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HomeMy WebLinkAbout09-1626Steven 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, County of Cumberland, Claremont Nursing and Rehabilitation Center IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER 1000 Claremont Road Carlisle, PA 17013 Plaintiff, V. KELLY STANLEY 7000 Wertzville Road Mechanicsburg, PA 17050 and DAVID HORN 609 Robert Street Mechanicsburg, PA 17055 Defendants. NO. 09- 14 al, aiv i l h° r14 TERM, 2009 CIVIL ACTION - LAW AND EQUITY 128878 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 128878 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, County of Cumberland, Claremont Nursing and Rehabilitation Center IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER 1000 Claremont Road Carlisle, PA 17013 _ Plaintiff, NO. ©cl - /L a 4 x4jt V. TERM, 2009 KELLY STANLEY 7000 Wertzville Road Mechanicsburg, PA 17050 and DAVID HORN 609 Robert Street Mechanicsburg, PA 17055 Defendants. CIVIL ACTION 128878 COMPLAINT AND NOW COMES, Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center, by and through its attorneys, Latsha Davis Yohe & McKenna, P.C., and files the within Complaint against Defendants, Kelly Stanley and David Horn, and in support thereof, avers as follows: Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center (hereinafter "Claremont"), is a county-operated skilled nursing care facility located at 1000 Claremont Road, Carlisle, Pennsylvania 17013. 2. Claremont provides living accommodations and skilled nursing care (hereinafter "Nursing Care Services") 3. Defendant Kelly Stanley (hereinafter "Ms. Stanley") is an adult individual currently residing at 7000 Wertzville Road, Mechanicsburg, Pennsylvania 17050. 4. Defendant David Horn (hereinafter "Mr. Horn") is an adult individual currently residing at 609 Robert Street, Mechanicsburg, Pennsylvania 17055. 5. Ms. Stanley's father, Mr. Horn, is a former resident of Claremont. 6. Mr. Horn appointed Ms. Stanley as his Attorney-in-Fact pursuant to a Durable Power of Attorney dated July 12, 2006. A true and correct copy of the Power of Attorney is attached hereto as Exhibit "A" and made a part hereof. 7. Mr. Horn was admitted to Claremont on or about February 15, 2007. 8. On or about February 15, 2007, Claremont and Ms. Stanley, on behalf of Mr. Horn, entered into an Admission Agreement whereby Claremont agreed to provide 128878 2 Mr. Horn with Nursing Care Services. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and made a part hereof. 9. Ms. Stanley is designated as "Responsible Party" under the Admission Agreement. 10. Ms. Stanley, as Mr. Horn's Attorney-in-Fact and Responsible Party, had both a fiduciary and a contractual duty to use Mr. Horn's assets and/or resources to compensate Claremont for the Nursing Care Services which it provided to Mr. Horn and to keep his account current. 11. At all times relevant, Claremont provided Nursing Care Services to Mr. Horn in accordance with the Admission Agreement. 12. Ms. Stanley has failed to use Mr. Horn's assets and/or resources to pay Claremont for the Nursing Care Services which Mr. Horn received at Claremont. 13. Mr. Horn was discharged from Claremont on October 26, 2007. 14. A balance in the amount of $32,824.83, plus interest, is currently due and owing to Claremont for the Nursing Care Services that it provided to Mr. Horn. A true and correct copy of the A/R Account Detail is attached hereto as Exhibit "C" and made a part hereof. COUNT I - BREACH OF CONTRACT County of Cumberland, Claremont Nursing and Rehabilitation Center vs. Kelly Stanley and David Horn 15. Paragraphs 1 through 14 above are incorporated herein by reference as if fully set forth at length. 128878 3 16. From February 15, 2007 through October 26, 2007, Claremont provided Nursing Care Services to Mr. Horn pursuant to the aforementioned Admission Agreement. 17. Mr. Horn had a contractual obligation to make payments to Claremont. 18. Ms. Stanley had a contractual obligation, as Mr. Horn's Responsible Party, to make payments on Mr. Horn's account from Mr. Horn's assets and/or resources. 19. Mr. Horn has an overdue balance in his account with Claremont, which is currently in the amount of $32,824.83 plus interest. 20. On or about February 7, 2009, Ms. Stanley made a payment in the amount of $200.00 toward the outstanding balance. A true and correct copy of the check is attached hereto as Exhibit "D" and made a part hereof. 21. The remainder of the balance remains unpaid. 22. The failure of Mr. Horn to pay the outstanding balance on his account with Claremont constitutes a breach of the Admission Agreement. 23. The failure of Ms. Stanley to pay the outstanding balance on Mr. Horn's account with Claremont constitutes a breach of the Admission Agreement. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $32,824.83 plus interest. COUNT II - QUANTUM MERUIT County of Cumberland, Claremont Nursing and Rehabilitation Center vs. Kelly Stanley and David Horn 24. Paragraphs 1 through 23 above are incorporated herein by reference as if fully set forth at length. 128878 4 25. Claremont has demanded payment in full for the Nursing Care Services which it provided to Mr. Horn, and has not received payment for the same. 26. Claremont is entitled to receive payment in full for the reasonable value of the Nursing Care Services it provided to Mr. Horn. 27. Mr. Horn has been unjustly enriched and enhanced by the receipt of Nursing Care Services which have been rendered by Claremont to him in the amount of $32,824.83 plus interest. 28. To the extent Ms. Stanley has retained Mr. Horn's assets and/or resources and has failed to pay for the care and services rendered by Claremont to Mr. Horn, Ms. Stanley has been unjustly enriched. WHEREFORE, Plaintiff demands judgment in its favor and against Defendants in the amount of $32,824.83 plus interest. COUNT III - CONVERSION County of Cumberland, Claremont Nursing and Rehabilitation Center vs. Kelly Stanley 29. Paragraphs 1 through 28 above are incorporated herein by reference as if fully set forth at length. 30. Upon information and belief, Ms. Stanley converted, misappropriated and deprived Mr. Horn of his right in, use and/or possession of his property as more fully set forth above. 31. To the extent Ms. Stanley's conversion, misappropriation and deprivation of Mr. Horn's right in, use and/or possession of the aforementioned property was for 128878 5 the purpose of hindering or delaying their transfer to Claremont, these actions were beyond Ms. Stanley's authority as Mr. Horn's Attorney-in-Fact. 32. As a result of the foregoing unlawful actions of Ms. Stanley, Claremont has incurred damages in the amount of $32,824.83 plus interest. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Ms. Stanley, in the amount of $32,824.83 plus interest. COUNT IV - FRAUDULENT TRANSFER County of Cumberland, Claremont Nursing and Rehabilitation Center vs. Kelly Stanley 33. Paragraphs 1 through 32 above are incorporated herein by reference as if fully set forth at length. 34. Upon information and belief, Ms. Stanley transferred Mr. Horn's assets and/or resources without receiving reasonably equivalent value and/or for the purpose of hindering and delaying their transfer to Claremont. 35. Upon information and belief, Ms. Stanley accepted the transfer(s) of Mr. Horn's 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 Claremont for the Nursing Care Services that it has rendered to Mr. Horn. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Ms. Stanley, in the amount of $32,824.83 plus interest. 128878 6 COUNT V - FILIAL SUPPORT County of Cumberland, Claremont Nursing and Rehabilitation Center vs. Kelly Stanley 36. Paragraphs 1 through 35 above are incorporated herein by reference as if fully set forth at length. 37. Upon information and belief, Ms. Stanley, as Mr. Horn's Attorney-in-Fact, transferred Mr. Horn's assets to herself or otherwise misappropriated said assets. 38. Upon information and belief, the above-referenced transfer and/or misappropriation of assets rendered Mr. Horn indigent and unable to pay the outstanding balance owed on his account. 39. Ms. Stanley is Mr. Horn's daughter. 40. As a result of Ms. Stanley's transfer or misappropriation of her father's assets, Ms. Stanley has the ability to satisfy her father's debt to Claremont. 41. Pursuant to 23 Pa.C.S. § 4603, Ms. Stanley has a statutory obligation to care for, maintain or financially assist her father. 128878 7 WHEREFORE, Plaintiff demands judgment in its favor and against Defendant, Ms. Stanley, in the amount of $32,824.83 plus interest. 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, County of Cumberland, Claremont Nursing and Rehabilitation Center 128878 8 VERIFICATION I, Viola Byerly, hereby verify that I am the Business Office Manager of Claremont Nursing and Rehabilitation Center; 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: iA/ _ 1 2-6011 Viola Bye ?- 128878 C?Okl ?-t ? A MJ d "%OE ®U3??AS_ 3N S31H3S 00008 NOTICE THE PURPOSE OF T81S POWER OF ATTORNEY THE PERSON YOU DESIGNATE (YOUR ' GENT POWERS TO HANDLE YOUR PROPERTY, IS TO GIVE POWERS TO SELL OR YO ") BROAD PERSONAL PROPERTY THERWISE WHICAY INCLUDE APPROVAL BY YOU ROUT ADVANCE NOTICE O REAL R YO oOR THIS POWER OF ATTORNEY DOES NOT ON YOUR AGENT TO EXERCISE GRANT POWERS ARE EXERCISED, YOU ED POWERSSg T DUTY TO ACT FOR YOUR BENEFIT AND IN ACCT MUST USE' SE DUE CARE POWER OF ATTORNEY. ORDANCE WITH THIS HIS YOUR AGENT MAY EXERCISE THE POWERS THROUGHOUT YOUR LIFETIME INCAPACITATED, UNLESS YO 'EVEN AFTER YOU ECO HERE U EX DURATION OF THESE POWERS ORPYOUSLY LIMIT THE ME POWERS OR A COURT ACTING ON REVOKE THESE YOUR AGENT'S AUTHORITY. YOUR BEHALF TERMINATES YOUR AGENT MUST KEEP YOUR FUN YOUR AGENT'S FUNDS. DS SEPARATE FROM. A COURT CAN TAKE AWAY THE P AGENT IF IT FINDS YOUR AGENT 1S NOT POWERS OF YOUR ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGE POWER OF ATTORNEY ARE EXPLAINED MORE C.S. C R 56. NT UNDER A FULLY IN 2Q PA. IF THERE IS ANYTHING ABOUT THIS FO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT FORM THAT YOU DO TO YOU. i HAVE REAP OR HAD EXPLAINED AND I UNDERSTAND ITS CONTENTS. TO ME THIS NOTICE AW OFFICES OF DAVID R. HORN Z O 3ENJ• HOGG DA E )VERSTREET 'Jri l tl v n UITE 101 ? ^ r "SLE,PAI7013 ??FIT?D,4,T?7??? POWER OF ATTORNEY I, David R. Horn, of Cumberland County, Mechanicsbur Pennsylvania, do hereby nominate, constitute and appoint g Stanley or, in the alternative, if Kelly F. Stanley is unwilling o un Fable so act, Carol A. Horn, as my true and lawful Attorney-In-Fact, to act ito my name, place and stead to do and perform any act that I myself n might perform if I were personally present in regard to the following: To endorse checks, notes, drafts and any other commercial papers in my name and to withdraw money from any bank accounts that I may have for my benefit, and to sign orders or receipts in my name; therefore To enter into any safe deposit box I may have in my own na or jointly with another person to inventory the contents of such me box to do or perform any act with respect to the contents that I mi or perform if I were personally present; ght legally To grant, bargain, sell and convey my real property or an thereof for such price and on such terms and conditions ash a y part shall deem proper, with or without the taking back of a purchase mone mortgage or deed of trust and to collect and receive the Proceed y any sale; s from To enter into any contract or contracts for the sale of the premises, or any part thereof with such persons and on such terms she shall in her discretion elect and to execute, acknowledge as and deliver in my name such deeds or conveyances, with such co en and conditions as she may deem proper, that may be required covenants ants transfer of said property or any part thereof or of any interest t the herein; To execute a mortgage or deed of trust on my real property i such amount and on such terms and conditions as she may deem in necessary and proper and to sign, execute and deliver, in my name or otherwise, such instruments as maybe required in connection with obtaining the mortgage or deed of trust, and to do any other ac might or could do in obtaining the mortgage or deed of trust on is as I property; the To sell and enter into a contract or contracts for the sale of all LAW OFFICES OF any part of my personal property, effects and belongings of eve ki or PHENJ• HOGG and nature wherever situated for my benefit with every nd rov>R STREET possession of said personal property and to exgotl+? I'pl jojdeliv?rl 1 SUITE 101 documents necessary to transfer title to said e ` `?? ?a_n?e any RLISLE, PA 17013 P. Ds Ill IfWdrtyZ _ 15 _ 2 j 3 7 "Ca 1-2-1924 . r' i C including bills of sale or other documents of title, and to security interest for any unpaid balance which m y Attorney-takeIn-any her discretion may deem necessary and proper; Fact in To borrow money from such sources and on such terms Attorney may deem fit and proper, and to execute in con• as my any loan of money a security agreement covering an of?unction y al with personal property and to execute, sign, acknowledge nd deliver or any form that instrument that may be required in conjunction transaction; with the LAW OFFICES OF "ffEN I HOGG -HOVER STREET SUITE 101 LISLE, PA 17013 To authorize my admission to medical, nursing, residents similar facility and to enter into agreements form al or to be construed and implemented in accordance with the Chapter 56 of Title 20, Consolidated y care. This power is on the date of execution of this Power of A Ylvania Statutesr?nl elffect of ttorney; To authorize medical and surgical procedures. This Power 1s to be construed and implemented in accordance with the Provision Chapter 56 of Title 20, Consolidated Pennsylvania Statutes, in e s, in es of on the date of execution of this Power of Attorney. ffect I direct that this Power of Attorney shall be a durable Pow Attorney and shall become effective immediately. er of David R. Horn Date fitness ^ r 7D #4 9 20 3 1 - 2 -15-2-377 r <1 ^Z C ACKNOWLEDGEMENT I, Kelly F. Stanley, have read the attached Power of Attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contra in the Power of Attorney or in 20 Pa. C.S. when I act as agent: rY I shall exercise the powers for the benefit of the principal. assets. I shall keep the assets of the principal separate from my I shall exercise reasonable caution and prudence. LAW OFFICES OF '-'qEN I NOGG liANOVER STREET SUITE 101 P.RILISLE, PA 17013 I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. jelly F./Stanley Date ` DAVI D > -CORD .14923 DATE 2-15-20.17 iC8 7-2-192'0 ACKNOWLEDGEMENT 1, Carol A. Horn, have read the attached Power of Attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contra in the-Power of Attorney or in 20 Pa. C.S. when I act as agent: ry I shall exercise the powers for the benefit of the principal. assets. I shall keep the assets of the principal separate from my 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. Carol A. Horn - I I/ ? I/ Date -:a LAW OFFICES OF 'rIEN I HOGG riANOVER STREET SUITE 101 .RLISLE, PA 17013 i)AVID 311 a' -'RD #4920 J.° j T DATE 2-15-2007 ti? B '°2-IJ927 i it Y Social Security Administration M2 Retirement, Survivors, and Disability Insurance Important Information DAVID R HORN 1000 CLAREMONT RD CARLISLE PA 17013 Mid-Atlantic Program Service Center 300 Spring Garden Street Philadelphia, Pennsylvania 19123-2992 Date: June 25, 2007 Claim Number: 201-16-6569 A RECEIVED JUN 2 6 2007 We have chosen KELLY STANLEY to be your representative payee. Your payee will receive your checks each month and will use this money for your needs. Information About Your Checks We are sending your regular monthly check of $241.00 to KELLY STANLEY around July 3, 2007. If You Have Any Questions We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-717-243-0085. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at: SOCIAL SECURITY 200 S.SPRING GARDEN ST CARLISLE,PA 17013 e? e SEE NEXT PAGE ?xti,b;+ 3 Mod %os ®a313kPi 93It13S 00009 Claremont Nursing and 1000 Claremont Road Carlisle, PA 17013-8805 11 Rehabilitation Center Main (717) 243-2031 Fax (717) 240-1952 ADMISSION AGREEMENT Resident Name As part of admission to Claremont Nursing and Rehabilitation Center, the Resident and the Responsible Party assisting the resident acknowledge and agree to the following: 1. If Claremont Nursing and Rehabilitation Center determines that the Resident is not appropriate or does not qualify for nursing home care, the Resident will discharge from Claremont Nursing and Rehabilitation Center following a 30 day notification of the need to make alternate living arrangements. 2. If the Resident cannot qualify for coverage under the Medical Assistance or Medicare programs, the Resident will pay daily rate for care at the nursing facility. 3. The Responsible Party (guarantor) assures that the Resident's bill will be paid from the Resident's assets/ft nds. If the Resident does not have personal funds or when personal funds are exhausted, the Responsible Party will make application to Medical Assistance on behalf of the Resident. If the Resident does not qualify for Medical Assistance funding, the Responsible Party will arrange discharge for the Resident if the bill is not paid in a timely manner. 4. The Resident authorizes Claremont Nursing and Rehabilitation Center to release information concerning their assets, real or personal, to the Cumberland County Board of Assistance. 5. If the Resident is being covered by the Medical Assistance Program, the Resident and Responsible Party recognize that all income the Resident receives during the month of admission, must be paid to the Claremont Nursing and Rehabilitation Center, regardless of the day of admission, unless waived by the Cumberland County Board of Assistance. The Resident and Responsible party acknowledge that all future income received by the Resident, while covered under the Medical Assistance program, must be paid to Claremont Nursing and Rehabilitation Center. Income not applied to charges for care will be placed in the Resident Guest Fund or refunded. Resident Signature or Mark Date Date ate 5 _ ?x???'+ ? CYarem_ont Nursinq & Reha 2 1000 Claremont Drive Carlisle PA 17013 (717)24 -2031 epArl rr??a? ^-_- a? 4920 Morn David R IOBIRTHDATE 11 SEX 'd"?" ?a OHR 31021927 04200702 A avid R Horn Kelly Stanley 7000 Wertzville Rd. echanicsburg, Pa 17050 42 REV. CD. 43 DESCRIPTION 44 HCPCS /RATE / HIPPS CODE 0120 R & B NURSING CARE - SEM 225.00 5 FED. TAX NO. Z3-6003119100107 b 45 SM.. DATE .. 46 SEN. UNRS 47TDTAL CHAMI NOWMAM CHARM 25 5625._0043 t_, gg••7R?L TMEM AUTFV>R ?? ? ? '¢' ?«55. I? t a r $ 7 8T2 3 01-9 z } .9 k'? S yy F? m 1"AC)A41T lla +""' t?s+{LAY: '"$+' P PIT aY 04104 t " ??- F'RINCiPAC-FROCEOCIA - K`? E-I '' -"S-CODE" _ W. E ° 76 ATTEIJDINO 1 '°aTrERp1 w, -,TOSEF MD ,CODE.'' .,:F'?wy 770P?RAT1fiQ?,: NP1 REMARKS Bloc LAST 314000000 NN 79 OTHER, :6L-RO7 ww v.9riggsCorp.wm UBA4 CMS 1450 APPROVED OMB NO.0938.0997. ; LAST XTJRC"? TFP 4dgo4F'ta THE CERTIFICATIONS ON THE REVERSE APPLY TO FIRST 68 aremont Nursin & Reha 2 CNTLL# '0003 X000 Clar mont Drive -ti, ` 4 92O', ?7 '] S e PA 1/ 1 J 5 FED. TAX NO. LATE I i ?7fE 1 ?Z7.Z1 -2j3-203 FS PATIENT _NA I. , a: 4 92 0 23-600311 0 9 010 7 0 9 3007 P 14 1081RTHDATE 115EX .. .. 78 V- - PAGE?_ OF _? CREATION DATE µ 10 0 9 CO) 7 675 0 ? S ,MOUE ID i •-.? R 18 ?-?? '?' - --flWTE?a'?a b Qf11?'A PROCEDURE z. . C O OTHER L- TA ... -- .x?.. PRV ID i a.. a r x??g 57 ' *tdtiMBER+_` _ f _ "B5 EI?iPL?YER,NAMEv u?..-? Z.,_ E C 68 Kry •?• v vLJLl' - COD??'.a DATE TI OPERATING` NF W REMARKS 81C LAST a B 314 0 0 0 0 0 0 - 713 ?A*W-'R LASE c 79.0THER , NPI 126L-R07 avnv.Bd E;Co com UB-04 CMS4450 APPROVED OMB NO 093&0997 - LAST 99 rp. RTUBC w== TPP24394638 THE CERTIFICATIONS OI • _. V 2 'laremont Nursing & Rehab g tee„ nt Drive rlisle FA 17013 9PIII74TE 243 0€ ?. q )avid R Horn 2^61ky fey '000 ertzville Rd. 5 FED. TAX NO."'?STAT? COQ : P6Eif(JD ` - 7 4920 3- I'M 44 HCPCS / WE / HIPPS CODE 45 SEWN DATE 45 SERV. UNITS 47 TOTAL CHARGES _ #S NON-COVI CHARGES n' PAGE OF CREAT ION DATE • } Futi P.,4ME?1, ?1n?iE'.c_ F ?• s , 57 OTHER - ....u . _ . 1 yy .'L[!t![?SViCY a.Gaf+IEPAY'E ..,??' '.R- Ta Z- ., ... # 6t GROUP N ? RY ID 63 TREATMENT A(I'fHORIZ4TION CODES l?? ' Or Il David R 01 20 1 66569 _ 777 1 ?.-_aas 39 ADMIT DX ._; 70 PATIENT,. , 77PPS . REASON DJE, . 75 74 :.` PRINCIPAL PROCEDURE --<N.- . 'h '. - '- RODE ... GATE ??:. ODDE UMERPROCEDURE . `'.. .. LOO= DATE 76 ATTENDING ' .< NPI OUAi _ LL a oTTiER PROCEiRJRE '- -; LAST FIRST . CODE =TE ?'': DA 770PERATING NPI 04104 aim LAST FIRST 30 REMARKS 81CC a E 3 9151D : OSEF, MD E T M b LAST c 79 OMERi:: „o n? l??C nG1 ,000MKfI hRIR ?Ih /10'iq.llg07 LAST ` - - THE f:FRTIFI[:ATIOA 6 FED. TAX NO. 03 38 B.1. tiT. ^vOVERS PERKiO - I ' '... David R Horn _Kel-ly Stanley 7000 Wertzville Rd. MPC)2B11i-C-S12Ur-aF 214 42 REV. C0. 43 DESCRIPTION d T? 04 HCPCS /RATE./ HIPPS CODE 45S EEN DATE 48 SEW.. UNITS 47TO7AL CHARGES N NOy.CCyEf C74ARGES 49 .. SE 77 r, an .4k'hf?..'u''f'?14.ak ?}. 1 y".•A*.a'l . '7?' ? ?.. . ,. .. rs? Z y 4 al ??r . . ` '4? 1.7 !1 N z PAGE OF EATON DATE • A C M 7 j ..+nC "' 6 er y ?rle:'T? CTHER,•. _ !i t gy?* m'lff ? 59 P. ?` FFN ID JN?D' UNICUE D '. ewI?? v 617 I - i ? ,v-n• . -. 1... w.ee , RNAMk n 62ItJCU?a1JCE'.GROUPNO:-=. i rni D w y. Qt .2 y;- y? :; - . ..fir .„_ ?VTt?iTHOv Y..; ... t..?r, ?„Z, 3„"•, ?'?le.. _ 64'DT50?1MENT'COfJTROL NUMBER -.:v - "z = C ` i4/? •K. a 65 EMPL xER A ' -' 1'" a u a•--.. ? ,u N ME ? 68 88 D ' ?t PPS " T 73 OOOE ; 74 _?DENClPAL PF#pC: ,d- OTHER PROCEDURE A-IA -1 E? @ @ - . CODE' - DATE 76 ATTENDING .. NM - pUAL c oTw 9TOCF?/Re. 95 OS S M ..CODE Wiz' 'DATE F'. z=.? 77 OPERATING- NPI D(1gU 80 REMARKS 81 CC LAST FIRST a 780THER'. NPI ply, L4ST FIRST 79 OTHER. NPI d BAST ---- "p-1 0 8 0 2 0 0 7 3a PAT. CNTL R RED x J ' Car 1701 R S FED. TAX NO. "B w STAT N COVER ERIOO'4? , A 7 Fgpfi jjjj? 23-6001319.06 107 06300 7 030 10 BIRTHDATE 1 E DHR a s al 44 HCPCS / RATE / HIPPS CODE 148 SERV. DATE 14a SERV. I&8TS 47TOTAL CHARGES j 46 NON•CWERED CHARGES 149 vsvss cxae,-a. 4Ytt3- r, "?I ?'+5?:.: +R:-Yg45Fx ,x PV PAGE OF CRE4TION DATE v?R< ap . PRIVATE PAY CLAREMONT - 'S T N P` - ?F'x2q OTHER PRV ID ? ... ?)3 U ?? fkf # i?' ? '?' ? : ? .?, .. fTREL 80'1N D'?k!?I?UE ?? ? r-} - ?J??''?-'u.€': - ? ?'?2 8t 6 F??? UP ? _ spa ? ., - -_ ? 3 ? ? ? v. ...rs -x .. ... ? ?. '. , E • >-? .n*?.? .? ?. , ., p.T _,. Y RO ,p., ., .? ...? ? .r :. ,.? , 1: '??w? . INSU P., •Ni,E GROU P'f70f 4Lrr OazaTi?N woES .:? _.<. ..:.. . -- oat.= 84 DOCUMEXTCANTROLNUM6ER :-_ _ « . " G%' 65 E1Pi E 0YERNA1-: y < a ? `x u S 67 II 2 04 ,wL "C E 04 r; 79 ?" 041 , 74 PRINCIPAL PROCEDURE'"., 'CQDE:.'• -;"'OATS ..`.: OTHER PROCEDURE-:.;• .,. CODE-= .. ..t DATE . 76A TTENDIN(3,? ". NR al W; ,.. .,.:: ,. 3950 JOSEF MD EKNEST M d 'C-- OTHER PROCEDURE '- ';. DATE - :. .:-. 770PERATINO° NPI QU9L LAST FIRST 80 REMARKS al CC 78 OTHER NPI OWL a b LAST FIRST. t 79 OTHER RM d L,43T .. mRsT07/06/2007 FED. TAX,* 23-6003119 050'107'05310 5 031 38 David R Horn Kelly Stanley 7000 Wertzville Rd. Mechanicsburg, Pa 17050 42 -Ca 0 DESCRIPTION _ 44 01 TOTAL PAGE OF °S CODE 46 am DA'E 46 SSW.. UNRS 47MIX cRAp n 48 NCfiCOVER®CNARpp 31 6475.00 cRE4770N DATE 57 OTHER PRV ID F" k yg(iq?} rN t DA-WWpi HORN POA = KELC T' ,MLEY 5 3 4718 , 609'ROH STREET CS Y `" MECHANI 6 67 7 BURG, PA 17055 R 60-1273 Date V 041 4 Pay to tfie 2 41 1 IN, ;t Order oaf z -PNCBANK Q opars 8 7 .?.. , . REMARKS PNC 13anic, NA 040 - CmtndPA' - -For - 40 3 1 3 1 2 7'3 8?' S 70 ' - - _ t 5-S-R07 ,-, BriggsCorp.com U6-04C 0 080 5 7 Lit 47 LIB 4 'rClaremont Nlarsi ?_ Claremont Carlisl Pe 1703 717 243-2031 orn David R 10 BIRTHRATE 11 SIX 0102192 7 M W 04203 David R Horn Kelly Stanley 7000 Wertzville Rd. Mechanicsbur , Pa 17050 42 REV. C4 43 DEXRIPRDN ? Par. 5 FEU TAX NO. -6003119 04 @07 043007 011 a Q NaN•COVEMCHAFKM 149 00 GE OF CREg77ON DATE 57 OTHER PRV ID ,.r4 " w ...??, MMO -u DAVID R. ?iOR1 KELLY STANLEY, PO , - 4718 - 1-1 609 ROBERT STREET ; MECHAI&SBURG PA 17055: 60-1273/313 647 A 5? a teW % LO 041 - -7 Pay to.thc " 2 041 Order of r J ?:PNCBA b ollars a NK Yx M P Bau1G NA. 040 ZMARKS Central PA For 1:0 3 13 12' 7 38? S0 70080 5 7 Ln L417 18 - •S-R07 www.BdggsCorp-corn UB-Oat a7ci. a.? e . ;TI f, , -, M j d °%os (MMAAH S3/H3S 00009 CL.AREMONT NURSING & REHAB CTR 1000 C MREMONT ROAD CARLISLE, PA 17013 Telephone: (717) 243-2031 David Horn Kelly Stanley 7000 Wertzville Rd. Mechanicsburg, Pa 17050 Please detach and return top portion with Payment. Date s _ DeSCri Lion ?B iance B/F - - - Your Account is Overdue Please Remit Payment Immediately DAVID R. HORN KELLY' STANLEY, POA 5006 Char ! Ravman 609 ROBERT STREEr MECHANICSBURG, PA 17055 - 60-12731313 Date 041 Pay to the. order of $?,J LTD ny PNCBANK U ` Dollars e rxc DeacA , NA 040 r 90 Days Amount Due Central P - For ,024.83 33,024.83 1:03 13 12 7 3131: 50700 - 80 5 7 Li1¦ ..500 - -- ---__., _.. Statement Date: 12/19/2008 Due Date: 01/01/2009 David R Horn - Account #: 4920 CLAREMONT NURSING & REHAB CTR 1000 CLAREMONT ROAD CARLISLE, PA 17013 Telephone: (717) 243-2031 STATEMENT Statement Date: 12/19/2008 Due Date: 01/01/2009 Amount Enclosed $ az Account #: 4920 RE: David R Horn Ul c? - C) -n 00 -^ W. fJ Sheriffs Office of Cumberland County R Thomas Kline super of custbEdward L Schorpp Sheri 4 Solicitor Ronny R Anderson ,±A Jody S Smith Chief Deputy OFFICE OF THE SkERIFF Civil Process Sergeant SHERIFF'S RETURN OF SERVICE 03/18/2009 07:00 AM - Dennis Fry, Deputy Sheriff, who being duly sworn according to law, states that on March 18, 2009 at 1900 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Kelly Stanley, by making known unto Kelly Stanley personally, at 7000 Wertzville Road, Mechanicsburg, Cumberland County, Pennsylvania its contents and at the same time handing to her personally the said true and correct copy of the same. SHERIFF COST: $53.00 (PAID) SO ANSWERS, March 19, 2009 R THOMAS KLINE, SHERIFF Deputy Sh f Docket No. 2009-1626 Claremont Nursing & Rehabilitation Center v Kelly Stanley ? ,? X ?? , ? ? ,. ..? ;= ..:?- a ?'. Sheriffs Office of Cumberland County R Thomas Kline 4a?'tr "`??°rrt ???D Solicitor Sheriff Ronny R Anderson Jody S Smith Chief Deputy OFFICE OF '"` IERIFF Civil Process Sergeant SHERIFF'S RETURN OF SERVICE 03/18/2009 07:00 AM - Dennis Fry, Deputy Sheriff, who being duly sworn according to law, states that on March 18, 2009 at 1900 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Kelly Stanley, by making known unto Kelly Stanley personally, at 7000 Wertzville Road, Mechanicsburg, Cumberland County, Pennsylvania its contents and at the same time handing to her personally the said true and correct copy of the same. 04/13/2009 03:10 PM - Ron Kerr, Deputy Sheriff, who being duly sworn according to law, states that on April 13, 2009 at 1510 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: David Horn by making known unto Kelly Stanley, POA, at One Courthouse Square, Room 303, Carlisle, Cumberland County, Pennsylvania, 17013, its contents and at the same time handing to her personally the said true and correct copy of the same. SHERIFF COST: $53.00 SO ANSWERS, April 14, 2009 R THOMAS KLINE, SHERIFF .- ::?Z= --?! ?' Dep y Sheri Depu y She i'f f Docket No. 2009-1626 Claremont Nursing v Kelly Stanley C? I 0 ? v {.-, yM a7orc AUroas Steven M. Montresor smontres(a1dylaw.com Attorney ID #74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tole: (717) 620-2424; Fax: (717) 620-2444 AM /o = S8 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER Plaintiff, NO. 09-1626 V. CIVIL TERM DAVID HORN, et at. Defendants PRAECIPE TO SETTLE, DISCONTINUE AND END TO THE PROTHONOTARY: Kindly mark the above-captioned matter settled, discontinued, and ended without prejudice. 1 30361 Respectfully submitted, LATSHA DAVIS YOKE & McKENNA, P.C. Dated: By: 6LA-?') Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424 Fax: (717) 620-2444 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center 1192b1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER Plaintiff, NO. 09-1626 V. DAVID HORN, et al. CIVIL TERM Defendants. CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Praecipe to Settle. Discontinue and End has been served, via first class mail, postage pre-paid, upon the person(s) listed below: Kelly Stanley 7000 Wertzville Road Mechanicsburg, PA 17050 David Hong 7000 Wertzville Road Mechanicsburg, PA 17050 Date: ?-/9- '?0/0 Steven M. Montresor 1 39261