical Assistance Eligibility as established by the federal Deficit Reduction Act of 2005 operates to deprive Resident of medical care, food, clothing or shelter, or if Resident's life would be endangered as a result of DPW's Medical Assistance Eligibility decisions, then in the event of Resident's incapacity, and if there is. no. other legal representative of Resident known to the Facility or any other friend or relative known to the Facility who is authorized and/or is promptly available or willing to act timely on behalf of Resident, Resident authorizes Facility to file a Hardship Waiver with. DPW on Resident's behalf, consistent with the procedures established by DPW pursuant to the requirements of Section 6011 of the Deficit Reduction Act of 2005. . 5.4 Medicare I !art A and F#& A its. To the extent that Resident is a beneficiary under either Medicare Part A or Medicare Part B insurance and the nursing services or ancillary services or supplies ordered by a physician are covered by such insurance, the Facility or other provider will bill the charges for the covered services or supplies to the Medicare program. The Resident is responsible for and shall pay any co-insurance or deductible amounts under Medicare Part A or Part B insurance. The Facility shall accept payment from the Medicare intermediary as payment in full only for those services deemed to be covered in full under the Medicare Part A or the Medicare Part B program. Services not covered by Medicare are identified in the Schedule of Charges. 5.5 Non-Covered S Om Resident is and rem obligated to pay the Facility for services and supplies not covered by the Medicaid or the Medicare programs. T 5.6 ePart B-F#jNv&t'Lj (a) Gam. Effective January 1, 2006, the Centers for Medicare and Medicaid Services ("CMS") imposed payment limitations on covered therapy services provided to individuals who are eligible beneficiaries under Medicare Part B. Under this financial limitation, Medicare will pay an annual capped amount for physical and speech therapy (combined) and an annual capped amount for occupational therapy. The capped amounts are revised by CMS annually. Facility shall provide resident and/or Responsible Person with notice of the current capped amounts as appropriate. (b) Resident's Responsibility to Pay for Therapy Services Beyond the Capped Amounts. Resident is responsible to pay the charges for all medically necessary therapy services in excess of the annual capped amounts, unless such therapy services are covered in whole or in part by private insurance or another government reimbursement program. In the event that another government reimbursement program or available third party payor or insurance, program denies coverage for therapy services provided to Resident after exhaustion of the annual capped amount, then Resident of responsible Person shall remain responsible to pay all fees and costs for all such therapy services. If resident is not eligible for Medical assistance, then failure to pay for therapy services rendered above the capped amount shall be grounds for termination and discharge from Facility pursuant to Section 11 of this Agreement. (c) Exception Requests. Medicare beneficiaries are entitled to request an exception to the annual therapy caps, for up to fifteen (15) additional treatment days. In the event that resident has exhausted the annual capped amount, then the following shall apply: i) Resident and/or Responsible Person may submit an exception request to the applicable CMS Medicare contractor; or ii) In the event of Resident's incapacity, and if there is no other legal representative of resident known to the Facility or. any other friend of relative known to the Facility who is authorized and/or is promptly available or willing to act timely on behalf of Resident, then Resident authorizes Facility to submit an appropriate exception request to the applicable CMS Medicare contractor. hi) If the exception request is granted, then therapy services provided to resident shall be covered by Medicare for the number of additional treatments approved. Once the additional approved treatments have been exhausted, Resident shall be responsible to pay all fees and costs for additional therapy services provided as noted in this Section 5.6(b). 1723 Nursing Agreement 12-15-04 iv) If the exception request is denied, then Resident shall be responsible to pay all fees and costs for additional therapy services provided as noted in this Section 5.6(b). 6. MANAGED CARE ORGANIZATIONS. 6.1 Particiuation in lVlaanAp Care Orggsi?'oM• The Facility is an authorized provider of skilled nursing services to members of certain managed care organizations (MCOs). The Resident will be given a list of the MCOs for whom the Facility is an authorized provider. 6.2 Ewollment in a MtaWd 919IJA ation. Resident or Responsible Person shall notify the Facility in writing prior to enrolling with a CO or switching Resident's MCO enrollment. 6.3 Actions of Manned Care Q& dp& tjo_n. Resident acknowledges that an MCO for whom the Facility is not an authorized provider may not approve payment for services provided by the Facility. Resident acknowledges that the Facility is not responsible for and has made no representations regarding the actions or decisions of any MCO for whom the Facility is an authorized provider, including decisions relating to a denial of coverage. nt. The Facility will accept payment from 6.4 Obligations of Reside the MCO as payment in full only for those services and supplies covered by the MCO. Resident is responsible for any co-payments or other costs assigned to Resident under the specific terms of the managed care plan. Resident also shall pay for any services or supplies not covered by the MCO under the specific terms of the managed care plan. Co-payments and other costs assigned to Resident and charges for services or supplies not covered by the specific terms of the managed care plan are identified in the Schedule of Charges. Managed care plans typically require pre-authorization of services by the MCO. If Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Facility for those services. Resident shall pay the Facility in a timely manner for all non-covered services retroactive to the date of the initial delivery of services. A- :W in ft r#M al fry Paa I+?CO. The Facility reserves 6.5 Kitla the right to terminate its contractual relationship and its status as a network or authorized provider with one or more of the listed. MCOs at any time in accordance with law. and the terms of the applicable. agreement. In the event that the Facility terminates its contractual relationship with the MCO in which Resident is enrolled, Resident may convert his or her coverage to a health plan for whom the Facility is an authorized provider or transfer to a facility that is an authorized provider for Resident's MCO. The Facility shall provide thirty (30) days advance notice of its decision to withdraw as a participating provider from Resident's MCO so Resident and the MCO can coordinate a transfer to another facility. 6.6 Notice of Change in Insurance Coverage. Resident and/or Responsible Person shall notify the Facility immediately of any change in Resident's insurance status or coverage made by the insurance carrier including, but not limited to, being dropped by the insurance carrier for any reason, or a decrease or increase in insurance benefits. Resident and/or Responsible Person. shall give the Facility notice before Resident is unable to meet Resident's insurance premium or before Resident implements an increase, decrease or termination from insurance coverage. 7. DURABLE FINANCIAIJHEALTH CARE POWER-OF-ATTORNEY. Resident is strongly encouraged to furnish to Facility, no later than the date of admission, a durable Financial/Health Care 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 health care decisions, financial decisions and payment of services. In the event Resident fails to designate an Agent under a Power-of-Attorney, Resident 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. 8. THIRD-PARTY PAYMENTS. 8.1 El bility for Third-Party Payments. Resident may be or may become eligible to receive financial assistance, reimbursement, or other benefits from third parties, such as private insurance, employee benefit plans, Medical Assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, managed care coverage, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance. It is the responsibility of the Resident and/or Responsible Person to apply for these benefits. If Resident is or becomes eligible to receive payments from any third parties for Resident's stay and care, the Facility reserves the right to collect such payments directly from the third- party source. The Resident and Responsible Person shall at all times cooperate fully with the Facility and each third-party payor to secure payment. Cooperation includes providing information; signing and delivering documents; and assigning to the Facility (to the extent permitted by law) any payments for the Resident from federal or state governmental assistance programs or any other reimbursement or benefits to the extent of all amounts due the Facility. 1723 Nursing Agreement 12-15-04 9 8.2 Asszgment_ of Payments. Resident irrevocably authorizes the Facility to make claims and to take other actions to secure for the Facility receipt of third-party payments to reimburse the Facility for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment of the Facility's charges, Resident hereby assigns to the Facility all of Resident's rights to any third-party payments now or subsequently payable to the extent of all charges due under this Agreement. Resident or Responsible Person promptly shall endorse and turn over to the Facility any payments received from third parties to the extent necessary to satisfy the charges under this Agreement. Resident or Responsible Person shall sign any necessary documents to forward third-party payments directly from the payor to the Facility. 8.3 Insurance. In the event of an initial or subsequent denial of coverage by the Resident's insurance carrier, Resident shall pay the Facility timely for all noncovered services retroactive to the date of the initial delivery of services, so long as such payment obligation is consistent with the regulations governing the Facility's participation in the Medicare and Medicaid Programs. 9. PERSONAL FINANCES. 9.1 Personal Funds MaWea?nent. Resident is responsible to provide his or her personal funds, and Resident has the right to manage his or her personal funds. Resident may authorize the Facility, in writing on a document provided by the Facility, to hold Resident's personal funds, and may revoke at any time the Facility 's authorization by providing the Facility with a written notice signed and dated by Resident or Responsible -Person. If Resident authorizes the Facility to hold Resident's personal funds, the Facility shall hold, safeguard and account for Resident's personal funds in accordance with applicable policies available to the Resident on request. 9.2 Refunds of Per gj_al Finds. Any personal funds or valuables of Resident held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due the Facility, such as any costs incurred by Facility to repair Resident's room for damages caused by Resident, within thirty (30) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such entities or persons entitled to the refund under current law. 9.3 Refunds of PreaaaMents or OyMpayMertts. Any prepayments or overpayments made by Resident and held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due the Facility, within sixty (60) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's i • • estate or to such other entities or persons entitled to the refund under current law. No interest shall accrue on any funds required to be refunded under this Agreement. 10. CHANGES IN ROOM ASSIGNMENTS. The Facility reserves the right and discretion to transfer Resident to another room or bed within the Facility, and the right and discretion to transfer Resident's roommate, if any, at any time consistent with the needs of the Facility. 11. TERMINATION, TRANSFER OR DISCHARGE. 11.1 Resident Initiated. Resident may terminate this Agreement upon seven (7) days written notice to the Facility. If Resident leaves the Facility for any reason other than a medical emergency or death, Resident must give written notice to the Facility at least seven (7) days in advance of transfer, discharge or termination of this Agreement. 11.2 Facility Initiated. The Facility may terminate this Agreement and Resident's stay and transfer or discharge Resident if: (a) the transfer or discharge is necessary to meet Resident's welfare and Resident's needs cannot be met in the Facility; (b) Resident's health has improved sufficiently so that Resident no longer needs the services provided by the Facility; (c) the safety or health of individuals in the Facility is or otherwise would be endangered; (d) Resident has failed, after notice, to pay for (or to have paid or treated as paid under the Medicare or Medicaid Programs) charges for Resident's care and stay at the Facility; or (e) The Facility ceases to operate. 11.3 Notice and Waiver of Notice. The Facility will notify Resident and Responsible Person (or if none, a family member or legal representative of the Resident, if known to the Facility) at least thirty (30) days in advance of transfer or discharge, except in situations when appropriate plans that are acceptable to. the Resident can be implemented earlier, and except in cases of emergencies, including those situations 1723 Nursing Agreement 12-15-04 11 described in subparagraphs (a) and (c) above, then only such notice as is reasonable under the circumstances shall be provided. 11.4 Withdrawal Azaxa# Advice. In the event Resident withdraws from. the Facility against the advice of his/her attending physician and/or without approval of the Facility, all of Facility's responsibilities for the- care of Resident are terminated. 12. READMISSION - BED HOLD POLICY. 12.1 Private Fay Residents. If Resident leaves the Facility for a period of hospitalization, therapeutic leave, or any other reason (other than Resident's death), and if Resident is not eligible for, or receiving, Medical Assistance benefits, Resident's bed will be reserved and Resident shall be obligated to pay the current Daily Routine Service Charge for any days that Resident's bed is reserved. The Facility will continue to hold the bed until notified in writing by Resident or Responsible Person that the bed is no longer desired. If Resident elects in writing not to reserve a bed, then Resident will be discharged from the Facility and readmission to. the Facility shall be subject to bed availability. 12,2 Medical Assistance Raddents. If Resident is eligible for, or is receiving Medical. Assistance benefits, and Resident leaves the Facility for a period of hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable maximum. number of days paid for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation period may be subject to change, in accordance with any changes in the Pennsylvania Medical Assistance Program. If the period of hospitalization or' therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania Medical Assistance Program, Resident will be entitled to the first available accommodation suitable for Resident's level of care if, at the time of readmission, Resident requires the services provided by the Facility. Alternatively, following the lapse of the bed reservation period covered by the Medical Assistance Program, Resident may reserve a bed by' electing to pay the Medical Assistance per diem rate charged immediately prior to the leave, and by providing written notice and advance payment for the days included in the reservation period. 12.3 Medicare Resi`deuts. In the event that a Resident eligible for Medicare Part A benefits is transferred to or readmitted to a hospital, Medicare Part A eligibility will be terminated on the day the Resident is admitted to the hospital. Resident's bed will be reserved at the Daily Routine Service Cl ,rge unless Resident or Responsible Person elects, in writing, not to reserve a bed, or under the Medical Assistance program (as described above)_ if Resident is eligible for benefits. 13. FACILI'T'Y RULES, REGULATIONS, POLICIES AND PROCEDURES. Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement, and the Facility 's rules, regulations, policies and procedures as published in the Facility 's Resident Handbook or other documents or publications made available by the Facility. The Facility reserves the right to amend or change its rules, regulations, policies and procedures. The Facility's rules, regulations, policies and procedures shall not be construed as imposing contractual obligations on the Facility or granting any contractual rights to Resident, and are subject to change from time-to-tune. The Facility does not permit smoking anywhere in the building. 14. PERSONAL AND OTHER PROPERTY. 14.1 Responsibility for Maintenance and Loss. Resident is . responsible for furnishing and maintaining his or her own clothing and other items of property as needed or desired. Resident is encouraged to and may. obtain at his or her own expense, casualty insurance to cover potential damage to or loss of any of Resident's 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 Disposition 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 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 of receipt of the letter, then Facility may dispose of Resident's property. 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, the Facility shall move and place Resident's personal property in storage until claimed. If Resident's personal property remains unclaimed for seven (7) days after permanent transfer or discharge, Resident shall be obligated to.pay a storage fee as assessed by Facility. After a thirty (30) day period in storage, the Facility may dispose of Resident's property. The Facility is not 1723 Nursing Agreement 12-15-04 13 responsible for any damages incurred to Resident's property if storage becomes necessary. 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. 14.4 Damage to Room or Facilft Pry Resident or Resident's estate is responsible for any damages caused to the Facility property beyond normal wear and tear, and shall. pay for the repair and replacement of damaged property, based on the actual charge or cost to the 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 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. TREATMENT AUTHORIZATION. Resident authorizes the Facility to provide care and treatment consistent with the terms of this Agreement. Resident also authorizes the Facility to obtain all necessary clinical and/or financial information from the hospital or nursing. facility from which Resident may be transferring. 17. DEATH OF RESIDENT. In the event of Resident's death, the Facility shall notify the person(s) designated by Resident. The Facility is authorized to arrange for the transfer of Resident's body to the designated funeral home. Resident's estate is responsible for the payment of all costs associated with the transfer and funeral expenses. Resident shall notify the Facility of any changes of the person(s) or funeral home to be notified in the event of death. 18. CAPACITY OF RESIDENT AND GUARDIANSHIP. If Resident is, or becomes unable, to understand or communicate, and is determined after admission to be incapacitated by Resident's Physician: or the Facility's Medical Director, the Facility shall have the right, 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, 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 attorney's fees, shall be paid by Resident or Resident's estate. 19. FACILITY'S GRIEVANCE PROCEDURE. 19.1 Reporting Complaints. If Resident, Responsible Person, or Resident's Attorney-in-Fact 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, Resident or Responsible Person shall make his/her complaint known to the Facility's Director of Nursing or Administrator. Resident, Responsible Person, or Resident's Attorney-in- Fact must first notify the Facility of any such complaints, and provide the Facility with sixty (60) days to resolve the complaint satisfactorily to Resident before the Resident may pursue arbitration. This notice requirement is not intended to preclude Resident, Responsible Person, or Resident's Attorney-in-Fact from filing a complaint with any appropriate governmental regulatory agency at any time. 19.2 Facility's Obligati:tions. The Facility will review and investigate the complaint and provide a response to Resident/Resident's Attorney-in-Fact or Responsible Person. 19.3 Mandatory 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. 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 to fulfill their obligations under this Agreement or the Responsible Person 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 1723 Nursing Agreement 12-15-04 15 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 any rights it may have to a jury trial or to bring claims in a court against the Resident. Subject to Section 19.3(f), the Arbitration shall be administered by ADR 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/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up their rights to a jury trial on any matter submitted to arbitration under this Agreement. (b) PersorW In IM or Medical Malpractice. 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 Section 193(f), the Arbitration shall be administered by ADR 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/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person 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 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 Resident nor the Facility is 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. This arbitration provision shall not impair the rights of Resident to appeal any transfer and/or discharge action initiated by the Facility to the appropriate administrative agency, and after the exhaustion of such administrative appeals, to appeal to the court exercising appellate jurisdiction over the administrative agency. (d) Right to Legal 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. (f) Time Limitation for Arbitration. Any request for arbitration of a dispute must be requested and submitted to ADR Options, Inc., prior to the lapse of two (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. (g) Limitation on Damages and Allocation of Costs 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 19.3(a-h) of this Agreement). Resident, or Resident's spouse or personal representative in the event of Resident's incapacity, have the right to rescind this arbitration clause by notifying the Facility in writing within thirty (30) days. (Notice of Right to Rescind form is available upon request.) 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 spouse or personal representative. 20. NOTICE. 1723 Nursing Agreement 12-15-04 17 Wherever written notice is required to be given to the 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: JB trator Facility Name P-0 AM [Address] Notice to Resident will be provided by personal delivery to Resident's room, or where applicable, by first-class mail to Responsible Person or other designated person. 21. INDEMNIFICATION. Resident shall indemnify and hold the Facility harmless from, and is responsible to pay for any damages or injuries to other persons and residents or to the property of other persons or residents caused by the acts or omissions of Resident, to the fullest extent permitted by law. 22. RELATIONSI IP OF NURSING HOME ADWSSION AGREEMENT TO OTHER ADMISSION AGREE)AENTS. Upon permanent transfer to a new level of care the existing admission agreement will be terminated. 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.. 23.2 Severe. The various provisions of tk4s 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 Captions. The captions used in connection with the sections and subsections of 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, nor shall such captions be . given any legal effect. 23.4 Entire Agreement. This Agreement, the Responsible Person Agreement and the Admission Application represent the entire Agreement and understanding between the parties and supersedes, merges and replaces, all prior negotiations, offers, warranties and previous representations, understandings or agreements, oral or written, between the parties. 23.5 Modifications. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in law, regulation or operations. To the extent reasonably possible, the Facility will give Resident and Resident's Responsible Person thirty (30) days advance written notice of any such modifications. The Resident may not modify this Agreement except by a written statement signed by the facility. 23.6 Waiver of Provisions. The 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 the Facility unless such waiver is in writing by the Facility. Any waiver by the Facility shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. 24. ACKNOWLEDGMENTS. 24.1 Schedule of Charges. Resident and Responsible Person acknowledge the receipt of a copy of the Schedule of Charges and the opportunity to ask questions about the Facility's charges. 24.2 Resident Rights. Resident and Responsible Person acknowledge being informed orally and in writing of Resident's Rights as reflected in the publication attached to this Agreement, and further acknowledge having an opportunity to ask questions about those rights. The Notice of Rights of Nursing Facility Residents (MA- 401) is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on the Facility or granting any contractual rights to Resident. 24.3 Advance Directives. Resident and Responsible Person acknowledge being informed, orally and in writing, of the Facility's policy on advance directives and medical treatment decisions. 24.4 Agreement. Resident and Responsible Person acknowledge that they have read and understand the terms of this Agreement, that the terms have been 1723 Nursing Agreement 12-15-04 19 explained to them by a representative of the Facility, and that they have had an opportunity to ask questions about this Agreement. 24.5 Resident Handbook. Resident and Responsible Person acknowledge the receipt of a copy of the Resident Handbook and the opportunity to ask questions about the Facility's policies contained in the Resident Handbook. The Resident Handbook is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on the Facility or granting any contractual rights to Resident. IN WITNESS WHEREOF, the parties, intending to be legally, bound, have signed this Agreement on the date written below. Witness Witness Resident Responsible Person (if any) Date D e s Aiiffiorized Representative d,4 Q, Da e .-ADDENDUM TO A] This addendum is made as of between Fr"v-,4 - MISSION AGREEMEN'T' lV (the "effective date"), (`Resident") and (?'acllnty' .). Baeicround The purpose of this Addendum is to comply with the Medicare Modernization Act of 2003 which created a new voluntary outpatient prescription drug program under the Medicare Part D program, beginning is 2006. Policy Statement The following outlines the understanding between the Facility and Resident regardinE the Medicare D prescription drug program: I . It -is the Resident's/Responsible Person's .obligation to enroll the Resident in a Prescription Drug Plan (PDP) of the Resident's choice and to inform the Facility of-the PDP selected. - It is not the responsibility of the Facility to ensure Resident enrollment in a PDP. 2. If a Resident elects to switch PDPs under the provisions of the Special Election Period, then the Resident will immediately advise the facility of this election. 3. The Facility is not responsible for the actions or decisions of the Resident's chosen PDP. The decisions as to formularies, coverage deciisions, appeals decisions, premiums or other charges are solely the responsibility-of the Resident through agreement with his or her chosen PDP. UCCFI #I727 12-05 Attach to the following agen==ts: 1716, 1718, 1721, 1723, 1725 Page I of 2 4.. : The Resident is responkbl . e for any cost-sharing obli ations with-the PDP. The Resident will directly receive the bill from the pharmacy for any cost-sharing obligations.. The Facility is not obligated to pay the cost-sharing portion of the Resident's chosen PDP and will not receive-the pharmacy bill. It is the Resident's ofiligation to pay for all premiums and amcsated charges; if any, to the PDP of their dice or to the pharmacy. 5. The Resident/Responsible Person has the responsibility to appeal any Part D. coverage determinations. The facility shall serve as an "appointed representative", as•allbwed.bylaw, to initiate a formulary appeal or-grievance on the Resident's behalf, should the Resident have no other "appointed representative". 6.. The Facility is not obligated to educate or inform the Resident/Responsible Person about what drugs will be covered and are excluded from a PDP's formulary. The Facility has no control over the formulary. Any questions or concerns should be directed to the Resident's PDP regarding why a prescription is or is not covered. This information is not provided to the Facility by the PDP. Responsible Pnty.ff Vplicable) Date S' ed. B signed Date Signed UceEi #1727 12-05 Page 2 .of 2. Attach to thz following agreements: 1716,1718,1721, 1723,1725 ;? rx0l d UNITED CHURCH OF CHRIST HOMES RESPONSIBLE PERSON AGREEMENT t x ponsible Person Agreement (hereinafter "Agreement") is made between (hereinafter referred to as "Facility") and the legal representative or representati ve individual (hereinaft Max, ed to as "Responsible Person") of the Resident, (hereinafter referred to as "Resident"). WHEREAS, the Responsible Person and Facility enter into this Agreement to facilitate the provision of care to the Resident. WHEREAS, the Responsible Person may be the Guardian, the Agent under a valid Power of Attorney, or any person authorized by Resident to serve as Resident's Responsible Person WHEREAS, Facility shall discuss and consult with Responsible Person regarding pertinent decisions related to Resident's stay and care at the Facility. THEREFORE, Facility and Responsible Person agree to the following terms and conditions: 1. Responsible Person affirms that - the information provided in the Admission Application and related documents are true and correct to the best of his or her knowledge. Responsible Person acknowledges that the submission of any false information, misrepresentation or lack of disclosure may result in the termination of the Nursing Home Admission Agreement (hereinafter "Admission Agreement") and may result in the discharge of the Resident from the Facility at the Resident and/or Responsible Person's expense. 2. If the Resident selects a Responsible Person, then said Responsible Person shall sign this Agreement and the Admission Agreement in recognition of this designation with the intent to be legally bound by this Agreement and the Admission Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of the Resident imposed by the Admission Agreement in accordance with the law governing fiduciary duties. Facility may petition a court to appoint a Guardian and take other legal action if Facility reasonably believes that the Resident's needs are not being properly met or the duties imposed by the Admission Agreement are not being fulfilled by the. Responsible Person. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. Nursing Responsible Person Agreement 1215-04 3. Responsible Person affirms that he or she has access to Resident's income and resources and that Resident's income and resources are available to pay for Resident's care in the Facility. The Responsible Person shall provide payment from Resident's income and resources for such care. Responsible Person shall apply Resident's income and resources to the costs and charges incurred during Resident's stay unless and until such costs are paid by private insurance or other benefits such as Medicare, Veteran's Health Insurance or Medical. Assistance. When the Resident's financial resources warrant it, Responsible Person shall take any and all actions necessary -and appropriate to initiate, make and conclude application for Medical Assistance benefits on behalf of the Resident, including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals. Responsible Person shall exercise diligent efforts in the application and appeal processes to assure continued benefits from any third party or government payor. Responsible Person shall utilize Resident's income and resources only for Resident and shall not utilize any of Resident's income or resources for Responsible Person's benefit nor transfer any of Resident's real property except for proceeds at fair market value for the benefit of Resident. 4. Responsible Person is obligated to pay Facility from Resident's financial resources for services and supplies provided to Resident in accordance with the Admission Agreement. If the Responsible Person withholds or misappropriates Resident's financial resources for personal use or gifts, or otherwise does' not use the Resident's financial resources to fulfill Resident's financial obligations to Facility for services and supplies provided to Resident in accordance with the Admission Agreement, then Responsible Person shall be personally liable for payment. Responsible Person is also obligated to pay Facility for all losses or damages incurred by Facility by the failure of the Responsible Person to fulfill his/her duties under the Admission Agreement. Failure to do so will result in legal action by Facility to assure payment for amounts-that are Resident's obligations. In the event that Facility initiates any legal actions or proceedings to collect payments due from Resident and Responsible Person. under this Agreement, or to enforce Responsible Person's obligations under the Admission Agreement, then Resident' and Responsible Person shall pay all damages, attorneys' fees and costs incurred by Facility in pursuing the enforcement of Resident's and/or Responsible Person's financial or other obligations under the Admission Agreement. Such damages, fees and costs may include, in the discretion of Facility, an amount equivalent to revenue lost by Facility due to Responsible Person's failure to timely submit or complete a Medical Assistance application or to cooperate with the Department of Public Welfare (hereinafter "DPW") in the Medical Assistance eligibility determination. Responsible Person shall: timely assist Resident in the preparation, completion and submission, if applicable, of Resident's application for Medical Assistance benefits. If Facility, in its sole discretion, decides to assist in the Medical Assistance application, Resident and Responsible Person Nursing Responsible Person Agreement 12-15-04 2 are still fully obligated to initiate, slake ' and complete the Medical Assistance application: Facility's assistance in the Medical Assistance application process does not waive Resident's or Responsible Person's duty or responsibility to timely complete and submit a Medical Assistance application if the Resident's financial resources become insufficient to pay amounts under the Admission Agreement. The failure to initiate' make and complete ' the Medical Assistance application process may result in the discharge of Resident for non-payment and in personal liability to Responsible Person for, losses incurred by Facility for Responsible Person's failure to apply timely for Medical Assistance benefits. In the event Resident applies for Medical Assistance benefits, Responsible Person shall pay the Patient Pay Amount monthly to Facility. Responsible Party, at the request of Facility and to the extent permitted by law, shall immediately sign over and/or designate the Facility as the representative/ designated payee for any income available to Resident in an amount not to exceed the Patient Pay Amount as determined by DPW. Responsible party should take whatever action as may be necessary to insure that such payments are made directly to Facility. Patient Pay Amount is determined by DPW and described in Section 53(b) of the Admission Agreement. If Resident is determined to be ineligible for. Medical Assistance because Responsible Person fails to provide or submit necessary documents or fails to appeal timely so that Facility is unable to obtain Medical Assistance reimbursement, then Facility may terminate the Admission Agreement for non-payment of stay and Responsible Person shall be personally liable for any losses sustained by Facility as a result of such failure. Responsible Person shall be responsible personally for compliance with all other terms of the Admission Agreement. 5. Responsible Person understands that if he or she fulfills his or her obligation under this Agreement, he or she shall not be held personally liable for the Resident's charges. However, Responsible Person understands that if he or she does not fulfill his or her obligation under this Agreement he or she shall be liable to Facility for whatever loss Facility sustains as a result of the Responsible Person's breach of this Agreement. 6. Responsible Person is obligated . to perform all provisions in the Admission Agreement related to Responsible Person. 7. The Responsible Person attests that the information set forth in the Application Agreement is true and correct to the best of his or her knowledge, information and belief. 8. The Responsible Person acknowledges that he or she has received a copy of the Admission Agreement and understands the terms and conditions contained therein. Nursing Responsible Person Agreement 12-15-04 3 9. Responsible Person acknowledges he or she has 'reviewed this Responsible Person Agreement and understands the information set forth herein. iN WTTNESS WHEREOF, the parties; intending to 1 a11y bound hereby, have -%y Of 04? sign this Responsible Person Agreement on this 20. Witness Witness. Responsible Person Representative Nursing Responsible Person Agreement 12-15-04 4 ?x k? ? -? C) CUMEERLAND CAO MEDICAID F.C. sox 599 NOT ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 *01010000000* TODD MEMORIAL HOME ATTN: BILLING 1000 W. SOUTH STREET CARLISLE'PA 17013 Notice ID: 86726192 PAGE 1 OF 1 121 0120192 0 PAN 00 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 09/03/2008 NOT: 042 OPT. 0 TYPE: N iF YOU 00 NOT UNDEWAW OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTAC( YOUR WORKER TWDZATELY. You failed to provide the following items by 9/2/08: 1. Dispostion of funds received in sale of home on 8/22/08; 2. proof that you have spent your available resources below the $8000 limit on medical or preplanning funeral expenses; 3. Verification of cash value of annuity or statement of irrevocability from Annuity Company. REGULATIONS:55 PA Code 201.1; 201.3 If you disagree with our decision, you have the right to appeal. - - - -^ •--•--• ?+? , • ?,? w oar anu io a I-Ir nearm IT you are currently receiving benefits and your oral request fora hearing is received in the County Assistance Office or your written request is postmarked or received on or before 09/16/2008 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. FRANCES R ROBERTS TODD MEMORIAL HOME 1000 WEST SOUTH STREET CARLISLE PA 17013 CAU ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 Notice ID: 86726192 21 0120192 0 PAN 00 WORKER: J PEIPER APPEAL: 09/16/2008 TELEPHONE: (800) 269-0173 MAIL DATE: 09/03/2008 NOT: 042 OPT: 0 TYPE: N 86726192 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG I LINE FIRST NAME ACCESS/ INDIVIDUAL NUMBER 01 FRANCES 330211031 1 00 BNFT V PKG THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUP MEDICAID BENEFITS. GROSSINCOME Line Line Line Line Line Line Line Line Earned: Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: "' '.°` You are responsible for patient Additional Deductions: below. Patient Pay Amount Pay amount to providers as indicated Medical Bills (as deduction): Line Date Pav to: Provider Amount Total Household Net Income: Budget Income Limit: The following medical-bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and. will not be covered by Medicaid Name of Provider Date of Service Amount I Name of Provider Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. - DETACH HERE DETACH HERE ----- Please check one of the boxes to show which type of hearing you want: ? I want a telephone Hearing. land my witnesses and anyone helping me will be at this phone number: ? 1 want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? 1 want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to-the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? I need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE ar...l unc Li-jerv 1 Kr-r. ADDRESS TELEP14CI11IF Nn nerc e',? ?-/ ? ),El e1/2V22?0 ' e: 04 7172459733 SARAH TODD HOME PAGE 02/03 R?11) CAO MEDICAID Nctlvo IC3:. 9.oacitaa- 1 F 1 F0srsox 59*4 NOT ELIGIBLE 33 WFSTMIMST31Z DRIVE NOTICE CARLIOLF PA 17013-059u CAO RETURN ADDRESS CSL.D 0036 *01010000000* TODD MEMORIAL ROME ATTN: BILLING 1000 W. SOUTH STREET CARLISIjE PA 17012 21• 0120192 0 PAN 80 .n, WORKER J PSIPSR TELEPHONE (800) 7.69-0173 MAIL DATE 12/30/2008 NOT. 042 OPT: o TYPE, N IF YOU DO MOr UFfAE745rAHD OUR DECIS W OR HAVE W ONESTIDR3..Pam owxT rai? w im Immuri L 1. PAGE 0 You failed to provide verification of the following items by 12/29/2008: 1. Statements for all bank accounts, annuities, Keoghs, IRAs Stocks and Bond:. as of a/i/08; 2. verification of proceeds received in sale of house, disposition of funds received after sale of home: 3. Verification of all resources sold transferred or given away in the past 36 months 4. Verification of why you received $45000 for home that is listed as FMV of 557,000 REGULATIONS:55 PA Code 201.1; 201.3 If you disagree with our decision, you have the rightto appeal. See attached form fora c6niplote expiaTation of vour richt to appeal and_ to a _tnir. howing. If you are currently receiving benefits and your oral request for a hewing is received. -in the County Assistance Office or your written request Iv postmarked or received on or before 01/12/2009 your assistance will continue pending the hearing decision, oxcept when the change is due to State or Federal law, FRANCTas R ROBERTS TODD MEMORIAL HOME 1000 WEST SOUTH STRFST CARLISLE PA 17013 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CART z3T.F PA 17013-0599 LAri1 7? tai MIDPXNN LEGAL 401-405 LOUTHER STR1:i :' CARLISLE 14 17013 (717) 243-9400 Notice ID: 90461:0; 01/2?3/2PAo 1d; I?4. 7172459733 SARAH TODD HOME PAGE 03103 coa6a1C7 MHOW410410THE 'FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESVINDIVIDUAL NUMBER V FKC4 I LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 rPANCT:S 330211031 1 00 BNFT PKG THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERNIIIN.t TION OF YOUR MEDICAID BENEFITS. Line Line Lino Lino Line Line Line 1e GROS IINC?OME ?arn©d: Unearnod: DED TIONS erne Income: Unearned Income: Depandant Care Individual Totals Additional Deductions: Medical Bills (as deductlo0 Patient Pay Amount Total Household Net Income: Budget Income Limit You are responsible for patient pay amount to prc)vinars as indicated below: Line Date Pay to Provider Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits, The unpalil bills are your responsibility and will not be covered by Medicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM POIRTION OF TI 11"i! FORM. •--- MACH rME DETACH HERE -? Please check one of the boxers to show which type of hearing you want: Q I want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number. _ I want a Telephone Healing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAC , ? I want a Face to Iraoe Heating. I and my witnesses and anyone helping me will be in the healing room with the Judge iFt Ilhe caseworker and CAO staff. ? I want a Face to Face Hearing, I and my witnesses and anyone helping. me wig be in the hearing room with the Judge. 11,1 caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. 1 PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HE=ARING PROBLEM OR DISABILITY OR YOU NEEE?IA Ii INTERPRETER: ? 1 have a hearing Impairment or disability. I will need special help. [] 1 need an interpreter. There will be no cost to me. What language? ADDRESS TELEPHnaaE bin DATE REP. ADDRESS ??(?-W"t SQLI`U Street )T7-.5.-2167 Te=a FDL. - nn,ye F ?>b,+ ? 01/15/20P2 92:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 WOst South Street Carlisle, PA 17013 PAGE 02/68 Statement Date: 10/10/20Ci13 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/25/2008 Re: Frances R Roberts Account N.r: 101955 _------------- ---------._......------..-_ _ _ Date Description Days Rate Charges Payments -^-Balance Quant -------------------------------------------------------------------------------- 09/02/08 BALANCE FORWARD Beauty & Barber 1 00 20 00 15,717.00 15,717.00 09/08/08 Therapeutic Exercis . 2.00 . 26.04 20.00 10 42 15,737.00 09/08/08 Therapeutic Acti.vit 1.00 27.40 . 5 48 15, 747.9,2 ' 09/08/06 Therapeutic Activit 1,00 27.40 . 15,7 52.91 09/08/08 Therapeutic Exercis 2.00 26.04 42 110 15,758.31) 09/08/08 Neuromuscular Reedu 1.00 27.08 . 5 42 15,768.812 09/09/08 Self Care Mngement 1,00 27.78 . 5 56 15,774.2:? 09/09/08 09/09/08 Therapeutic Activit T 2.00 27,40 . 10.96 15,779.7.3 15 79 09/09/08 herapeutic Activit Therapeutic Exercis 1.00 2 00 27.40 5.48 , 6.2 15 ,796. 09/09/06 Therapeutic Exercis . 1.00 26.04 26.04 10,42 5 21 64 15 ,80 6.6# 09/09/08 Beauty & Barber 1.00 20.00 . 20 00 15,8 .85 115 09/10/08 Self Care Mngement 1.00 27.78 . 5 56 31 15 ,831.8., 09/10/08 Therapeutic Exercis 1.00 , 26.04 . 5 21 15,837.9:_ 09/10/08 Therapeutic Activit 2.00 27.40 . 96 10 15,842.6: 09/10/08 Therapeutic Activit 1.00 27,40 . 5 48 15,853.5(3 09/10/08 Therapeutic Exercis 2.00 26.04 . 10 42 15,859. Ei 09/11/08 Therapeutic Exercis 2.00 26.04 . 10 42 4 15 ,869.4(; 09/11/08 Therapeutic rxercis 1.00 26.09 . 5 21 15,879.9(. 09/11/08 Self. Care Mngement 1.00 27.78 . 5 56 15,885.17. 09/11/08 Therapeutic Activit 1.00 27.40 . 5 48 X5,890.6.' . 15,695.1; 91/15/22x9 92:45 7172459733 SARAH TODD HOME PAGE 63/68 Statement United Church of Christ Homes Sarah A. Todd Memorial. Home 1000 West South Street Carlisle, PA 17013 Statement Date: 10/10/20013 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/25/2008 Re: Frances R Roberts Account Mr: 101955 --------- Date ---------------------- Description -------- Days --------- Rate -W`Charges --Payments-- Balan-r c'? --------- ------------ ---------- uan 4 t -------- ---------- ------ 09/12/08 09/12/08 Self Care Ndngement Therapeutic Ex i 1.00 27.78 ----- 5.56 --------------------- 15,901. 09/12/08 Therapeutic erc s Exercis J-00 2.00 26.04 26.04 5.21 10 42 92 15,906.9: 09112108 Neuromuscul ar Reedu 1.00 27.08 . 5 42 15,917.34 09/12/08 Therapeutic Activit 1.00 27.40 . 1,5,922.7E 09/12/08 Therapeutic Activit 2,00 27.4 0 10 96 15,928.2(1 09/15/08 Therapeutic Activit: 2.00 . 27.40 - 10 96 15,939.2(1 09/15/08 Therapeutic Exercis 1.00 26.04 . 5 21 15,95 .161 09/15/08 'Therapeutic Activit 2.00 27.40 . 10 96 5.37 15,955.3;' 09/15/08 Therapeutic Exercis 1.00 26.04 . 5 21 151966.33 09/16/08 Therapeutic Activit 1.00 27,40 . 5 48 15,971.5 09/16/08 Therapeutic Activit 2.00 27.40 . 10 96 15,977. 09/16/08 Therapeutic Exercis 1.00 26.04 . 5 21 9E 15,987.9E 09/16/08 Therapeutic Exercis 1.00 26.04 , 5 21 15,993.10 09/16/08 Beauty & Barber 1.00 20.00 . 20 00 0 15,998.4C 09/16/08 Self Care Mngement 1.00 27.78 . 5 56 16,018.4C 09/17/08 Therapeutic Activit 1.00 27,40 . 5 16,023.96 09/17/08 Therapeutic Activit 1.00 27,40 48 16,029.44 09/17/08 Therapeutic Exercis 2.00 26.04 . 10 42 16,034.92 09/17/08 Therapeutic Exercis 2.00 26.04 . 10 42 16,045.34 09/18/08 Therapeutic Exercis 2.00 26,04 . 1 4 16.055.76 09/18/08 Therapeutic Activit 1,00 27.40 5 8 16,066. 09/18/08 Therapeutic Exercis 2.00 26.04 . 10 42 66 16,071.66 . 16,082.08 91/15/2P99 99:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 PAGE 04/08 Statement bate: 10/10/200$ Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/25/2008 Re: Frances R Roberts Account Mr: 101955 Date ---------------- Description -------- Days ------- Rate Charges Pa ---^Balance Yments Balance ------ Quant -------- ---------- - 09/18/OB 09/19/08 Therapeutic Therapeutic Activit Exe i 1.00 27.40 ---------- 5.48 --------------------- 16,087.5E 09/19/08 Therapeutic c s Activit 2.00 2 00 26.04 27 40 1 0 92 16,097.98 09/19/08 Therapeutic Exercis . 2.00 . 26.04 . 0. 96 x 5 1.6,108.9 09/19/08 09/22/08 Therapeutic Thera euti Activit 1.00 27.40 . .48 5 48 16,11.4.15 16 119 fi3 09/22/08 p c Therapeutic Activit Exercis 1.00 2 00 27.40 26 04 5.48 , . 16,125.1:1 09/22/08 Therapeutic Exercis . 2.00 . 26.04 10,42 10 42 16,135.513 09/22/08 Therapeutic Activit 1.00 27.40 . 5 1.6,145. 09/23/08 Therapeutic Activit 1.00 27.40 48 43 16,151.43 09/23/08 09/23/08 Beauty 4 Barber Beaut & B b 1.00 20.00 . 20.00 16,156.91 16 176 9' 09/23/06 y ar er Therapeutic Exerrcis 1.00 2.00 16.00 26 04 16.00 , . 26,192.9:. 09/23/08 Therapeutic Exercis 2.00 . 26.04 10 42 10 42 16,203.3:3 09/24./OB Therapeutic Exercis 1.00 26.04 . 5 16,213.7;; 09/24/08 Therapeutic Activit 1.00 27.40 48 16,218.9E 09/24/08 Therapeutic Activit 1.00 27.40 . 16,27.4..44: 09/24/08 Therapeutic Exercis 2.00 26.04 10 42 16,229.94: 09/24/08 Self Care Mngement 1.00 27.78 , 5 56 16,240.34 09/25/08 09/25/08 Therapeutic Therapeutic Activit E i 2.00 27.40 . 10.96 16,246.90 16,256.8E 09/26/08 Therapeutic xerc s Exercis 1.00 2 00 26.04 26 04 5.21 16,262.07 09/26/08 Therapeutic Activit . 1.00 . 27,40 10 .42 5 48 X6,272.7 . 16,277.997 91I15/2?T2 9°:45 7172459733 SARAH TODD HOME PAGE 05/68 Trisha Roberts 63 E. North St Carlisle, PA 17013 --------------------------- Date Description -- Statement Date: 10/10/20C+13 Due Date: 10/25/2008 Re: Frances R Roberts Account Nr: 101955 n Rate Charges Payments Balance 09/26/08 Therapeutic Exercis 2.0 ! 26 04 09/29/08 Therapeutic Activit I I 2.0 . 27 40 09/30/08 Medical supplies 1.0 . 151 47 09/30/08 09/30/08 Medical Equipment R . 1,1.0 . 1131.90 09/30/08 Oxygen Cable Television ?1.0 11.0 156.30 17 00 09/30/08 Personal Laundry Se . 1.0 . 30 00 09/30/08 COINSURANCE,, BILLED I i . 128 00 09/30/08 Finance Charge 1 . 09/30/08 Beauty & Barber 1 1 ,1.0 20 00 10/01/08 Room F Board - Semi 1 f I ! 3 i . 235.00 NOTE: ****# jL i 10.42 16,288-3!) 10.96 16,299.35 151.47 16,450.82 1,131.90 17,582.7? 156.30 17,739.0'.; 17.00 17, 756. 02 30.00 17,786.02 640.00 18,426.0;: 72.11 18,998.1: 20.00 ?9,518.1C 7,285.00 25,803.13 PAYMENT IS DUE U N RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** i Piease remit the LAST AMOUNT printed on your statement. Include the # from the statement on the MEMO LINE of your check. Payments arte T1,08%•08 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBACT TO A 1.25$ LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED RETURNED CHECKS ** i I Statement United 4hurch of Christ Homes SaraY A. Todd Memorial Home 100,0 est South Street Ca isle, PA 17013 i I I? I? 01/15/2Ca0 09:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 PAGE 06/08 Statement Date: 11/14/2008 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 11/25/2008 Re: Frances R Roberts Account Nr: 101955 ---------------------------------_----_-- Date Description Days Rate Charges Payments Balance, Quant --------------------------------------------------------------------------------- 10/07/08 BALANCE FORWARD Beauty & Barber 1 00 20 00 25,803.13 25,803.12 10/10/08 Wheelchair Mgmt Tra . 2.00 . 25.34 20.00 10 14 2 5 2 8 3.13 10/10/08 10/10/08 PT Evaluation Th 1.00 66.53 . 13.31 ,8 2 5, 3 3 .2; 25,896.5E 10/14/08 erapeutic Activit Beauty & Barber 4.00 1 00 27.40 20 00 21.92 25,868.50 10/21/08 Beauty & Barber . 1.00 . 20.00 20.00 20 00 25,888.5[- 10/31/06 10/31/08 Personal Laundry Se 1.00 30.00 . 30.00 25,908.5C 25,938.5C 10/31/08 Cable Television Beauty & Barber. 1.00 1 00 17.00 16 00 17.00 25,955.5C 10/31/08 Finance Charge . . 16.00 197 36 25,971.5C 10/31/08 Personal Suppli.Fs 1.00 1.25 . 1 25 26,168.86 10/31/08 10/31/08 Medical Supplies O 1.00 224.33 . 224.33 26,170.11 26,394.44 10/31/08 xygen Medical Equipment R 1.00 1.00 31.26 1483.62 31.26 1 483 62 26,425.70 10/31/08 10/31/08 Beauty & Barber B 1.00 10.00 , . 10.00 27,909-32 27,919.32 11/01/08 eauty & Barber Room & Board - Semi. 1.00 7 5.00 235 00 5.00 1 645 00 27,924.32 . , . 29,569.32 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on your Statement. Include the ACCT# from the statement on the MEMO LINE Of your check. Payments after 11/06/08 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT To A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** 01/15/2292 912:45 7172459733 SARAH TODD HOME PAGE 07/08 Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Statement Date: 12/12/20C8 Trisha Roberts 63 E. North St Carlisle, PA 1707,3 Due Date: 12/26/2008 Re: Frances R Roberts Account Nr: 101955 ---------....----. -------------------- Date Description Days Rate Charges -Payments- Balancs Quant -------------------------------------------------------------------------------- 11/04/08 BALANCE Beauty FORWARD & Barber 1 00 20 00 29,569.32 29,569.3;2 11/07/08 Medical Equipment R . 1.00 . 405.10 20.00 405 10 29,589.32 11/07/08 1 1/07/08 Persona l Laundry Se 1.00 30.00 . 30.00 29,994.92 30 024 4:? . 11/07/08 Cable Television Oxygen 1.00 17.00 17.00 , . 30,041.42 11/07/08 Medical Supplies 1.00 1.00 15.63 40.95 15.63 90 95 ,- 11/30/08 Finance Charge . 325 01 30,098.01) . 30,423.01 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** please remit the LAST AMOUNT printed on your statement. Include -he ACCT# from the statement on the MEMO LINE Of your check. Payments after 12/11/08 do not reflect on statement. MOTE: ** LATE PAYMENT'S ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE,, WILL BE CHARGED for RETURNED CHECKS ** 01/15/2009 99:45 7172459733 SARAH TODD HOME Statement t sited Church of Christ [comes Sarah A. Todd Memorial Home 1000 West South Street- Caglisle, PA 17013 PAGE 08/08 Statement Date: 01/14/20UF1 Trisha Roberts 63 E. North St Carlisle, PA 17C?i3 Due Date: 01/25/2009 Re: Frances R Roberts Account Nr: 101955 --------------- ------- Date Description -`-------------------------?------.. Days Rate charges Payments Balance; Quant --------------------------------------------------------------------------------- BALANCE FORWARD 12/31/OB Finance charge 301423.01 373.68 NOTE: ***** PAYMENT Ir DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH **-** Please remit the LAST AMOUNT printed on Your statement. include ;,he ACCT# from the statement on the MEMO LINE of your check. Payments after 01/09/09 do not reflect on Statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** 30, 423.0]. 30, 796. 6S3 01 1J d 'W V _ hJ . ?' r Q -- Steven M. Montresor smontres@ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA UNITED CHURCH OF CHRIST HOMES, INC. : d/ b/ a SARAH A. TODD MEMORIAL HOME Plaintiff, NO. 09-1159 V. CIVIL TERM, 2009 TRICIA ROBERTS CIVIL ACTION - LAW AND EQUITY and FRANCES ROBERTS Defendants. PLAINTIFF'S MOTION FOR PRELIMINARY INJUNCTION AGAINST TRICIA ROBERTS AND NOW COMES, Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home (hereinafter "Sarah Todd"), pursuant to the provisions of Pa. 128491 1 R.C.P. 1531, and makes the following Motion for Preliminary Injunction Against Tricia Roberts, stating in support thereof as follows: 1. On February 27, 2009, Sarah Todd filed its Complaint against Tricia Roberts and Frances Roberts. A true and correct copy of the Complaint is attached hereto as Exhibit "A" and incorporated by reference as if fully set forth herein. 2. The Complaint sets forth claims against Tricia Roberts relating to breach of contract, injunctive relief, quantum meruit, conversion, fraudulent transfer, and filial support. 3. As more fully set forth in the Complaint, Tricia Roberts had a contractual obligation to assist in securing Medical Assistance benefits for Frances R. Roberts. 4. As more fully set forth in the Complaint, Tricia. Roberts did not comply with her contractual obligation to assist in securing Medical Assistance benefits for Frances R. Roberts. 5. As more fully set forth in the Complaint, Tricia Roberts failed to turn over certain information and documentation requested by the Cumberland County Assistance Office ("CAO") 6. As a result of Tricia Roberts failure to turn over certain information and documentation requested by the CAO, the CAO denied Frances Roberts' application for Medical Assistance benefits on or about December 30, 2008. 7. The information and documentation which Tricia Roberts failed to provide to the CAO is listed in the "Medicaid Not Eligible Notice" dated December 30, 2008, which is attached to the Complaint as Exhibit "E" 128491 2 8. Sarah Todd has no other means of securing the information and documentation requested by the CAO. 9. The only person who has access to said information and documentation is Tricia Roberts, who is Frances Roberts' daughter and Agent. 10. Sarah Todd has filed an appeal of the CAO's denial of benefits, which is now scheduled for hearing on April 2, 2009 at 1:00 p.m. A true and correct copy of the hearing notice is attached hereto as Exhibit "B." 11. In advance of the hearing, the CAO has provided a list of outstanding issues, a true and correct copy of which is attached hereto as Exhibit "C." 12. If the information and documentation listed in Exhibit "C' is not provided to the CAO, the BHA will ultimately deny the appeal of the denial of benefits. 13. The failure of Tricia Roberts to comply with her contractual obligation presents issues of immediate and irreparable harm to Frances Roberts and to Sarah Todd in that the CAO denied Frances Roberts' application for Medical Assistance benefits to which she would otherwise be entitled. 14. The requested injunction would restore the parties to the status quo as it would return Tricia Roberts to compliance with her contractual obligations to Sarah Todd, and return Tricia Roberts to compliance with Medical Assistance laws and regulations. 15. Greater injury would result from the denial of the requested injunction than from the granting of the same. 16. Sarah Todd's right to relief is clear. 128491 3 17. Sarah Todd lacks an adequate remedy at law. WHEREFORE, Plaintiff, Sarah Todd respectfully requests that this Honorable Court schedule a hearing on its request for injunctive relief, and thereafter enter an Order directing Tricia Roberts to take all steps necessary to provide to the CAO the information and documentation identified by the CAO in the list of outstanding issues, together with any other information and documentation that may be requested by the CAO. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.C. Dated: 3 ?00,\ By: StQ Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, United' Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home 128491 4 103/31/2009 08:53 7172459733 SARAH TODD HOME PAGE 11111 VERIFtC?'ITON 1, Mary Jane Walker, hereby verify that I am the Administrator of Sarah A. Todd Memorial Home; that I am authorized to make the within Verification; and the statements of fact in the foregoing Motion for Preliminary Injunction are true and correct to the best of $ny knowledge, information and belief. I understand that any fall wi! statements therein are subject to the penalties contained in 1.8 Pa. C. S. § 4904, relating ha unsworn falsification to authorities. Dated.: -- M J e tker, NHA 12M% CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a true and correct copy of the foregoing Plaintiff's Motion for Preliminary Injunction was served by first-class United States mail, postage prepaid, upon the following: Tricia Roberts 63 East North Street Carlisle, PA 17013 Frances R. Roberts 65 East North Street Carlisle, PA 17013 Date: -? 31. ??t - ------ - Steven M. Montresor 128491 Steven M. Montresor smontres@ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS i ? J j n C. CUMBERLAND COUNTY, PENNSYLVANIA -,-, IT, M r r, ? UNITED CHURCH OF CHRIST HOMES, INC.; ct) d/b/a SARAH A. TODD MEMORIAL HOME _ -T 1000 West South Street Carlisle, PA 17013 Plaintiff, ?9- NO. rc? V. TERM, 2009 TRICIA ROBERTS CIVIL ACTION - 63 East North Street LAW AND EQUITY Carlisle, PA 17013 and FRANCES ROBERTS 65 East North Street Carlisle, PA 17013 Defendants. 128481 NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyers Reference Service Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (800) 990-9108 (717) 249-3166 128481 Steven M. Montresor smontres@ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA UNITED CHURCH OF CHRIST HOMES, INC. d/b/a SARAH A. TODD MEMORIAL HOME 1000 West South Street Carlisle, PA 17013 Plaintiff, V. TRICIA ROBERTS 63 East North Street Carlisle, PA 17013 and FRANCES ROBERTS 65 East North Street Carlisle, PA 17013 Defendants. NO. TERM, 2009 CIVIL ACTION LAW AND EQUITY 128481 COMPLAINT AND NOW COMES, Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home, by and through its attorneys, Latsha Davis Yohe & McKenna, P.C., and files the within Complaint against Defendants, Tricia Roberts and Frances Roberts, and in support thereof, avers as follows: 1. Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home (hereinafter "Sarah Todd"), is a Pennsylvania non-profit corporation with offices located at 30 North 31 st Street, Camp Hill, Pennsylvania 17011. 2. Sarah Todd owns and operates a long-term care skilled nursing facility located at 1000 West South Street, Carlisle, Pennsylvania 17013. 3. Sarah Todd provides living accommodations and skilled nursing care (hereinafter "Nursing Care Services") 4. Defendant Tricia Roberts is an adult individual currently residing at 63 East North Street, Carlisle, Pennsylvania 17013. 5. Defendant Frances Roberts is an adult individual currently residing at 65 East North Street, Carlisle, Pennsylvania 17013. 6. Tricia Roberts' mother, Frances Roberts, is a former resident of Sarah Todd. Frances Roberts appointed Tricia Roberts as her Agent pursuant to a Durable General Power of Attorney dated March 27, 2008. A true and correct copy of the Power of Attorney is attached hereto as Exhibit "A" and made a part hereof. 8. Frances Roberts was admitted to Sarah Todd on or about May 29, 2008. 9. On or about May 29, 2008, Sarah Todd and Tricia Roberts, on behalf of Frances Roberts, entered into a Nursing Home Admission Agreement (hereinafter "Admission 128491 2 Agreement"), whereby Sarah Todd agreed to provide Frances Roberts with Nursing Care Services. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and made a part hereof. 10. Tricia Roberts is designated as "Responsible Person" under the Admission Agreement. 11. On or about May 29, 2008, Sarah Todd and Tricia Roberts, as Frances Roberts' Responsible Person, entered into a Responsible Person Agreement. A true and correct copy of the Responsible Person Agreement is attached hereto as Exhibit "C" and made a part hereof. 12. On or about July 24, 2008, Sarah Todd submitted a Medical Assistance application to the Cumberland County Assistance Office ("CAO") on behalf of Frances Roberts. 13. On August 22, 2008, Tricia Roberts, as Agent for her mother, sold Frances Roberts' property located at 67 East North Street, Carlisle, Pennsylvania 17013, which property has an assessed total value of $67,480.00, to a Gary Leach for $45,000.00. 14. The CAO denied the Medical Assistance application on September 3, 2008 due to Tricia Roberts' failure to provide certain documentation requested by the CAO. A true and correct copy of the "Medicaid Not Eligible Notice" is attached hereto as Exhibit "D" and made a part hereof. 15. The documentation requested by the CAO included: a. Verification of the disposition of the funds received from the sale of Frances Roberts' home on August 22, 2008; b. Verification that Frances Roberts' available resources were below the $8,000 limit; and 128481 C. Verification of the cash value of a certain annuity or statement of irrevocability from the annuity company. 16. On or about November 12, 2008, Sarah Todd submitted a second Medical Assistance application to the CAO on behalf of Frances Roberts. 17. The CAO denied the second Medical Assistance application on December 30, 2008, due to Tricia Roberts' failure to provide certain documentation requested by the CAO. A true and correct copy of the "Medicaid Not Eligible Notice" is attached hereto'as Exhibit "E" and made a part hereof. 18. The documentation requested by the CAO included: a. Verification of statements for all of Frances Roberts' bank accounts, annuities, Keoghs, IRAs, stocks and bonds as of August 1, 2008; b. Verification of the proceeds received in the sale of Frances Roberts' home, disposition of funds received after the sale of the home; C. Verification of all resources of Frances Roberts sold, transferred or given away in the past 36 months; and d. Verification of why Frances Roberts received $45,000 for her home that was listed as having a fair market value of $57,000. 19. Tricia Roberts, as Frances Roberts' Agent and Responsible Person, had both a fiduciary and a contractual duty to use Frances Roberts' assets and/or resources to compensate Sarah Todd for the Nursing Care Services which it provided to Frances Roberts and to keep her account current. 20. At all times relevant, Sarah Todd provided Nursing Care Services to Frances Roberts in accordance with the Admission Agreement. 128481 4 21. Tricia Roberts has failed to use Frances Roberts' assets and/or resources to pay Sarah Todd for the Nursing Care Services which Frances Roberts received at Sarah Todd. 22. Frances Roberts was discharged from Sarah Todd on November 8, 2008. 23. A balance in the amount of $30,796.69, plus interest is currently due and owing to Sarah Todd for the Nursing Care Services that it provided to Frances Roberts. A true and correct copy of the A/R Account Detail is attached hereto as Exhibit "F" and made a part hereof. COUNT I - BREACH OF CONTRACT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts and Frances Roberts 24. Paragraphs 1 through 23 above are incorporated herein by reference as if fully set forth at length. 25. Tricia Roberts, as Frances Roberts' Responsible Person, entered into the Responsible Person Agreement with Sarah Todd as more fully set forth above. See Exhibit "C". 26. The Responsible Person Agreement obligates Tricia Roberts to provide payment from Frances Roberts' income and resources and to apply Frances Roberts' income and resources to the costs and charges incurred during her stay. 27. From May 29, 2008 through November 8, 2008, Sarah Todd provided Nursing Care Services to Frances Roberts pursuant to the aforementioned Admission Agreement. 28. Frances Roberts had a contractual obligation to make payments to Sarah Todd. 29. Tricia Roberts had a contractual obligation, as Frances Roberts' Responsible Person, to make payments on Frances Roberts' account from Frances Roberts' assets and/or resources. 128481 5 30. Frances Roberts has an overdue balance in her account with Sarah Todd, which is currently in the amount of $30,796.69, plus interest. 31. The failure of Frances Roberts to pay the outstanding balance on her account with Sarah Todd constitutes a breach of the Admission Agreement. 32. The failure of Tricia Roberts to pay the outstanding balance on Frances Roberts' account with Sarah Todd constitutes a breach of the Responsible Person Agreement. 33. According to Section 3.2 of the Admission Agreement, Sarah Todd may recover attorney's fees and costs of collection, which total $2,605.50 as of January 31, 2009. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $33,402.19 together with interest, attorney's fees and costs of collection. COUNT II - INJUNCTIVE RELIEF United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 34. Paragraphs 1 through 33 above are incorporated herein by reference as if fully set forth at length. 35. The Responsible Person Agreement obligates Tricia Roberts, as the Responsible Person, to take any and all actions necessary and appropriate to initiate, make and conclude an application for Medical Assistance benefits on Frances Roberts' behalf, "including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals." See Exhibit "C", ¶ 3. 36. Tricia Roberts did not comply with this contractual obligation. 128481 6 37. The failure of Tricia Roberts to comply with her contractual obligation to assist in the Medical Assistance application process constitutes a breach of the Responsible Person Agreement. 38. The breach of the Responsible Person Agreement resulted in the CAO denying Medical Assistance benefits. See Exhibits "D" and "E". 39. Sarah Todd has no other means of securing the documents necessary to be turned over to the CAO in order for it to make a determination on Frances Roberts' benefits. 40. As Agent and Responsible Person, Tricia Roberts is the only person with such access to Frances Roberts' documentation. WHEREFORE, Plaintiff requests that the Court enter an order compelling Tricia Roberts to take all steps necessary to turn over to the CAO any and all the information identified in the CAO's Medicaid Not Eligible Notice dated December 30, 2008. COUNT III - QUANTUM MERUIT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts and Frances Roberts 41. Paragraphs 1 through 40 above are incorporated herein by reference as if fully set forth at length. 42. Sarah Todd has demanded payment in full for the Nursing Care Services which it provided to Frances Roberts, and has not received payment for the same. 43. Sarah Todd is entitled to receive payment in full for the reasonable value of the Nursing Care Services it provided to Frances Roberts. 128481 7 44. Frances Roberts has been unjustly enriched and enhanced by the receipt of Nursing Care Services which have been rendered by Sarah Todd to her in the amount of $30,796.69 plus interest. 45. To the extent Tricia Roberts has retained Frances Roberts' assets and/or resources and has failed to pay for the care and services rendered by Sarah Todd to Frances Roberts, Tricia Roberts has been unjustly enriched. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $30,796.69, together with any other relief the Court deems just and equitable. COUNT IV - CONVERSION United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 46. Paragraphs 1 through 45 above are incorporated herein by reference as if fully set forth at length. 47. Upon information and belief, Tricia Roberts converted, misappropriated and deprived Frances Roberts of her right in, use and/or possession of her property as more fully set forth above. 48. To the extent Tricia Roberts' conversion, misappropriation and deprivation of Frances Roberts' right in, use and/or possession of the aforementioned property was for the purpose of hindering or delaying their transfer to Sarah Todd, these actions were beyond Tricia Roberts' authority as Frances Roberts' Agent. 49. As a result of the foregoing unlawful actions of Tricia Roberts, Sarah Todd has incurred damages in the amount of $30,796.69 plus interest. 128491 8 WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest. COUNT V - FRAUDULENT TRANSFER United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 50. Paragraphs 1 through 49 above are incorporated herein by reference as if fully set forth at length. 51. Upon information and belief, Tricia Roberts transferred Frances Roberts' assets and/or resources without receiving reasonably equivalent value and/or for the purpose of hindering and delaying their transfer to Sarah Todd. 52. Upon information and belief, Tricia Roberts accepted the transfer(s) of Frances Roberts' assets and/or resources with full knowledge that the transfer was not for reasonably equivalent value and/or that the purpose of the transfer was to avoid paying Sarah Todd for the Nursing Care Services that it has rendered to Frances Roberts. WHEREFORE, Plaintiff demands judgment in its favor, and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest. COUNT VI - FILIAL SUPPORT United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home vs. Tricia Roberts 53. Paragraphs 1 through 52 above are incorporated herein by reference as if fully set forth at length. 128481 9 54. Upon information and belief, Tricia Roberts, as Frances Roberts' Agent, transferred Frances Roberts' assets to herself or otherwise misappropriated said assets. 55. Upon information and belief, the above-referenced transfer and/or misappropriation of assets rendered Frances Roberts indigent and unable to pay the outstanding balance owed on her account. 56. Tricia Roberts is Frances Roberts' daughter. 57. As a result of Tricia Roberts' transfer or misappropriation of her mother's assets, Tricia Roberts has the ability to satisfy her mother's debt to Sarah Todd. 58. Pursuant to 23 Pa.C.S. § 4603, Tricia Roberts has a statutory obligation to care for, maintain or financially assist her mother. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Tricia Roberts, in the amount of $30,796.69 plus interest, together with an Order directing Defendant, Tricia Roberts, to take all steps necessary to turn over to the CAO any and all the information identified in the CAO's Medicaid Not Eligible Notice dated December 30, 2008. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.C. Dated: ?• By; )- Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home 128481 10 VERMCATION I, Mary Jane Walker, hereby verify that I am the Administrator of Sarah A. Todd Memorial Home, that I am authorized to make the within Verification;' and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: ?. •/ °? ' -U `? V'I Q 0- J ) /?'" Jane alker, NHA f Exhibit A pila"LE sENERw>! NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT,) BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE 'OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR VPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY OR YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AOENrS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA. C. S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. March 18, 2008 I-It FRANCES R. ROBERTS d KNOW ALL MEN BY THESE PRESENTS, that 1, FRANCES R. ROBERTS, of Carlisle, Pennsylvania, do by these presents make, constitute and appoint STEPHANIE E. LEACH, andl or TRICIA P. ROBERTS, jointly or independently (thereinafter referred to as "my agent"), my true and lawful agent under a power of attorney, for me and in my name and on my behalf generally, to do and perform all matters and things, including, without Iinhiting the generality of the foregoing, to transact all business, to make, execute, acknowledge, endorse and deliver all deeds of conveyance, certificates of stock, bonds, car titles, releases of lien or satisfaction of bonds and mortgages, contracts, orders, releases, checks, notes and endorsements, transfers and assignments of any such contracts, specifically including but in no way limited to the execution in my name of checks or orders of any nature for the withdrawal of funds standing to my credit in any type of account in any bank, building and loan association or other financial institution, and also to deposit in any accounts in my name in any such institutions any money, funds, checks or drafts, payable or belonging to me; to enter my safe deposit boxes in any and all banking institutions and to establish new safe deposit boxes and to add to and to remove any of the contents thereof; to borrow money and to mortgage, pledge or hypothecate any property, real or personal, now or hereafter owned by me as security therefore; to buy, sell possess, insure, manage, maintain, improve, lease, mortgage, pledge, encumber, convey and otherwise dispose of, or take any other action with respect to, any property, reap or personal, now or hereafter owned by me, on such terms and conditions as my agent may consider appropriate, and in the event of sale of any of my real estate, to execute the sales agreement and the deed in my name and to make settlement and receive the proceeds; and to prepare, execute and file any tax returns, governmental reports and other instruments of whatever kind, and likewise to execute any and all writings, assurances, instruments or documents which may be requisite or proper to effectuate any matter or thing appertaining or belonging to me. I hereby authorize my agent to contract with and arrange for my entrance to any hospital, nursing home, health center, convalescent home, residential care facility or similar institution, to authorize medical, therapeutic and surgical procedures for me and to pays all bills in connection therewith. GIVING AND GRANTING unto my agent full authority and power to do and perform any and all other acts necessary or incident to the performance and execution of the powers herein expressly granted, with power to do and perform all acts authorized hereby as fully to all intents and purposes and with the same validity as I might or could so if personally present, hereby ratifying and confirming whatsoever all that my agent shall lawfully do or cause to be done by virtue hereof. AND, I hereby declare that any act or thing lawfully done hereunder by my agent shall be binding on myself and my heirs, legal and personal representatives and assigns. AND, if incapacity proceedings for my estate or person are hereafter commenced. I hereby nominate my agent to be appointed the guardian of my estate or person by any court having jurisdiction in accordance with the provisions of Section 5604 (c ) (2) of the Probate, Estates and Fiduciaries Code. This Power of Attorney shall continue in force and may be accepted and relied upon by anyone or any entity to whom it is presented despite my purported revocation of it or my death, until actual written notice of any such event is received by such person or entity. In the event of my incapacity from whatever cause, this Power of Attorney shall not thereby be revoked but shall thereupon become irrevocable and may be accepted and relied upon by anyone or any entity to whom it is presented despite such incapacity, subject only to it becoming void and of no further effect only upon receipt by such person or entity either of (1) written evidence of the appointment of a guardian (or similar fiduciary) of my estate following adjudication of incapacity, or (2) written notice of my death. This Power of Attorney shall not be affected by my subsequent disability or incapacity. This power of attorney shall rescind and revoke any other powers of attorney previously made by me. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 18' day of March 2008. WITNESSED BY: 4 (SEAL) LACES R. ROBERTS COMMONWEALTH OF PENNSYLVANIA : :SS: COUNTY OF CUMBERLAND On this, the 18TH day of March 2008, before me, the undersigned officer, personally appeared FRANCES R. ROBERTS, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that she executed same for the purposes therein contained. COMMONMAL'IH OF PENNSMAMA NOTARIAL SEAL Harold S. a?b i' Notary County Notary Public My m mtision expires February 06, 2411 AQ?cNOw? wirmik G1 IIIIEmy A INT 1, STEPHANIE E. LEACH, and I, TRICIA P. ROBERTS, have read the attached Power of Attorney executed by FRANCES R. ROBERTS and am the person identified as the Agent for the PRINCIPAL. I hereby acknowledge that in the absence of a specific' provision to the contrary in the Power of Attorney or in 20 PA. C. S. when I act as Agent: I shall exercise the powers for the benefit of the PRINCIPAL. I shall keep the assets of the PRINCIPAL separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the PRINCIPAL. March 21._.? .. ?' 52008 STEPHANIE F.A. LEACH March '77 2008 t UL TRICIA P. ROBERTS COMMONWEALTH OF PENNSYLVANIA : COUNTY OF CUMBERLAND :SS: On this, the 77 day of March 2008, before me, the undersigned ofFicet, personally appeared STEPHANIE E. LEACH and TRICIA P. ROBERTS, known to me or satisfactorily proven to be the persons whose names are subscribed to the within acknowledgment and acknowledged that they executed same for the purposes therein contained. WITNESS my hand and seal the day and year COIrAlOAIWEAE TH OF PEWSYL.YANIA v -"- " \_.A? NOTARIAL SEAL Notary Public Harold S. Irwin Iii, Esq, Notary Public Carlisle, Cmnberlaod Comity MY eo WM expires FftM K 2011 Exhibit B UNITED CHURCH OF CHRIST HOMES NURSING HOME ADMISSION AGREEMENT This Agreement is made by and between 3 a Pennsylvania non-profit nursing home, (hereinafter called "Falcility") and Resident and his/her legal representative and/or the individual who has access to Resident's income 'and financial resources available to pay for nursing care (hereinafter called "'Responsible s ") for the provision of nursing services for 6 (hereinafter called "Resident"). Resident and Responsible Person affirm that the information provided in the Admission Application is true and correct to the best of their knowledge, and acknowledge that the submission of any false information may constitute grounds to terminate this Agreement. Therefore, the Facility, Resident and Responsible Person, intending to be legally bound, agree to the following terms and conditions: 1. PROVISION OF SERVICES. 1.1 Nursing Services. Be ginning on the designated admission date, the Facility will provide Resident with (a) the routine nursing services described in the Schedule of Charges, attached to this Agreement and incorporated by reference; (b) private or semi-private accommodations, as applicable; (c) three meals each day, except as otherwise medically indicated; (d) blankets, bed linens, towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services; and (g) activity programs and social services as established by the Facility. 1.2 Ancillary Services and Supplies. The' Facility will provide ancillary services and supplies as identified on the Schedule of Charges, and such other ancillary services and supplies at the option and upon the request of the Resident, or upon the direction of Resident's treating physician or the Facility's Medical Director. The ancillary services and supplies identified on the Schedule of Charges are subject to change from time to time at the discretion of the Facility. 1.3 Services of Other Providers. The services of outside providers such as a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, rehabilitation therapies and diagnostic services, laboratory, x-ray, podiatry, optometry, medications, ambulance services and hearing aid. repair are available from time to time at the Facility. These services are available under guidelines and procedures established by the Facility and may be utilized by Resident at his or her own expense. 1723 Nursing Agreement 12-15-04; 5-06 1.4 1 The Resident shall select a qualified physician, f? =o a t of phy?, who will provide medical care during the Resident's stay at the Facility and who shall comply with the Facility's rules, regulations, policies and procedures. The Facility is not permitted to provide Resident with any medicines, treatments, special diets or equipment without specific orders or directions from Resident's attending physician. In the event Resident's personal physician is unavailable, the Facility's Medical Director may issue appropriate orders. Resident is responsible to pay for all services or equipment ordered by Resident's atkwAing physician or the Fity's Medical Director for Resident's care. 2. CHARGES. 2.1 e f S Resident shall pay the Daily Routine Service Charge, speeded in the S dtt e of Charges in effect at the, time the service is rendered, for routine nursing services provided to Resident. The Daily Routine Service Charge may be changed from time-to- time in accordance with the provisions of Section 3.3. Charge for a resident whose payor source is other than Medicare Part A or Medicaid willbegan on the desisted admission date or actual admission, whichever is earlier; charges for a resident whose payor source is Medicare Part A or Medicaid will begin no earlier than the date of admission. 2.2 Ad 'sa Resident shall pay for other services and supp ` provided by or throes the SANy which are not covered by the Daffy Routine Service Charge as set forth in the Schedule of C rges in effect at the time such ancillary services or supplies are rendered. Any items ordered by a physician, which are not identified on the Schedule of Charges, wlil be provided at charges identified by the Facility.- The charges for ancillary services and supplies are subject to change from time to time. 2.3 ghff&es for . In addition to the Facility's charges, Resident shall pay an fe" and costs for goods or services furnished to or for Resident by anyone other than the Facility as described in Subsection 1.3 (Services of Other Providers) unless otherwise covered in full by Medicare or Medicaid or another third-party payor. Resident or Responsible Person is obligated to pay such fees and costs whether the goods and services are furnished by a person or provider made available by the Facility, or by a person or provider selected by Resident, and whether the goods or services are provided at the Facility or elsewhere. These frees and costs are not included in the Daily Routine Service Charge. Fees for professional services rendered by a physician are not included in the Daily Routine Service Charge and will be charged directly to the Resident by the Physician. 1723 Nursing Agreement 12-15-04 2 3. PERIODIC BILLINGS AND PAYMENT DUE DATE. 3.1 Monthly Statements and Other Billings. If permitted, prepayment for one month of the basic monthly rate is required at the time of admission. The Facility will mail Resident or Responsible Person on or about the tenth (10th) calendar day of the month a billing statement reflecting charges for nursing services for the upcoming month and charges for ancillary services and supplies which were incurred in the prior month Statements are due and payable upon receipt of the Monthly Statement. 3.2 Late Charges and Cost of Collection. Any monthly statements not paid within thirty (30) days of the date of the statement are subject to a late charge of one and one-quarter percent (1.25%) per month (annual rate of fifteen percent (15%)), and Resident or Responsible Person is obligated to pay any late charges. In the event the Facility initiates any legal actions or proceedings to collect payments due from Resident under this Agreement, Resident or Responsible Person shall be responsible to pay all attorney's fees and costs incurred by the Facility in pursuing the enforcement of Resident's financial obligations under this Agreement. 3.3 Modification of Charges. The Facility reserves the right to change the Schedule of Charges reflecting the amount of any of its charges or how.and when charges are computed, billed or become due. The Facility shall provide thirty (30) days advance written notice of any such changes. 3.4 Obligations of Resident's Estate and AssipMent of Property. Resident and Responsible Person 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 the 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 the Facility an amount equivalent to any unpaid obligations of Resident under this Agreement. 4. OBLIGATIONS OF RESPONSIBLE PERSON. 4.1 General Obligations. Resident has the right to identify a Responsible Person (usually the Agent in the Resident's Power of Attorney or Guardian), who shall be entitled to receive notice in the event of transfer or discharge or material changes ' the ident' c on, and changes to this Agreement. Resident elects to name th Ra, of 1723 Nursing Agreement 12-15-04 [address], as the Responsible Person. The Resident's selected Responsible Person shall sign this Agreement and the Responsible Person Agreement in recognition of this d ag cm with the it ,t to be legally bound by all provisions in this Agreement and the Responsible Person Agreement. The Responsible Person shall be obligated to i 11 the dubes, on half of the Resident imposed by this Agreement and the Respond Pew Agent inn awe with the law governing fiduciary duties. The F sty may potion a court to appaint a Guardian and take other legal action if the Fadlity ray bias tlrutt the Resident's needs are not being properly meet or the duties impamd by this Agreement or the,Responsible Person Agreement are not being fd by the ResponsiWe Person.. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. 4.2 Poto;?g Li m. The Responsible Person's duty, ob ations and responsibiht es are set forth in the Responsible Parsers A g r t, which is incorporated by reference herein in its entirety. By signing this Agar Rible Persons acknowledges he/she has read the Responsible Person Agveeuw4, ds the terms therein, and that he/she shall be bound by all terms set forth in the Responsible Person Agreement. 5. MEDICAP.E/MEDICAID PROGRAMS. 5.1 Partic.ar-awm in XWOMW The Facility curreWy Patel in the Pennsylvania (Medical Askance program ("meth d") and the i ai. Medicare program. The Facility reserves the right to withdraw from the Medicaid or Med-icare programs at any time in accordance with law. 5.2 Ac:tjM_ of N#AjWd tad ; The Pen W, Department of Public Welfare ("DPW") is resPOIRS"e for a?ig bavAts under the Medicaid program. The Centers for Medicare and Medkasid Services ("CMS" ), of the United. States Department of Health and Human Services, is resp?le for admiarsistering the Medicare program through an interdiary. Resadmt wl .ges that the Facility is not responsible for, and has made no repions rig, the actions or decisions of DPW, CMS or the Medicare ins di ry in ? the 1 95 programs. 5.3 MoV id &NO • (a) Resident is oblted to make full and complete disclosure regarding all f rewnuces and income during the application process. Failure to identify all resources and income, or the submission of false information, may result in the term*iatibon of this Agreement. Resident is obligated to notify the Facility when Resident's resources available to shy the 1723 Nursing Agsement 12-15-U4 4 Resident's financial obligations under this Agreement have been reduced to Fifteen Thousand Dollars ($15,000). Resident is obligated to apply for Medicaid benefits at such time as Resident's resources will no longer be sufficient to pay all the Facility charges for Resident's care and stay or when directed to do so, by the Facility. In the event Resident applies for Medicaid benefits, Resident shall continue to pay and apply all of Resident's available resources toward the fulfillment of Resident's financial obligations under this Agreement while the Medicaid application is pending an eligibility determination by DPW. (b) Patient Pay Amount. For residents approved for Medicaid benefits, the Facility will accept payment from the Commonwealth of Pennsylvania and, if applicable, the Resident's Patient Pay Amount as determined by DPW as payment in full only for those services covered by the Medicaid program. Resident remains obligated to pay such Patient Pay Amount, less any qualified medical expense deductions, on a monthly basis. Services not covered by Medicaid are identified in the Schedule of Charges and Resident remains obligated to pay for such services. In the event Resident applies for Medical Assistance benefits, Resident or Responsible Person, to the extent permitted by law, shall arrange for assignment to the Facility of any payment on behalf of Resident in an amount equivalent to the Patient Pay Amount as determined by DPW. (c) Determination of Eligibility. Resident and Responsible Person are -obligated to ' cooperate fully in any Medicaid eligibility determination or redetermination process. In the event that Resident's eligibility fori, Medicaid benefits is denied, interrupted or terminated due to the failure of Resident or Responsible Person to cooperate in the Medical Assistance application, redetermination or appeal process, the Resident and Responsible Person shall be liable for the D4y Routine Service Charge plus charges for ancillary services and supplies during any non-payment, and the Facility may terminate this Agreement. . (d) Authorization to Appeal (Medicaid).i In the event of Resident's incapacity and in situations where Resident's resources are depleted or appear to be depleted to the extent that Resident can no longer pay privately for nursing care, and it appears that Resident has become or will'become eligible for Medicaid benefits to cover the cost of Resident's continued stay in the Facility; and if there is no other legal representative of Resident known to the Facility or other friend or relative known to the Facility who is authorized and/or is available or willing to act on Resident's behalf, after the Facility has made a good faith effort to identify such persons; then Resident hereby authorizes the Facility to request, file and/or apply for Medicaid benefits on behalf of Resident for the limited purpose of assisting Resident to secure payment through the Medical Assistance program for Resident's continued stay in the Facility. In the event the application for Medicaid benefits filed on behalf of the Resident is denied, or in the event Medicaid benefits are granted and subsequently 1723 Nursing Agmement 12-15-04 5 discontinued, Resident hereby authorizes the Fatty to file on Resident's behalf an appeal- of any such denial of Med d el ty or disc of Maw: benefits, and to take such actions to secure Resident's Medicaid bend as the FadW deems reasonably necessary or appropriate and cotes wi law. R "Went warrants and represents that the financial information dicloased in the Admission App al is true and accurate and may be relied on by the Facility in pursuing be bits on behalf of Resident. (e). A n to F' a W gv D' n pf KjjdM& If DPW's applicat am of the "trair of assets„ or "look-back period" requirements for ;Medical Assistance Eli gWfifty as wished by the federal Deficit Redaction Act of 2005 operates to deprive Resident of uudical cage, food, clothing or shelter, or if Resident's life would be endangered as a result of DPW's Medical Assistance Eligibility decisions, then m. the event of Resu enfs incapacity, and if there is. no. other legal representative of Resident known to the Facility or any other friend or relative known to the Facility who is authorized and/or is promptly available or willing to act timely on behalf of Re=sident, Re ideat aut torizes Facility to file a Hardship Waiver with. DPW on Resident's behalf, consist with the procedures established by DPW pursuant to the requirements of Section 6011 of the Deficit Reduction Act of 2005. 5.4 a To the extent that Resident is a beneficiary udder either 'I+ 6=e part A or aajre Part B inswance and the nursing services or ancillary services or suppers ordered by a physidw are covered by such insurance, the Facility or outer provider will bill the charges for the covered services or supplies to the Medicare program. The Rdt is rasparw*k for and shall pay any co-insurance or deductible amounts under Medicare Part A or Part B insurance. The Facility shall accept payanent from the Medxare mtermediary as payment in full only for those services deed to be covered in full under the Medicare Part A or the. Medicare Part B program.. Services not covered by Medicare are identified in the Schedule of Charges. 5..5 TQtt&2ve rv i s. Resident is and rerutins obligated to pay the Facility for services and supplies not covered by the Medicaid or the Medicare programs. 5.6 e (a) ,% . Effective January 1, 2046, the Centers for Medicare and Medicaid Services ("CMS") imposed payment limitations on covered therapy services provided to individuals who are eligible beneficiaries under Medicare Part B. Under thin financial Limitation, Medicare will pay an annual capped amount for physical and speech therapy (combined) and an annual capped amount for 1723 Nursing Agreement 12-15-04 6 occupational therapy. The capped amounts are revised by CMS annually. Facility shall provide resident and/or Responsible Person with notice of the current capped amounts as appropriate. (b) Resident's Responsibility to Pater Therapy Services Beyond the Capped Amounts. Resident is responsible to pay the charges for all medically necessary therapy services in excess of the annual capped amounts, unless such therapy services are covered in whole or in part by private insurance or another government reimbursement program. In the event that mother government reimbursement program or available third party payor or insurance program denies coverage for therapy services provided to Resident after exhaustion of the annual capped amount, then Resident of responsible Person shall remain responsible to pay all fees and costs for all such therapy services. If resident is not eligible for Medical assistance, then failure to pay for therapy services rendered above the capped amount shall be grounds for termination and discharge from Facility pursuant to Section 11 of this Agreement. (c) Exception Requests. Medicare beneficiaries are entitled to request an exception to the annual therapy caps, for up to fifteen (15) additional treatment days. In the event that resident has exhausted the annual capped amount, then the following shall apply: i) Resident and/or Responsible Person may submit an exception request to the applicable CMS Medicare contractor; or ii) In the event of Resident's incapacity, and if there is no other legal representative of resident known to the Facility or any other friend of relative known to the Facility who is authorized and/or?is promptly available or willing to act timely ou behalf of Resident, then Resident authorizes Facility to submit an appropriate exception request to the applicable CMS Medicare contractor. iii) If the exception request is grantedl then therapy services provided to resident shall be covered by Medicare for the number of additional treatments approved. 'Once the additional approved treatments have been exhausted, Resident shall be responsible to pay all fees and costs for additional therapy services provided as noted in this Section 5.6(b). 1723 Nursing Agreement 12-15-04 ? iv) If the exception requet is did, alum Rat shall be responible to gray all fees and COBW for anal therapy services provided as noted in this Sectkm 5.6(b). 6. CAGED CARE ORGAN ATIONS. 6.1 P ce, The Facility is an authorized provider of skilled nursing services to mbsrs of certain td care organizations (MCOs). The Resident will be given a list of the MCOs for whom the Facility is an authorized provider. 6.2 a Resi st or Responsible Person shall notify the Facility in writing prior to enrol king with a MCO or switching Resident's MCO enrollment. 6.3 Actitvrts of 11AS M . Resident acknowledges that an MCO for whom the Facility is not an au4mized provider may not approve payment for services provided by the Facility. Reaideat acknowledges thAt the Facility is not responsible for and has made no representations regarding the actions or decisions of any MCO for whom the Facility is an authorized provider, including decisions relating to a denial, of coverage. 6.4 ONjW WM of The Facility will accept payment from the MCO as payment in full only for those services and supplies covered by the MCO. Resident is responsible for any co-payments or other costs assigned to Resident under the specific terms of the managed care plan. Resident also shall pay for any services or supplies not covered by the MCO under the specific terms of the managed care plan. Co-payments and other costs assigned to Resident and charges for services or supplies not covered by the specific terms of the managed care plan are identified in the Schedule of Charges. Managed care plans typically require pre-authorization of services by the MCO. If Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Facility for those.services. Resident shall pay the Facility in a timely manner for all non-coveted services retroactive to the date of the initial delivery of services. 6.5 Wit ca al frcuu Parma in t MgO. The Facility reserves the right to ate its contractual relationship and its status as a network or authorized provider with, one or more of the listed MCOs at any time in accordance with law. and the terms of the applicable agreement. In the event that the Facility terminates its contractual relationship with the MCO in Which Resident is enrolled, Resident may convert his or her coverage to a health plan for whom the Facility is an 1723 Nursing Agreement 12-15-04 8 authorized provider or transfer to a facility that is an authorized provider for Resident's MCO. The Facility shall provide thirty (30) days advance notice of its decision to withdraw as a participating provider from Resident's MCO so Resident and the MCO can coordinate a transfer to another facility. 6.6 Notice of Change in Insurance Coverage, Resident and/or Responsible Person shall notify the Facility immediately of any change in Resident's insurance status or coverage made by the insurance carrier including, but not limited to, being dropped by the insurance carrier for any reason, or a decrease or increase in insurance benefits. Resident and/or Responsible Person. shall give the Facility notice before Resident is unable to meet Resident's insurance premium or before Resident implements an increase, decrease or termination from insurance coverage. 7. DURABLE FINANCLAI /HEALTH CARE POWER-CIF-ATTORNEY. Resident is strongly encouraged to furnish to Facility, no later than the date of admission, a durable Financial/ Health Care 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 health care decisions, financial decisions and payment of services. In the event Resident fails to designate an Agent under a Power-of-Attorney, Resident 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. 8. THIRD-PARTY PAYMENTS. 8.1 Eligibility for Third-Party Pa ments. Resident may be or may become eligible to receive financial assistance, reimbursement, or other benefits from third parties, such as private insurance, employee benefit plans, Medical Assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, managed care coverage, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance. It is the responsibility of the Resident and/or Responsible Person to apply for these benefits. If Resident is or becomes eligible to receive payments from any third parties for 'Resident's stay and care, the Facility reserves the right to collect such payments directly from the third- party source. The Resident and Responsible Person shall at all tilmes cooperate fully with the Facility and each third-party payor to secure payment. Cooperation includes providing information; signing and delivering documents; and assigning to the Facility (to the extent permitted by law) any payments for the Resident from federal or state governmental assistance programs or any other reimbursement or benefits to the extent of all amounts due the Facility. 1723 Nursing Agreement 12-15-04 q 8.2 Resident irrevocably authorizes the Facility to make claims and to take otfier actions to secure for the Fity receipt of third-party payments to reimburse the Facility for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payn=t of the Facility's charges, Resident hereby assigns to the Facility all of Resident's rights t0 any third-party payments now or subsequently payable to the extent of all charges due under this Agreement. Resident or Respanexible Person promptly " endorse and turn over to the Facility any paymento; received from third parties to the extent necessary to satisfy the charges under this Agreewmt. Rent or Respww a Person shall sign any necessary documents to forward third-party payments directly from the payor to the Facility. 8.3 Insurance. In the event of an initial or subsequent denial of coverage by the Resident's insurance carrier, Resident .sh;all pay the Facility timely for all noncovered services retroactive to the date of the initial delivery of services, so long as such payment obligation is consistent with the regulations governing the Faciliti's participation intthe Medicare and Medicaid Programs. 9. PERSONAL NNA.NCE6. 9.1 Pers+al hipippOW& jj? Resident is responsible to provide his or her personal funds, and Resident has the right to n axtage his or her personal funds. Resident may authorize the Facility, in writing on a document provided by the Facility; to hold Resident's personal funds, and may revoke at any time the Facility 's authorization by providing the Facility with a written notice signed and dated by Resident.or Responsible -Person. If Resident authorizes the Facility to hold Resident's personal funds, the Facility shall hold, safeguard and account for Resident's personal funds in accordance with applicable policies available to the Resident on request. 9.2 RL,ads of Peoo _EMU& Any personal funds or valuables of Resident held by the Facility will be refunded, sub*ct to deductions for payment of any outstanding bills or other amounts due the Facility, such as any costs incurred by Facility to repair Resident's room for damages caused by Resident, within thmi ty (30) days after Resident's discharge or death. In the event of Resident's death., such refund will be made to the duly authorized representative of Resident's estate or to such entities or persons entitled to the refund under current law. 9.3 Refun& of PreR&XMg or Qy ,,,ay Any prepayments or overpayments made by Resident and held by the Facility will be refunded, subject to deductions for payment of any outstanding bids or other amounts due the Facility, within sixty (60) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's 1723 Nursing Agreement 12-15-04 10 estate or to such other entities or persons entitled to the refund under current law. No interest shall accrue on any funds required to be refunded under this Agreement. 10. CHANGES IN ROOM ASSIGNMENTS. The Facility reserves the right and discretion to 'transfer Resident to another room or bed within the Facility, and the right and discretion to transfer Resident's roommate, if any, at any time consistent with the needs of the Facility. 11. TERMINATION, TRANSFER OR DISCHARGE. 11.1 Resident Initiated. Resident may terminate this Agreement upon seven (7) days written notice to the Facility. If Resident leaves the Facility for any reason other than a medical emergency or death, Resident must give written notice to the Facility at least seven (7) days in advance of transfer, discharge or termination of this Agreement. 11.2 Facility Initiated. The Facility may terminate this Agreement and Resident's stay and transfer or discharge Resident if. (a) the transfer or discharge is necessary to meet Resident's welfare and Resident's needs cannot be met in the Facility; (b) Resident's health has improved sufficiently so that Resident no longer needs the services provided', by the Facility; (c) the safety or health of individuals in the Facility is or otherwise would be endangered; (d) Resident has failed, after notice, to pay for (or to have paid or treated as paid under the Medicare or Medicaid Programs) charges for Resident's care and stay at the Facility; or (e) The Facility ceases to operate. 11.3 Notice and Waiver of Notice. The Facility will'',notify Resident and Responsible Person (or if none, a family member or legal representative of the Resident, if known to the Facility) at least thirty (30) days in advance of transfer or discharge, except in situations when appropriate plans that are acceptable to the Resident can be implemented earlier, and except in cases of emergencies, including those situations 1723 Nursing Agreement 12-15-04 11 described in subparagraphs (a) and (c) above, then only such notice as is re able under the ciramu& aces shall be provided.. 11.4 Withdraws AAWW, Ate. In the event Resident withdraws from. the Facility against the advice of his/her attending physician and/or without approval of the Facility, all of Facility's respon"Akies for the- care of Resident are terminated. 12. READMISSION - BED HOLD POLICY. 12.1 Private Pay Resf+dertts. If Resident leaves the Facility for a period of hospitalization, therapeutic leave, nor any other reason (other inn Resident's death), and if Resident_ is not eligible for, or receiving, Medical AswWtance bene ,let's bed will be reserved and Resident shall be obligated to pay the current Da4y Routine Service Charge for any days that Reaident's bed is reserved. The Facility will continue to hold the bed until notified in writing by Resident or Responsible Person that the bed is no longer desired. If Resident elects in writing not to reserve a bed, then Resident will be discharged from the Fatty and readmission to, the Facility shall be subject to bed availability. 122 Medico A...§j If Resident is eligible for, or is receiving Medical Assist mce berets, and Relent leaves the Facility for a period of hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable maximum. number of days pad for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation period may be subject to change in accordance with any changes in the Pennsylvania Medical Assistance Program. If the period of hospitalization or ' therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania Medical Assis a Program, Resident will be entitled to the first available accommodation suitable for Resident's level of care if, at the time of readmission, Resident requires the services provided by the Facility. Alternatively, following the lapse of the bed reservation period covered by the Medical Assistance Program, Resident may reserve a bed by electing to pay the Medical Assistance per diem rate charged immediately prior to the leave, and by providing written notice and advance payment for the days included in the reservation period. 12.3 Medlcace R In the event that a Resident eligible for Medicare Part A benefits is transferred to or readmitted to a hospital, Medicare Part A eligibility will be terminated on the day the Resident is admitted to the hospital. Resident's bed will be reserved at the Daily Routine Service Charge unaess Resident or Responsible Person elects, in writing, not to reserve a bed, or under the Medical Assistance program (as described above) if Resident is eligible for be efrits. 13. FACILITY RULES, REGULATIONS, POLICIES AND PROCEDURES. 1723 Nursing Agrmnent 12-15-04 12 Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement, and the Facility 's rules, regulations, policies and procedures as published in the. Facility 's Resident Handbook or other documents or publications made available by the Facility. The Facility reserves the right to amend or change its rules, regulations, policies and procedures. The Facility's rules, regulations, policies and procedures shall not be construed as imposing contractual obligations on the Facility or granting any contractual rights to Resident, and are subject to change from time-to-time. The Facility does not permit smoking anywhere in the building. 14. PERSONAL AND OTHER PROPERTY. 14.1 Responsibility for Maintenance and Loss. Resident is . responsible for furnishing and maintaining his or her own clothinjg and other items of property as needed or desired. Resident is encouraged to and may obtain at his or her own expense, casualty insurance to cover potential damage to or loss of any of Resident's 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 Disposition 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 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 of receipt of the letter, then Facility may dispose of Resident's property. 14.3 Disposition and Storage Upon Resident's Tannsfer or Discharge. If Resident's personal property is not claimed or removed within twenty-four (24) hours of Resident's permanent transfer or discharge, the Facility shallll move and place Resident's personal property in storage until claimed. If Resident's personal property remains unclaimed for seven (7) days after permanent transfer or discharge, Resident shall be obligated to. pay a storage fee as assessed by Facility. After a thirty (30) day period in storage, the Facility may dispose of Resident's property. The Facility is not 1723 Nursing Agreement 12-15-04 . 13 responsible for . any damages incurred to Resident's property if storage becomes necessary. Resident or Resident's elate s W be crud to pay 841 costs of storage or disposition and shall bear the risk of loss or dauwge to the may. 14.4 D to #AM as;, XMpiqW. ROd60t or R ent's estate is responsible for any damages caused to the Fw y prop y beyond normal wear and tear, and shall. pay for the repair and replacement of dauwtged property, basedon. the actual charge or cost to the Fatty for such repair or replace aunt 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 otherhealth care providers frarm: whom the Rodent reaves services, to third-party payors of health care service, to any MCO in which Resident may be enrolled, or to others deemed ready necessary by the Fatty for poses of treatment payment and operations. Release of records for other purpom s shall be done in accordance with applicable law, with a specific aut4mizatim from the P.=dent where required. Authorized agents of the state or federal govenment, ilvlg the Long Term Care Ombudsman, may obtain Resident's records without the written consent or authorization of Resident. 16. TREATMENT AUTHORIZATION. Resident authorizes the Facility to provide care and treatraent consistent with the terms of this Agreement Resident also authorizes the Fa cibiy to obtain all necessary clinical and/ or financial information from the hospital or nag fadhty from which Resident may be transferring. 17. DEATH OF RESIDENT. In the event of Resident's death, the Facility shall notify the person(s) designated by Resident. The Facility is authorized to arrange for the transfer of Resident's body to the designated funeral house. Resident's emote is responsible for the payment of all costs associated with the transfer and funeral expenses. Resident shall notify the Facility of any changes of the person(s) or feral, horme to be notified in the event of death. 18. CAPACITY OF RESRWENT AND GUARDIANSEUr. If Resident is, or becomes unable, to understand or communicate, and is determined after admission to be incapacitated by Resident's Physician or the Facility's Medical Director, the Facility shall have the right, in the absence of Resident's prior 1723 Nursing Agro meat 12-15-04 14 designation of an authorized legal representative, or upon the unwillingness or inability of the legal representative to act, 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 attorney's fees, shall be paid by Resident or Resident's estate. 19. FACILITY'S GRIEVANCE PROCEDURE. 19.1 Reporting Complaints. If Resident, Responsible Person, or Resident's Attorney-in-Fact 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, Resident or Responsible Person shall make his/her complaint known to the!Facility's Director of Nursing or Administrator. Resident, Responsible Person, or Resident's Attorney-in- Fact must first notify the Facility of any such complaints, and provide the Facility with sixty (60) days to resolve the complaint satisfactorily to Resident before the Resident may pursue arbitration. This notice requirement is not intended fo preclude Resident, Responsible Person, or Resident's Attorney-in-Fact from filing a complaint with any appropriate governmental regulatory agency at any time. 19.2 Facility's Obliag_tions. The Facility will review and investigate the complaint and provide a response to Resident/ Resident's Attorney-in-Fact or Responsible Person. 19.3 Mandatory 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. 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 to fulfill their obligations under this Agreement or the Responsible Person 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 1723 Nursing Agnxment 12-15-04 15 disputes or claims ,that the Resident may have against the Facul ty. It also means that the Reskjont is re uishing or giving up all rWh* the the wit auky, ve to a jury trial to resolve any disputes or ckuns ag t the Facility. It also meam tbat ibe Facility is giving up any rights: it may have to a jury trial or to bra r in a court ag t the Resident. Subject to Section 19.3(f), the Arbitration shall be administered by ADR Options, Inc., in accordance with the A.DR 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/or Reek Person acknowledge(s) and understand(s) that there will be no jury triae l on any claim or dispute submihied to arbitratian, and Resident and/or Responsible Person reii ui and give up t r rights to a jury trial on any nutter submitted to arbitration under this Agreement. (b) FCr#Q"Lk1JW ox g"MAWMaWe. Any claim that the Resident may have against the Fat ty for any persanal ides steed by the Resident arising from or relating to any aDeged medical m pre ti , as equate care, or any other cause or reason while residing in the Farty, shall be settled exduaively by arbitration. This means that the Resident will not be able to file a lawau in any court to bring any claims that the Resident may have against the Facility for personal injuries incurred whale residing in the Facility. It also means that dw Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to litigate any skims for damages or losses allegedly incurred as a result of personal ir*unes sustai d while residing in the Facility. Subject to Section 19.3(f), the Arbitration shall be admired by ADR Options, Inc., in accordance with the ADR Cti Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Respozible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute . submitted to arbitration, and Resident and/or Responsive Peroon rel*uitsh. and give up the Resident's right to a jury trial on any claims for damages ari g from gersdnal i uries to the Resident which are submitted to arbitration under this Agreement (c) Ex4usW E Those disputes which have been excluded from mandatory arbitration (i.e., guardJauship pry, collection actions initiated by the Facility, and disputes involving amounts m 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 Rat nor the Facility is required to use the arbitration process. Any legal actions related to those matters may be filed and litigated in any court which may have jurisdaction over the dispute. This arbitration provision skull not impair the rigbb of Resident to appeal any transfer and/or discharge action initiated by the Fairy to the appropriate administrative agency, and after the exhaustion of such adulanistrative appeals, to appeal to the court exercising appellate jurisdiction over the administrative agency. 1723 Nursing A regiment 12-15-04 16 (d) Right to Legal 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. (f) Time Limitation for Arbitration. Any request for arbitration of a dispute must be requested and submitted to ADR Options, Inc., prior to the lapse of two (2) years from the date on which the event giving rise to the dispute occurred. In the event ADR Options, Inc., is unable or unwillirtg 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. (g) Limitation on Damages and AllocCilon of Costs 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 Mandator Arbitration Clause (Sections 19.3(a-h) of this Agreement). Reslident, or Resident's spouse or personal representative in the event of Resident's incapacity, have the right to rescind this arbitration clause by notifying the Facility in writing within thirty (30) days. (Notice of Right to Rescind form is available upon request.) 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 spouse or personal representative. 20. NOTICE. 1723 Nursing Agreement 12-15-04 17 Wherever written notice is required to be given to the Facility under this Agreement, it shall be sufficient if notice is provided by pe Wly deWering it or by first-class nail, return receipt requested, add d to: isirawr Facility Nagle 4 [Address] Notice to Resident will be provided by personal delivery to Resident's room, or where applicable, by first-class mail to Respansible.Per3on or other designated person. 21. INDEMNIFICATION. Resident shall indemnify and hold the Facility harmless "from, and is responsible to pay for any damages or injuries to other persons and resi is or to the property of other persons or residents caused by the acts of omissions of Re dent, to the fullest extent permitted by law. 22. RELATIONSHIP OF NURSING HOW A]3bIISWOK AGR T TO OTHER ADMLSSION AG EUMNTS. . Upon permanent transfer to a new level of care the existing admission agreement will be terminated. - 23. h(ISCELLANEOUS PROVISIONS. 23.1 GovgUling 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 tD the benefit of each of the underw ed pies and their respective heirs, personal representatives, successors and assigns. be 23.2 Sev_AW&. The various provisions of this Agreement shall 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 fence and effect as if the invalid provision had not been a part of this Agreement. 23.3 Caaptfons. The caption used in connection with the sections and subsections of 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 1723 Nursing Agreement 12-15-04 is scope, meaning or intent of the provisions of this Agreement, nor shall such captions be. given any legal effect. 23.4 Entire Agreement. This Agreement, the Responsible Person Agreement and the Admission Application represent the entire Agreement and understanding between the parties and supersedes, merges and replaces, all prior negotiations, offers, warranties and previous representations, understandings or agreements, oral or written, between the parties. 23.5 Modifications. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in law, regulation or operations. To the extent reasonably possible, the Facility will give Resident and Resident's Responsible Person thirty (30) days advance written notice of any such modifications. The Resident may not modify this Agreement except by a written statement signed by the facility. 23.6 Waiver of Provisions. The 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 the Facility unless such waiver is in writing by the Facility. Any waiver by the Facility shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. 24. ACKNOWLEDGMENTS. 24.1 Schedule of Charges. Resident and Responsible Person acknowledge the receipt of a copy of the Schedule of Charges and the opportunity to ask questions about the Facility's charges. 24.2 Resident Rights. Resident and Responsible Person acknowledge being informed orally and in writing of Resident's Rights as reflected in the publication attached to this Agreement, and further acknowledge having an opportunity to ask questions about those rights. The Notice of Rights of Nursing Facility Residents (MA- 401) is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on the Facility or granting any contractual rights to Resident. 24.3 Advance Directives. Resident and Responsible Person acknowledge being informed, orally and in writing, of the Facility's policy on advance directives and medical treatment decisions. 24.4 Agreement. Resident and Responsible Person acknowledge that they have read and understand the terms of this Agreement, that the terms have been 1723 Nursing Agreement 12-15-04 19 explained to them by a representative of the Facility, and that they have had an opportunity to ask questions about this Agreement. 24.5 MIWOt U#Mlk Resident and . Responsible Person acknowledge the receipt of a copy of the Resit Handbook and the opportunity to ask questions about the Facility's policies conta4-ted in the Re tdent H k. The Resident Handbook is subject to change from time-to-tune and sll not be construed as imposing any contractual obligations on the Facty or granOng any usual rights to Resident. IN WTITtMS WHEREOF, the parties, in g to be legally bound, have signed this Agreement on the date written below. Witness Witness Resident Responsible Person (if any) Representative Date d?41w-- Dake'( Da e 1723 Naming Agemmt 12-15-04 20 ADDF"UM To This addendum is made as of between 9E MSI®N AGIC9EAZNT- ?V (the "effective date" ), ("Resident') and $aClWou nd The purpose of this Addendum is to comply with the Medicare Modernization Act of 2003 which created a new voluntary outpatient prescription drug program under the Medicare Part D progzam, beginning in 2006. Policy Statement The following outlines the understanding between the Facility and Resident regardins the Medicare D prescription drug program I . It is the Resident's/Responsible Person's obligation to enroll the Resident in a Prescription Drug Plan (PDP) of the Resident's choice and to inform the Facility of.th.e PDP selected, - It is not the responsibility of the Facility to ensure Resident enrollment in a PDP. 2. If a Resident elects to switch PDPs under the provisions of the Special Election Period, than the Resident will immediately advise the facility of this election. 3. The Facility is not responsible for the actions or decisions of the Resident's chosen PDP. The decisions as to formularies, coverage decisions, appeals decisions, premiums or other charges are solely the responsiibilityof the Resident through agreement with his or her chosen PDR LTCCFI #1727 I2-05 Page I of 2 Attach to the following agreements: 1716, 171 8, 1721, 1723, 1725 4.. : The Resident is re gnim6ble for any cost-sharing obligations with the PDP. ' The Resident will directly receive the bill. from the pharmacy for any cost-sharing obi gatiaas.. the Facility is not obligated to -pay the aDst-sharing portion of the Residwt's chosen PDP and will not receive-the ph many bill. Ifis the Resident's oblijation to pay for *E , 4MMMIC and wed: charges; If any, to the PDP of ter choke or to the pharmacy. 5. The ResidennVRosptm i?le Person has the responsibility to appeal any Part D. coverage determinations. The facility shall serve as an "appointed representative", as allowed. by law, to. initiate a formulary appeal or grievance on the Resident's behalf, should the Resid.eut have no other "appointed representative". 6.. The Facility is not obligated to educate or inform the Resident/Responsible Person about what drugs will be covered and are excluded from a PDP's formulary. The Facility has no control over the formulary. Any questions or concerns should be directed to the Resident's PDP regarding why a prescription is or is not covered. This information is not provided to the Facility by the PDP. ed pato y' ?at? Sigak /4 c Tate Signed UCCH # 172.7 12-05 . Page 2 -of 2. A=b to tbz following agreements: 171 f,1718,1721, 1723,1725 Responsible emly.?il appucaate} Exhibit C UNTIED CHURCH OF CHRIST HOMES RESPONSIBLE PERSON AGREEMENT T R sponsible Person Agreement (hereinafter "Agreement") is made between (hereinafter referred to as "Facility") and the legal representative or representative individual (hereinaft of ed to as . "Responsible Person'") of the Resident, (hereinafter referred to as "Resident"). WHEREAS, the Responsible Person and Facility enter into this Agreement to facilitate the provision of care to the Resident. WHEREAS, the Responsible Person may be the Guardian] the Agent under a valid Power of Attorney, or any person authorized by Resident to serve as Resident's Responsible Person. WHEREAS, Facility shall discuss and consult with Responsible Person regarding pertinent decisions related to Resident's stay and care at the Facility. THEREFORE, Facility and Responsible Person agree to the following terms and conditions: 1. Responsible Person affirms that- the information, provided in 'the Admission Application and related documents are true and correct to the best of his or her knowledge. Responsible Person acknowledges that the submission of any false information, misrepresentation or lack of disclosure may result in tl?e termination of the Nursing Home Admission Agreement (hereinafter "Admission Agreement") and may result in the discharge of the Resident from the Facility at the Resident and/or Responsible Persons expense. 2. If the Resident selects a Responsible Person, then said'',Responsible Person shall sign this Agreement and the Admission Agreement in recognition of this designation with the intent to be legally bound by this Agreement and the Admission Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of the Resident imposed by the Admission Agreement in accordance with the law governing fiduciary duties. Facility may petition a court to appoint a Guardian and take other legal action if Facility reasonably believes that the Resident's needs are not being properly met or the duties imposed by the Admission Agreement are not being fulfilled by the. Responsible Person. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. Nursing Responsible Person Agreement 12-15-04 l 3. Responsible Person affirms that he or she has access to Resident's income and resources and 'that Resident's income and resources are available to pay for Resident's care in the Facility. The Res ortsEble Person shall provide payment from Resident's income and resources for such care. Responsible Person shall apply .Resident's income and resources to the costs and charges in¢uaTad during Resident's stay unless and until such costs are paid by private insurance or otter its such as Medicare, Veteran's Health Insurance or Medical Assoiance. VVhm the Resident's financial resources warrant it, Responsible Person shall take any and all actions necessary and appropriate to initiate, make and code asn for Medical Assistance benefits on behalf of the Resident, including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals. Responsible Person shall exercise diligent efforts in the application and appeal processes to assure continued benefits from any third party or government payor. Responsible Person shall utilize Resident's income and resources only for Resident and shall not utilize any of Resident's income or resources for Responsible Person's benefit nor transfer any of Resident's real: property except for proceeds at fair market value for the benefit of Resident. 4. Responsible Person is obligated to pay Facility from Resident's financial resources for services and supplies provided to Resident in accordance with the Admission Agreement. If the Responsible Person withholds or misappropriates Resident's financial resources for personal use or gifts, or otherwise does not use the Resident's financial resources. to fulfill Resident's financial obligations to Facility for services and supplies provided to Resident in accordance with the Admission Agreement, then Responsible Person shall be personally liable for payment Responsible Person is also obligated to pay Facility for all losses or des incurred by Facility by the failure of the Responsible Person to full his/her duties under the Admission Agreement. Failure to ;do so will result in legal action by Facility to assure payment for amounts that are Resident's obligations. In the event that Facility initiates any legal actions or proceedings to collect . payments due from Resident and Responsible Person. under this Agreement, or to enforce Responsible Person's obligations under the Admission Agreement, then Resident and Responsible Person shall pay all damages, attorneys` fps and costs incurred by Facility in pursuing the enforcement of Resident's and/or Responsible Person's financial or other obligations under the Admission Agreement. Such damages, fees and costs may include, in the discretion of Facility, an amount equivalent to revenue lost by Facility due to Responsible Person's failure to timely submit or complete a Medical Assistance application or to cooperate with the Department of Public Welfare (herea.rudter "DPW") in ' the Medical Assistance eligibility determination Responsible Person shall timely assist Resident in the preparation, completion and submission, if applicable, of Resident's application for Medical Assistance benefits. If Facility, in its sole discretion, decides to assist in the Medical Assistance application,. Resident and Responsible Person Nursing Responsible Person Agreement 12-15-04 2 • e? are still fully obligated to initiate, make ' and complete the Medical Assistance. application- Facility's assistance in the Medical Assistance application process does not waive Resident's or Responsible Person's duty or responsibility to timely complete and submit a Medical Assistance application if the Resident's financial resources become insufficient to pay amounts under the Admission Agreement. The failure to initiate, make and complete ' the Medical Assistance application process may result in the discharge of Resident for non-payment and in personal liability to Responsible Person for, losses incurred by Facility for Responsible Person's failure to apply timely for Medical Assistance benefits. In the event Resident applies for Medical Assistance benefits, Responsible Person shall pay the Patient 'Pay Amount monthly to Facility. Responsible Party, at the request of Facility and to the extent permitted by law, shall immediately sign over and/ or designate the Facility as the representative/ designated payee for any income available to Resident in an amount not to exceed the Patient Pay Amount as determined by DPW. Responsible party should take whatever action as may be.necessary to insure that such payments are made directly to Facility. Patient Pay Amount is determined by DPW and described in Section 5.3(b) of the Admission Agreement. If Resident is determined to be ineligible for. Medical Assistance because Responsible Person fails to provide or submit necessary documents or fails to appeal timely so that Facility is unable to obtain Medical Assistance reimbursement, then Facility may terminate the Admission Agreement for non-payment of stay and Responsible Person shall be personally liable for any losses sustained by Facility as a result of such failure. Responsible Person shall be responsible personally for compliance with all other terms of the Admission Agreement. 5. Responsible Person understands that if he or she', fulfills his or her obligation under this Agreement, he or she shall not be held personally liable for the Resident's charges. However, Responsible Person understands that if he or she does not fulfill his or her obligation under this Agreement he or she shall be liable to Facility for whatever loss Facility sustains as a result of the Responsible Person's breach of this Agreement. '6. Responsible Person is obligated to perform all provisions in the Admission Agreement related to Responsible Person. . 7. The Responsible Person attests that the information set forth in the Application Agreement is true and correct to the best of his or her knowledge, information and belief. 8. The Responsible Person acknowledges that he or she has received a copy of the Admission Agreement and understands the terms and conditions contained therein. Nursing Responsible Person Agreement 12-15-04 3 j ?. 9. Responsible Person acknowledges he or she has reviewed 1iis Responsible Person Agreezavnt and enders ds the information get fob herein. IN WITNESS WPIEREOF, the parties, intending to ; b© e?lry, have Si this Responsible Person Agreement on this of Witness Witness. Nursing Responsible Pelson Agreement 12-15-04 4 Respondble Person Representative Exhibit D CUMBERLAND CAO MEDICAID P.O, sox 599 NOT ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 *01010000000* TODD MEMORIAL HOME ATTN: BILLING 1000 W. SOUTH STREET CARLISLE 'PA IF YOU DO HOT UNDERSTAND WRI DECISION OR HAVE MM QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. You failed to provide the following items by 9/2/08: 1. Dispostion of funds received in sale of home on 8/22/08; 2. proof that you have spent your available resources below the $8000 limit on medical or preplanning funeral expenses; 3. Verification of cash value of annuity or statement of irrevocability from Annuity Company. REGULATIONS:55 PA Code 201.1; 201.3 If you disagree with our decision, you have the riqht to anneal. • r.rvw v-1-1y11 U1 VUU1 IIHrIL LV MWOM1 HfIO 10 a Talr nearing. it you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 09/16/2008 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. FRANCES R ROBERTS TODD MEMORIAL HOME 1000 WEST SOUTH STREET CARLISLE PA 17013 CAU ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 Notice ID: 86726192 . PAGE 1 OF 1 21 0120192 0 PAN 00 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 09/03/2008 17 013 NOT: 042 OPT: 0 TYPE: N MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 Notice ID: 86726192 86726192 THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER V PKG LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER 01 FRANCES 330211031 1 00 BNFT V PKG ssum j?? ` u; THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUP MEDICAID BENEFITS. Line Line Line Line Line Line Line Line GROSS INCOME arneck Unearned: DEDUCTIONS Earned Income: Unearned Income: Dependant Care NET INCOME Individual Totals: Additional Deductions Medical Bills (as deduction): Patient Pay Amount: Total Household Net Income: Budget Income Limit: You are responsible for patient pay amount to providers as indicated below. Line Date Pay to: Provider Amount The following medical-bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your responsibility and. will not be covered by Medicaid Name of Provider Date of Service Amount Name of Provider Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM. •-- DETACH HERE DETACH HERE ----• Please check one of the boxes to show which type of hearing you want: ? 1 want a telephone Hearing. I and my witnesses and anyone helping me will be at this phone number. ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker' and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to-the hearing room. PLEASE CHECK BELOW IF YOU NEED HELP BECAUSE OF A HEARING PROBLEM OR DISABILITY OR YOU NEED AN INTERPRETER: ? I have a hearing impairment or disability. I will need special help. ? 1 need an interpreter. There will be no cost to me. What language? CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS Tci cou^a0c Re^ nw TO Exhibit E 01/28/2009 14:04 7172459733 SARAH TODD HOME PAGE 02/03 cUMEFRLANU CAC MEDICAID Notice 117 9.Daci102? F.O. BOX 59? NOT ELIGISLE PAGE 1 OF 1 33 WESTMINST7.M DRIVE NOTICE CARLISIM PA 17013-0599 CAO RETURN ADDRESS CSLD 0026 21• 0120192 0 PAN 80 *'01010000000* TODD MEMORIAL HOME ATTN: BILLING 1000 W. SOUTH STREET CARLISLE PA 1.7012 WORKER: 3 PSIPSR TELEPHONE: (g00), 769-0173 ;MAIL DATE: 12/30/2008 NOT: o42r. OPT. 0 TYPE N ? ?i,???dMMn IF YOU w HOT U?TAND R DDC7S w OR NAVE M ' OBEST,Tvm..PIBASE cONI'ACT,YoUR at t JMNED?A'rrL you failed to provide verification of the following items by 12/$9/2008: 1. Statements for all bank accounts, annuities, Keoghs, IRAs Stocks and Sondes as of a/i/08; 2. Verification of proceeds 'received in sa1im! of house. disposition of funds rec®i•ved after sale of home: S. Verification of all resource-is sold transferred or given away in the past 36 months 4, Verification of why you received $45000 for home that is listed as FMV of•$57` 000 REGULATIONS:55 PA Code 201.1; 201.3 If you disagree with our decision, you hove the right' to appeaL fte x taehad form for a c eta xa io of vow right t- MMMI and W a fair earina If you are currently receiving enofits and your oral request for a hearing is received. ,in the County Assistance Office or your written request is postmarked or received on or before 01/12/2009 your assistance will continue pending the hearing decision, oxcept when the change is due to State or Federal law. MNCT:S R ROPERTS TODD MEMORIAL HOME 1000 WEST 50t1n STR99T CARLISLE PA 17013 CUMBERT,,AND CAO P.O. POX 599 33 WESTMINSTER DRIVE CARLIST.F PA 17013-DS99 MIDPM L8OAL 9SR?'7: 1? 401*405 LOUTHER S1'FtE:i :' cARS,IBLE F:1 17013 (7111) 243-9400 Notice 'JD 9046117: 21 0120192 0 PAN i3C NORKER: J FEIABR 4PPEAL: 01/12/2009 TELEPHONE. (800) 269-0273 NAIL DATE: 12/30/2009 NOM 042 OPT; 0 TYPE N ;01/28/2009 14:04 7172459733 SARAH TODD HOME PAGE 03/03 ® e THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE BNFT BNFT PKG LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER V PKCZ LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER ' 01 rP-kNC139 330211031 1 00 I THE FOLLOWING PERSON(Sl INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DEfERMln'.1'rlON OF YOUR MEDICAID BENEFITS. ne Line Line Lino Ling Line Line Line GROSS INCOME Tar-no Unearnod: DEDUCTIONS EarMa Income: Unearned Income, Dependant Care NI=T INCOME Individual Totals You are responsible for patient Household Net Income: Additional Deductions: below: Medical Bills (as deductlon} Line a Pav to Provid®r Patient Pay Amount Total Household Net Income: Budget Income Limit amount to prow : gars as indicated I Amount The following medical bills have been used as a deduction to calculate your eligibility for Medicaid' benefits. The unpalil bills are your responsibility and will not be covered by Madicaid. Name of Provider Date of Service Amount I Name of Provider Date of Service Amount IF YOU WISH TO APPEAL„ PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF •--- rxrom om FORM. I arx" M _- Pleass check one of the boxes to show which type of hearing you want: Q I want a telephone Hearing. I and my witnesses and anyone helping me WIN be at this phone number _ ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAC , ? I warn a Face to Face Heating. I and my witnesses and anyone helping me will be in the hearing room with the Judge she caseworker and CAO staff. ? 1 want a Face to Face Hearing, I and my witnesses and anyone helping. me WIN be in the hearing rooms with the Judge. 11,1 caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room. II PLEASE CHECK BELOW IF YOU NEED HELP 13ECAUSE OF A BEARING PROBLEM OR DISABILM Y OR YOU NF-EE Ii INTERPRETER: ? 1 have a heating impairment or disability. I will need special help. ? 1 need an interpreter. There will be no cost to me. What language? ADDRESS TELSPH nIE K?r+ DATE a logo-.wss-+-- Sa?rt h ?trAAfi ?' x-: .2187 EI REP. ADDRESS TFf a~vL. - n A TC Exhibit F .01/15/2009 09:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Trisha Roberts 63 E. North St Carlisle, PA 17013 PAGE 02/08 Statement Data: 10/10/20(13 Due Date: 10/25/2008 Re: Frances R Roberts Account Nr: 101955 Date ------------ Description ------- Days --- ----- Rate ---------------- Charges ----- --- Payments Balance! --------- ---------------------- Quant ------- -------- -------------- -------------------- 09/02/08 BALANCE FORWARD Beatat,y & Barber 1.00 20.00 15,717.00 20 00 15,717.0.0 09/08/08 Therapeutic Exercis 2.00 26.04 . 10.42 15,737.00 15 747 42 09/08/08 09/08/08 Therapeutic Activit 1.00 27.40 5.48 , , 15,7'52.9) 09/08/08 Therapeutic Activit Therapeutic Exercis 1.00 2 00 27.40 26 04 5.48 15,758.33 09/08/08 Neuromuscular Reedu . 1.00 . 27.08 10.42 5.42 15,768.811 15 774 22 09/09/08 09/09/08 Self Care Mngement Therapeutic Activit 1.00 2 00 27.78 27 40 5.56 , . 15,779.7; 09/09/08 Therapeutic Activit . 1.00 . 27.40 10.96 5.48 15,790.7.1 15 796 22 09/09/08 09/09/06 Therapeutic Exercis Th 2.00 26.04 10.42 , . 15,806.61 09/09/08 erapeutic Exercis Beauty & Barber 1.00 1 00 26.04 2 5.21 15,ell. 85 09/10/08 Self Care Mngement . 1.00 0.00 27.78 20.00 5 56 15,831.85 09110108 Therapeutic Exercis 1.00 . 26.04 . 5.21 15,837.4:- 15 842 68: 09/10/08 09/10/08 Therapeutic Activit Th 2.00 27.40 10.96 , . 15,853.58 09/10/08 erapeutic Activit Therapeutic Exercis 1.00 2.00 27.40 26.04 5.48 10 42 15,859.0f; 09/11/08 Therapeutic Exercis 2.00 26.04 . 10.42 15,869.4Ei 15 879 90 09/11/08 09/11/08 Therapeutic. Exercis S lf C 1.00 26.04 5.21 , . 15,885.17. 09/11/08 e . are Mngement Therapeutic Activit 1.00 1.00 27.78 27.40 5.56 5 48 15,890.67 c . 15,896 1 101/15/2009 09:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 PAGE 03/08 Statement Date: 10/10/2008 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/2'5/2008 Re: Frances R Roberts Account Mr: 101955 Date _--- Description ---------- -------- Days -- Rate charges ^--`-----"-"" Payments Balance --------- ------------ ---------- Quant -------- ---------- ---------- 09/12/08 09/12/08 Self Care Mngement Therapeutic Exercis 1.00 1 00 27.78 - 5.56 --------------------- 15,901.7: 09/12/08 Therapeutic Exercis .. 2.00 26.04 26.04 5.21 10 42 15,906.9;. 09112108 Neuromuscular Reedu. 1.00 27.08 . 5 42 1 5,917.3} 09/12/08 Therapeutic Activit 1.00 27.40 . 5 48 5,92 1.76 09/12/08 Therapeutic Activit 2.00 27.40 . 10 96 1 8.24 15, 928.2() 09/15/08 Therapeutic Activit 2.00 27.40 . 10 96 15,939.2(! 09/15/08 Therapeutic Exercis 1.00 26. D4 . 5 21 15,950.1E 09/15/08 Therapeutic Activit 2.00 27.40 . 10 96 15,955.3;' 09/15/08 Therapeutic Exercis 1.00 26.04 . 5 21 15 ,966. 4 09/16/08 Therapeutic Activit 1.00 27.40 . 5 46 5 1 5 ,97 .54 09/16/08 Therapeutic Activit 2.00 27.40 . 10 96 7 15 ,977. E 09/1.6/08 Therapeutic Exercis 1.00 26.04 . 5 9 ,587.9E 15 09/16/08 Therapeutic Exercis 1.00 26.04 21 15,993.10 09/16/08 Beauty & Barber 1.00 0 . , 15,998.46 09/16/08 Self Care Mngement 1.00 27 .78 5 56 16,018.46 09/17/08 Therapeutic Activit 1.00 27.40 . 5 48 16,023.96 09/17/08 Therapeutic Activit 1.00 27.40 . 5 48 16,029.44 09/17/08 Therapeutic Exercis 2.00 26.04 . 10 42 16,034.92 09/17/08 Therapeutic Exercis 2.00 26.04 . 10 42 16,045.34 09/18/08 Therapeutic Exercis 2.00 26.04 . 10 42 16,055.76 09/18/08 Therapeutic Activit 1.00 27.40 . 5 48 16,066. 09/16/08 Therapeutic Exercis 2.00 26.04 . 10 42 66 1 6,071.66 . .. 16,082.08 01/15/2009 09:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 PAGE 04/08 Statement bate: 10/10/2008 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/25/2008 Re: Frances R Roberts Account Mr: 101955 Date Description --------- -------- Days --------- Rate ----------- Charges ------ Payments -Balance --------- ------------ ---------- Quant -------- ---------- ----------- --- 0.9/18/08 09/19/08 Therapeutic Therapeutic Activit Exe i 1.00 27.40 5.48 ------------------ 16,087.5E 09/19/08 Therapeutic rc s Activit 2.00 2.00 26.04 27.40 10.42 10 96 16,097.98 09/19/08 Therapeutic Exercis 1.00 26.04 . 5 21 16,108.9: 09/19/08 Therapeutic Activit 1.00 27.40 . 5 48 16,114.1 09/22/08 Therapeutic Activit 1.00 27.40 . 5 48 16,119.6... 09/22/08 09/22/08 Therapeutic Th Exercis 2.00 26.04 . 10.4,2 16,125.1:1 26,135.5 9 09/22/08 erapeutic Therapeutic Exercis Activit 2.00 1 00 26.04 27 40 10.42 1 1 6,145. 09/23/08 Therapeutic , Activit . 1.00 . 27.40 5.48 5 48 43 1 6 ,151. 1 09/23/08 09/23/08 Beauty & Barber B 1.00 20.00 . 20.00 16,7.56.9 9:! 16,176.9 09/23/08 eauty & Barber Therapeutic Exercis 1.00 7 00 16.00 26 04 16.00 1 6,192.3 1 09/23/08 Therapeutic Exercis _. 2.00 . 26.04 0.42 10 42 ,203.33;3 1 6 09/24/08 Therapeutic Exercis 1.00 26.04 . 5 21 16,213.7,; 09/24/08 Therapeutic Activit 1.00 27.40 . 5.48 1166,218.E: 442 224 09/24/08 09/24/08 Therapeutic Therapeutic Activit Exercis 1.00 2 00 27.40 5.48 , .. : 16,229.94: 09/24/08 Self Care Mngement . 1.00 26.04 27.78 10.42 5 56 16,240.34 09/25/08 09/25/08 Therapeutic Activit 2.00 27.40 . 10.96 16,245.9E 16,256.8E 09/26/08 Therapeutic Therapeutic Exercis Exercis 1.00 2 00 26.04 26 04 5.21 16,262,09 09/26/08 Therapeutic Activit . 1.00 . 27.40 10.42 5 48 6,272.97 , 1 16,277.97 ,01/15/2009 09:45 7172459733 United Sara 100 Ca i SARAH TODD HOME L I Statement urch of Christ Homes ?. Todd Memorial Home est South Street i s l-e, PA 17 013 PAGE 05/08 Statement Date: 10/10/20013 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 10/2'5/2008 Re: Frances R Roberts Account Nr: 101955 ----------------------- Date Description ^----- 09/26/08 Therapeutic Exercis 09/29/08 Therapeutic Activit 09/30/08 Medical supplies 09/30/08 Medical Equipment R 09/30/08 Oxygen 09/30/08 Cabie Television 09/30/08 Personal Laundry Se 09/30/08 COINSURANCE BILLED 09/30/08 Finance Charge 09/30/08 Beauty & Barber 10/01/08 Room 6 Board - Semi i ------------------------------------------ Rate Charges Payments Ba.lanca -- .0 ---------- 26.04 ---------------- 10.42 ----------------•- 16,288.3'7 .0 27.40 10.96 16, 299.351.. .0 151.47 151.47 16 450 83 .0 1131.90 1,131.90 , . 17,582.72 .0 156.30 156.30 17,739.0' : .0. 17.00 1.7.00 . 1. 7, 756. 02 .0 30.00 30.00 7.7,786.0' 126.00 640.00 18,426.0; 72.11 18,998.1:1 10 20.00 20.00 78,518.1: 3 235.00 7,285.00 25,803.13 I !i NOTE: * * * * * PAYMENT IS DUE IU .?3N RECEIPT' * * * * * BUT NO LATER THAN THE 25TH OF THE MONTH ***** I ,ie 1 ase remit the LAST AMOUNT printed on your statement. Include the # from the statement on the MEMO LINE of your check. Payments afte IT 8%•08 do not reflect on statement. NOTE: ** DATE PAYMENTS ARE SUBACT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGEDIfo?,? RETURNED CHECKS ** 01/15/2009 09:45 7172459733 SARAH TODD HOME PAGE 06/08 11 Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Statement Date: 11/14/2008 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 11/25/2008 Re: Frances R Roberts Account Nr: 101955 -------------------------------_----------- Date Description Days Rate Charges Payments _-Balance: Quant --------------------------------------------------------------------------------- 10/07/08 BALANCE FORWARD Beauty & Barber 1 00 20 00 25,803.13 25,803.1: 10/10/08 Wheelchair Mgmt Tra . 2.00 . 25.34 20.00 10 14 25,823.1, 10/10/08 PT Evaluation 1.00 66.53 . 13.31 25,833.2 25 846 5E 10/10/08 Therapeutic Activit 4.00 27.40 21.92 , . 25 868 50 10/14/08 10/21/08 Beauty & Barbex B 1.00 20.00 20.00 , . 25,888.5[• 10/31/08 eauty & Barber Personal Laundry Se 1.00 1.00 20.00 30.00 20.00 30 00 25,908.50 10/31/08 Cable Television 1.00 17.00 . 17.00 25,938.5C 25 955 5C 10/31/08 Beauty & Barber. 1.00 16.00 16.00 , . 25 971 50 10/31/OB 10/31/08 Finance Charge P 197.36 , . 26,168.8E 10/31/08 ersonal Supplies Medical Supplies 1.00 1 00 1.25 224 33 1.25 26,170.11 10/31/08 Oxygen . 1.00 . 31 26 224.33 31 26 26,394.44 10/31/08 Medical Equipment R 1.00 . 1483.62 . 1,483.62 26,425.70 27 909 32 10/31/08 10/31/06 Beauty & Barber B 1.00 10.00 10.00 , . 27,919,32 11/01/08 eauty & Barber Room & Hoard -- Semz 1.00 7 5.00 235 00 5.00 1 645 00 27,924.37 . , . 29,569.32 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the LAST AMO[TNT printed on your statement. InClU de the ACCT# from the statement on the MEMO 11NE Of Your check. Payments after 11/06/08 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** 01/15!2009 09:45 7172459733 SARAH TODD HOME Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 PAGE 07/08 Statement Date: 12/12/20C89 Trisha Roberts 63 E. North St Carlisle, PA 170],3 Due Date: 12/2',6/2008 Re: Frances R Roberts Account Nr: 101955 ------ ------------------------------- Date Description Days Rate Charges Payments BalancT Quant --------------------- -------------------------------------------- ------ 11/04/08 BALANCE Beauty 6. FORWARD Barber 1.00 20 00 29,569.32 20 00 29,569.3;2 11/07/08 Medical Equipment R 1.00 . 405.3.0 . 405.10 29,589.32 29 994 42 11/07/08 Personal Laundry Se 1.00 30.00 30.00 , . 30 024 42 11/07/08 Cable Te levision 1.00 17,00 17.00 , 30 041 42 11/07/08 Oxygen 1.00 15.63 15.63 , . 30 057 03 11/07/08 Medical supplies 1.00 40.95 40.95 , . 30 098 00 11/30/08 Finance Charge 325.01 , . 30,423.01 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on your statement. Include the ACCT# from the statement on the MEMO TINE Of your check. Payments after 12/11/08 do not reflect on statement. NOTE: ** T,.P,TE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $1.0.00 FEE WILL BE CHARGED for RETURNED CHECKS ** ,01/15/2009 09:45 7172459733 SARAH TODD HOME Statement tri:ited Church of Christ comes .'•_,arah A. Todd Memorial Home 1000 West South Street- Caxlisle, PA 17013 PAGE 08/08 Statement Date: 01/14/200-1 Trisha Roberts 63 E. North St Carlizle, PA 17c;13 Due Date: 01/25/2009 Re: Frances R Roberts Account Nr: 101955 ----------------------------------------------------- .. Date Description Days Rate Charges Payments Balance Quant --------------------------------------------------------------------------------- BALANCE FORWARD 12/31/08 Finance charge 30,423.01 373.68 30,423.01 30,796.69 NOTE: ***** PAYMENT It DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH Please remit the LAST AMOUNT printed on your statement. Include :,he ACCT# from the statement on the MEMO LINE of your check. Payments after 01/09/09 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25° LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** •03120/2009 12:19 7172459733 SARAH TODD HOME PAGE 02109 Bur of Hearings-Appeals 2330 Vartan Way Second Floor Harrisburg PA 17110-9946 NOTICE OF HEARING DATE AND TIME Mary Jane Walker Todd Memorial Home 1000 West South Street Carlisle PA 17013 COMMONWEALTH OF PENN, 1,'LVANiA DEPARTMENT OF PUBLIC WF:I,..FARE Bureau of Hearings & Appeals Phone: (717) 783-3950 Fax: (717) 772.2769 Date March 17, 2009 Appellant Name and Address: Frances Roberts Todd Memorial Home 1 o00 West South Street Carlisle PA 17013 Case No, 2101201!)2-001 RE: PA/MA 162 Date of Notice: 12/30/08 Dear Ms. Roberts: Notioe ID# 80461182 This acknowledges your request for a fair hearing from a decision by the Cumberland CAO concerning Nursing Facility Care Denial: Verification, A telephone hearing has been scheduled for you. The Administrative Law Judge will call you at the telephone number you provided on your appeal at the date and time specif9ed below. Please notify my office immediately if this number has changed or is incorrect, or if you want a face-to-face hearing it Harrisburg. Hearing Date: April 2, 2009 Time: 01:00 P.M. You will be called at: (717) 245-2187 Administrative I_aw Judge (AU): Tina Williamson "IMPORTANT: If you, or a representative for you, is not available for the hearing, you will lose the case. If, before he hearing, you give me a reason for your unavailability and the Bureau of Hearings and Appeals deems the reason to be ar;r optable, the hearing will be postponed. If the Bureau of Hearings and Appeals deems your reason to be unacceptable and YOU :ire not available for the hearing, your appeal will be dismissed. CONTINUED ON REVERSE Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS" form below, cut or, lilhe dotted line and return as soon as possible In the postage-paid reply envelope to the Bureaju of Hearing arljd llippeals. .............?..... •, ... r........, ir.. •- . .....? ..................... ........... .._........ . ........... -... -------................. ............... REPLY TO BUREAU OF HEARINGS AND APPEALS Check all that apply: I will be available for the hearing on April 2, 2009 at 01:00 p.m. with ALJ Tina Williamson El My correct telephone number, El I need an interpreter. Language needed: F] I will NOT be available for the hearing because: I wish to withdraw my appeal at this time (Only the person who filed the appeal or his/her authorized representative can withdraw the appeal). Signature Date El I am a person with a disability] and I need an act :nrrmodation to participate in the hearing. The accommodation I reed is: Frances Roberts 210120192-001 PW i>00A Wd 1705 - 0/03 .031201.2009 12:19 7172459733 SARAH TODD HOME PAGE 03/09 BROCHURP.: A brochure is included with this notice which provides a summary of the hearing process and inf,xmation regarding optional hearing methods. If you have any questions regarding the contents of this notice or the brcic 1,ire, please contact my office at the telephone number in the heading of this letter. The Bureau of Hearings and Appeals complies with the Americans with Disabilities Act. We will provide remci:irtable accommodations upon request. Please contact my office at the address or telephone number in the heading of this letter if you wish to discuss special accommodations OR you may describe the accommodation on your °Reply to the I:a,rreau of Hearings and Appeals". Sincerely, (" Y 44r-? Site Adminnlstr?a'tort cc: Cumberland CAO Mary Jane Walker MER Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS"'form below, cot. ci n the dotted line and return as soon as possible In the postage-paid reply envelope to the Bureau of Hearing an it Appeals. _... ............................................................. ......................................................................... I................................... ..._., ............ IIl?ii111111fI?11A'?I'IAA?1 ?Ii?1IIIIIfI'11i111111 BUREAU OF HEARING AND APPEALS 2330 VARTAN WAY SECOND FLOOR HARRISBURG PA 17110-9946 PwiTim.k PW 1705 . 11 /p1 .03/20/2009 12:19 7172459733 SARAH TODD HOME PAGE 04/09 Information About Your Nearing -- Recipient Appeals Bureau of Hearings and Appeals Department of Public Welfare 1. WTRODUCtION =,1 The Bureau of Hearings and Appeals (Bureau) is an administrative office authorized by the Secretary of Public 'A'. ,Fare to conduct fair hearings for the Department of Public Welfare (Department). The hearings are presided over by an ,'.'v: ministrative Law Judge (ALJ). This brochure will provide information regarding recipient related appeals. Recipient related wipeals are conducted in accordance with the regulations found at 55 Pa. Code Chapter 275. The subject Matter includes, 1?,il is not limited to the following: e Denial, reduction, suspension, or termination of Cash Assistance, Medical Assistance or Food Stamp t!enefits. e Appropriate level of care for nursing home residents. s Provisions of Low Income Energy Assistance Programs (LIHEAP). IL TWO TYPES OF HEARINGS You may choose to have either a telephone hearing or a face-to-face hearing. _ A.. Telephone- Hearing- The appeal is handled over the telephone, on the date and time that appears on your notice. The AU will' r 3'11 all parties involved in your case. There will be a telephone connection between you, all witnesses, and the ALJ. Thd.::adl will be placed at the telephone number you provide to the Bureau. If you have not given us a teljephone number %&Ii :=re you can be reached, you should go to the County Assistance Office (CAO) or Agency Office againbt whom you filed I V a appeal. The judge will call you at that location. If you are going to be at a different telephone number, please call Ito Site Administrator at the telephone number listed on your "Notice of Hearing Date and Time" latter. On the date of your hearing, please try to keep your telephone line clear of other calls at least ten (10) mintiIi s before and after the time shown on your "Notice of Hearing.Date and Time" letter. If you get disconnected during the hearing, please hang up. The ALJ will call you right back. DO NOT CAt_t HE ALJ. B. Face-to-Face Hearing At a face-to-face hearing, your case is heard in a courtroom. The face-to face hearing will be in one of six E? v!as in Pennsylvania (Erie, Pittsburgh, Harrisburg, Reading, Wilkes-Barre, or Philadelphia) depending on where yol.i live. If you have chosen a face-to-face hearing, the "Notice of Hearing Date and Time" will tell you where your hearing mill be held. Ill. THE JUDGE'S ROLE The responsibilities of the ALJ include conducting the hearing in an orderly manner. The ALJ Is also responsibIc -lor gathering the facts necessary to decide whether or not the Department's or State Agency's actions were, correct. The AU ,;lust base his/her decision on the evidence presented during the hearing. The Al-Ts decision must comply with the law J`.:}Ili will receive - acopy.. I`Abe.ALJs.decision_.in.w.ribng.-O esionailylbeALJ wilLarinounceJ3is/her_.decision..olratlKat-tbe_coo W:i`ilir.Lof.the hearing but you will always receive a written decision either handed to you at that time or sent to you in the rrrJiil.1! IV. THE HEARING The AU will conduct the hearing in an orderly but informal manner. The hearing will be recorded, The AU will v sk all witnesses at the hearing to swear or affirm to tell the truth. Then, the ALJ will clarify what you'1are appealing. Th,: AU will ask the person or people (for example, your caseworker) from the Department or State Agency to explain why they ! i,ide their decision or took their action. After the Department's witness testifies, you or your representative may ask him or ner questions. (This is called "cross-examination.") Then it will be your turn to present your case. You should explain why you appealed and why', you disagree with ;,ie things said at the hearing by the Department or State Agency. If you have any witnesses, you or your representative n•:i!r ask them questions. The people from the Department or State Agency may cross-examine you and your witnesses. No one Is allowed to interrupt anyone who is testifying. The AU may ask anyone questions at any time. If you have any papers to help prove what you have said at the hearing, be sure to tell the ALJ what they are. 7-:!Il the AU that you want to "introduce these papers into evidence." You should do this even if you have already mailed the pap!irs to the AU before the hearing. If you need more time to get papers to the ALJ, be sure to tell him or her before the hearing 1!! over. It may be too late if you tell the ALJ after the hearing is over. PA 899 8105 x3/2042009 12:19 7172459733 SARAH TODD HOME PAGE 05/09 V. YOUR RIGHTS You Have the Right: • To Have Someone Represent You at Your Hearing: You may be represented at your hearing by a laaw.,,er, paralegal, friend, relative, or anyone else you choose. The Bureau does not provide you with a representative. If yrn.j would like to have an attorney for your hearing, but you can't afford one, please contact your local legal aid office f°,:• assistance. If you choose not to have a representative, you may represent yourself. To See Your Case File: You can see any part of your file that is riot confidential. You',can see any part :)V the file that the caseworker will talk about or read from at the hearing. Your caseworker can make copies of the file ia.r you, free of charge, up to ten (10) pages. • To Have Witnesses: You may have people talk on your behalf at both the telephone Dearing and the fa,:-,::P-to-face hearing. If you would like to subpoena a witness, contact the Site Administrator before the hearing so tl W the witness will be notified in enough time to prepare for the hearing. In addition, you have the right to know prior to ,,he hearing the names of the witnesses who will testify for the Department. Contact-your CAO fort their witness infoi cation. • To Submit Documents: You are responsible for proving what you say at the hearing, if you have any ki- ters, notices, documents, or other papers that help prove your case, mail them to the ALJ right away. Be sure to kesp E:; copy of them for your own use at the hearing. Before the hearing, you must also mail a copy c f the papers to th.!.! CAO or agency that made the decision you are appealing. (if *you choose a face-to-face hearing, you do not hav s to mail them to the ALJ; keep them until the hearing.) • To a Hearing Decision: You have the right to get a written hearing decision within 90 days after you fikNI your appeal for Cash Assistance or Medical Assistance, and within 60 days for food stamps, if you ido not get your h!: oring decision ade . 't'his is called within these times, you may call the Department or CAO and ask for benefits until the decision is made.' Interim Relief. Not all cases qualify, so contact your caseworker with questions. • To Appeal the Judge's Decision: If you lose your appeal or are dissatisfied with. the',ALJ's decision, yc i, may appeal to the Secretary of Public Welfare and the Commonwealth Court of Pennsylvania. The, procedure for doi • I; this will be explained in the written notice of the decision. • To Withdraw Your Appeal: You may withdraw your appeal at any time. Your withdrawal must be in wrVi-ig and must be signed. You may check the box next to "i wish to withdraw my appeal at this time". on the "Reply to tl i E! Bureau of Hearings and Appeals," sign it, and return it to the Bureau. If you have already sent in jthe "Reply to thte !:!ureau- of Hearings and Appeals" and later want to withdraw your appeal, contact the office shown on the "Notice- :;I Hearing Date and Time." If you want to withdraw at the time of the hearing, tell the ALJ. • To Interpreters, Translation and.Accommodatlons for Disabilities: If you need and interpreter at the oaring because you do not speak or have limited understanding of English, or because you have a hearing inilr!hrment, please call the Site Administrator or mall back the "Reply to Bureau of Hearings and Aopeais" from the I: ottom of the "Notice of Hearing Date and Time" after checking the appropriate box. The Site Administrator can be n9ii Chad through the telephone number on the "Notice of Hearing Date and Time." Free interpreter and translation servi,c?i„! will be provided at the hearing and for any notices, hearing decisions, or any other documents that are sent fo ;tu. You may bring a friend or relative to assist you at the hearing, but the Bureau's interpreter will ble the official inten.-roter. Individuals needing special accommodation because of their disability should notify the Site Administrati: r immediately in order to obtain assistance with any hearing. VI. PREPARING FOR THE HEARING Dies You Remember Ti): • Gather all documents for your case? s identify witnesses for your case? • Make sure you and your witnesses are aware of the date, time and location of your hearing? • Decide who will represent you at your hearing? VII. PRE-HEARING CONFERENCE OPTION It Is customary for the Department to contact an appellant (you) after an appeal as been flied hu I before the hearing to try to resolve whatever is being. appealed. This is typically called a pe-hearing conipi i!ince. A pre- hearing conference will not interfere with your right to a fair hearing. You may wish to take advti Aage of this opportunity to settle your dispute. Often pre-hearing conferences resolve the motor and may !ellvoinate the need for a hearing altogether. VIII. INTERNET SITE For further Information on fair hearings, you may refer to Title 55 of the Pennsylvania Code § 275.4, one, the Department's Internet site st www.dpw.state.pa.us/general/aboutdpw/dpworganization/ a/003670503.htiii. PA 659 81135 Fact Sheet Appeal #: 21/0120192 - 001 Frances Roberts Participants: Judy Peiper, IMCW Laura Wolaver, IMCW Supervisor Trisha Roberts, Daughter/Power of Attorney Frances Roberts, applicant Timeline: 11/17/08 600L received for Frances Roberts requesting Long Term Care Medicaid from 5/29/08 to 11/8/08 11/25/08 Pending letter sent to Frances Roberts, Trisha Roberts and Todd Memorial Home 12/30/08 162 Notice to Applicant sent to Frances Roberts, Trisha Roberts and Todd Memorial Home Outstanding issues: 1. The application was received and the requested effective date was 5/29/08. As per policy the County Assistance Office may only authorize three months prior to application date of 11/17/08. Effective date would be 8/1/08 to 11/8/08. 2. Ms. Roberts sold her home on 8/22/08 for $45,000. Fair' Market Value of Home as per tax assessment is $57,220. Ms. Roberts failed to provide verification of why she only received $45000. If for no good reason she received less than Fair Market Value a penalty would be applied from 8/1/08 to 9/21/08. 3. Ms. Roberts received $19,475.45 after pay off of first and second mortgage at Member's Ist and other settlement costs. MS. Roberts failed to provide verification of the disposition of funds received in the sale of the home. If the money was unaccounted for, the period .. ....... . ueat-i sui-Ve uu i e OT Ms. xooerts trom Todd Memorial Home, 4. Ms. Roberts failed to provide Member's Ist Federal Credit' Union Bank Statements for 8/1/2008 55 PA Code: 178.1,178.104; 178.3; 181.1; 201.1; 201.3 FILED-& i=( 2F OF THEE RO^;,-HI'-'.1OWY 2009 MAR 31 Pik 31 ?%- i1 AFFIDAVIT OF PROCESS SERVER ) t ?uvwc?c?-r ?yw?w?rm X R" -%--vw.%x.,Vsuac lnyyxk7. :T= LA ?+`` , ,1 NAME OP CO?R ?? l 1AuhrIA A-- (VJA Ovs?RV-kPr U, PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT I declare that I am a citizen of the United States, over the age of eighteen and not a party to this action. And that within the bounds of the state where service was effected, I was authorized by law to ]perform said service. SERVICE: I served. NAME OF PERSON / ENTITY BEING SERVED with the (documents) BY LEAVING COPIES AT THE DWELLING, HOUSE OR USUAL PLACE OF ABODE OF THE PERSON BEING SERVED, WITH A MEMBER OF THE HOUSEHOLD, EIGHTEEN OR OLDER AND EXPLAINING THE NATURE OF THE PAPERS. DESCRIPTION: AGE-20 SEX RACE W HAM, 6 WGT a. - GLASSES N_ OTHER i? wkO.Q.6 NON- SERVICE: AFTER DUE SEARCH, CAREFUL INQUIRY AND DILIGENT ATTEMPTS AT THE ADDRESNES, I HAVE BEEN UNABLE TO EFFECT SERVICE OF PROCESS UPON THE PERSON / ENTITY BEING SERVED FOR THE FOLLOWING REASONS: THIS PERSON aS) OR (IS NOT) IN THE MILITARY- N 14 SIGNATURE OF PROCESS SERVER SUBSCRIBED AND SWORN BEFORE ME M M ANN C . G Wr?pjei No -Uq 0 NOTAR& PUBLIC U031t MGM= 93WIdX3 MMIMM AW Amnw owiv3siNno "dAU ONIkddS U3AIIS Oil" AWIM'ONIlIIor8FJ1 *0 NW WYW '1V3S lVlklVlON VINVAIASNN3d A0 HI 13MNOWWOJ 13UNMx5s ON Q.- a-l - OQ AT UL 5 S t+l1- M R OF SERVICE: PERSONALLY DELIVERING COPIES TO THE PERSON/AGENT B ING SERVED. 0F NOTARY 1199 PIA ? l Pi 4j 2 ,' , ti? of "?;rS Ol ts` X, , ,-' ' 13' v_ r i??i? ?il??Vx111 ihr?a,ac`c?3::,: <.; t,fJiiltlAblidi?C 4?- //S? AFFIDAVIT OF PROCESS SERVER NAME OF V ki?4 e" eke s-? vs-To V` I PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT I declare that I am a citizen of the United States, over the age of eighteen and not a party to this action. And that within the bounds of the state where service was effected, I was authorized by law to perform said service. SERVICE: I served ?TR?iIP?-?o N,4ME OF PERSON / ENTITY BEING SERVED with the (docu PERSONALLY DELIVERING COPIES TO THE PERSON/AGENT BE G SERVED. BY LEAVING COPIES AT THE DWELLING, HOUSE OR USUAL PLACE OF ABODE OF THE PERSON BEING SERVED, WITH A'.MEMBER OF THE HOUSEHOLD, EIGHTEEN OR OLDER AND EXPLAINING THE NATURE OF THE PAPERS. DESCRIPTION: AGE-Q51- SEXV RACE HAIR k? w n WGT !W GLASSES OTHER , ? NON- SERVICE: AFTER DUE SEARCH, CAREFUL INQUIRY AND DILIGENT ATTEMPTS AT THE ADDRESSES, I HAVE BEEN UNABLE TO EFFECT SERVICE OF PROCESS UPON THE PERSON / ENTITY'BEING SERVED FOR THE FOLLOWING REASONS: THIS PERSON as) OR (IS NoT) IN THE MILITARY - N -SIGNATURE OF PROCESS SERVER SUBSCRIBED AND SWORN BEFORE ME IA=A%i y 0.0 Ot5MI N0 AiA& 0 44MM 3.).09 NOT PUBLIC COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL MARY ANN C. GARBARINO, NOTARY PUBLIC SILVER SPRING TWP., CUMBERLAND COUNTY MY COMMISSION EXPIRES DECEMBER 13, 2012 ON `L- Wl -0!3 AT - Sa u • m . MANNER OF SERVICE: FILED- ?. i I if `./E. OF THE ? -c r{, "Mn - RY 2099 MAR IV I FPS 3: 29 I ; a ! k rl i APR 0 R 20Q8? Steven M. Montresor smontres(a?ldylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, United Church of Christ Homes, Inc. d/b/a Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA UNITED CHURCH OF CHRIST HOMES, INC. : d/b/a SARAH A. TODD MEMORIAL HOME: Plaintiff, V. TRICIA ROBERTS and FRANCES ROBERTS Defendants. NO. 09-1159 CIVIL TERM, 2009 CIVIL ACTION - LAW AND EQUITY RULE TO SHOW CAUSE AND NOW, this day of _ 2009, upon consideration of the foregoing motion, it is hereby ordered that 128491 1 (1) a rule is issued upon Tricia Roberts to show cause why plaintiff is not entitled to the relief requested; (2) Defendant Tricia Roberts shall file an answer to the motion within days of this elate; tire . 6.7; lj? UUMPfULCM ays o this c ate; a hearing shall be held on 2009, at in. in Court Room No. Cumberland County Courthouse, 1 Courthouse Square, Carlisle, ? , Pennsylvania; and (?) notice of the entry of this order shall be provided to all parties by the plaintiff. o? 128491 2 ?Z :Z 4+td ?? ?r1i16$?Z ?? ? ???? AFFIDAVIT OF PROCESS SERVER b - bq-kn l (jcw%pi.R I-it dbn SRa?h q ?o m??,A ? PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT I declare that I am a citizen of the United States, over the age of eighteen and not a party to this action. And that within the bounds of the state where service was effected, I was authorized by law to-perform said service. SERVICE: I served ?Ric tPr cvs NAME OF ERSON / ENTITY BEING SERVED with the (documents)7?uQa2 iD S Dw ea„sa by servin at HOM n Note a ? W S tv?6 `5 . Np+?? St• w Sm.Vc?c ON N- - 13 -C)q AT?? '•D? • I`n R OF SERVICE: PERSONALLY DELIVERING COPIES TO THE PERSON/AGENT BE G SERVED. BY LEAVING COPIES AT THE DWELLING, HOUSE OR USUAL PLACE OF ABODE OF THE PERSON BEING SERVED, WITH A MEMBER OF THE HOUSEHOLD, EIGHTEEN OR OLDER AND EXPLAINING THE NATURE OF THE PAPERS. c? DESCRIPTION: AGE SS SEX RACE HAIR t4Q lSOvkn WGT155 GLASSES .OTHER 5 /C-O NON- SERVICE: AFTER DUE SEARCH, CAREFUL INQUIRY AND DILIGENT ATTEMPTS AT THE ADDRESSES, I HAVE BEEN UNABLE TO EFFECT SERVICE OF PROCESS UPON THE PERSON / ENTITY $EING SERVED FOR THE FOLLOWING REASONS: SIGNATURE OF PROCESS SERVER f',+" OF THE MOOT ;OKAMY 2009 APR IS Ali 11 4 D CU AFFIDAVIT OF PROCESS SERVER • dot-II uhi-+ekcw"?\ dpp SRw?h M4MOR?H l PLAINTIFF/PETITIONER DEFENDANT/RESPONDENT I declare that I am a citizen of the United States, over the age of eighteen and not a party to this action. And that within the bounds of the state where service was effected, I was authorized by law to rfo said service. SERVICE: I served NAME OF PERSON ENTITY BEING SERVED ?Zuu - ---1-o S41ow with the (documents) by at O AT 4. OF SERVICE: PERSONALLY DELIVERING COPIES TO THE PERSON/AGENT BEING SERVED. BY LEAVING COPIES AT THE DWELLING, HOUSE OR USUAL PLACE OF ABODE OF THE PERSON BEING SERVED, WITH A MEMBER OF THE HOUSEHOLD, EIGHTEEN OR OLDER AND EXPLAINING THE NATURE OF THE PAPERS. DESCRIPTION: AGES _ SEX-E---RACE HAIR G WGT21s GLASSES Y_ OTHER NON- SERVICE: AFTER DUE SEARCH, CAREFUL INQUIRY AND DILIGENT ATTEMPTS AT THE ADDRESSES, I HAVE BEEN UNABLE TO EFFECT SERVICE OF PROCESS UPON THE PERSON / ENTITY BEING SERVED FOR THE FOLLOWING REASONS: SIGNATURE OF PROCESS SERVER FILED-OFACE OF THE PP77H NOTi ( 2009 APR 15 AM 11: 40 PLINNISYLk,(?'4!A UNITED CHURCH OF CHRIST, HOMES, INC., d/b/a SARAH A. TODD MEMORIAL HOME, Plaintiff v. TRICIA ROBERTS and FRANCES ROBERTS, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 09-1159 CIVIL TERM CIVIL ACTION - LAW AND EQUITY ORDER OF COURT AND NOW, this 15th day of April, 2009, the Defendant, Frances Roberts, is directed to sign favor of the Plaintiff to enable them to obtain Members 1st Federal Credit Union and Legg Mason successors. Said release to be signed within 1 date. If the release is not signed, this Order authorization for those institutions to provide information to the Plaintiff. a release in records from or its D days of today's shall operate as the requested In all other respects, the request for a preliminary injunction is DENIED. even M. Montresor, Esqu Attorney for Plaintiff X y!`ricia Roberts 63 East North Street Carlisle, PA 17013 Xra n ces Roberts 65 East North Street Carlisle, PA 17013 srs 99 *10I WV L 6 8JV 6 OZ ;