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HomeMy WebLinkAbout09-1736``COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS Judicial District, County Of ombidav NOTICE OF APPEAL FROM DISTRICT JUSTICE JUDGMENT COMMON PLEAS No. (", NOTICE OF APPEAL Notice is given that the appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice on the date and in the case referenced below. L- J t o /C>13 lsh-kpn D. cv- C?Ovc?29 ?-fig This block will be signed ONLY when this notation is required under Pa' R.C.P.D.J. No. 10088. This Notice of Appeal. when received by the District Justice. will operate as a SUPERSEDERS to the judgment for possession in this case. 3004- ar AWh-0Wy-0WW was before a Df W Justice, A COMPLAINT MUST BE FLED within twenty (20) days alter tiling do NOTICE O (APPEAL. PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of Ann to be used ONLY when appellant was DEFENDANT (see Pa.R C.P.D.J. No. 1001(7) in action before District Justice. IF NOT USED, detach from copy of noboo of appeal to be served upon appellee. PRAECIPE: To Prothonotary Enter rule upon 5%. appellee(s), !o 8ie a complaint in this appeal of SADON a(al (Common Pleas No. _ r ?r Y 1l R in fiMSMy (20) days aver service of rule or suffer entry of judgment of non pros. i) ?-C,0,n - ftmWn ofapp~orsdvnW orayanr RULE: TO 4? t•tt?t?l L s.yYrCr?l'11z-r (1) You are notified that a rule is hereby entered upon you to file a complaint in this appeal within twenty (20) days after the date of service of this rule upon you by personal service or by certified or registered MON. (2) 0 you do not file a complaint within this time, a JUDGMENT OF NON PROS MAY BE ENTERED AGAINST YOU. (3) The date of service of this rule if service was by mal is the date of the mailing. Date: Adl `j /f . 20 Q`CJ ,? ??1 rIL? , 4ft YOU MUST INCLUDE A COPY OF THE NOTICE OF JUDGMENTITRANSCRIPT FORM WITH THIS NOTICE OF APPEAL. AOPC 312-02 1'cd2o, ez? WHITE - OOURT FILE TO K FILED WITH PROTHONOTARY GREEN - COURT FILE YELLOW - APPELLANT'S COPY PINK - COPY TO K SERVED ON APPELLEE GOLD - COPY TO BE SERVED ON DISTRICT JUSTICE PROOF flFSMMC'E.OF,NO E iDF APPEAL AND RULE TO FILE CST (This proof of service MUST BE FUE UV1THtM l!Lr (10) DAYS AFTER filing of the notice of appeal. Check applicable boxes.) COMMONWEALTH OF PENNSYLVANIA COUNTYOF ; ss AFFIDAVIT: 1 hereby (swear) (affirm) that I served ? a copy of the Notice of Appeal, Common Pleas , upon the District Justice designated therein on (date of service) 20 Q by persona;) service 0 by (certified) (registered) mail, sender's receipt attached hereto, and upon the appellee, (name) on ,20 Q by personal service 0 by (certified) (ruled) raW sender's receipt attached hereto. (SWORN) (AFFIRM F.A)AND SUBSCRIBED BEFOfZEA4E THIS DAY OF 120 Signature of official before Aom affidav C was made TWO Of 00=1 My commission expires on 20 Signature of alliant C +v c .. ? n ' (M err: mom -tj :- ::3 rrt fo"7 1 nC -5m rv FW23/200940N 03:07 PM LIF UTHERAN SERVIC COMMONWEALTH OF PEN LVANIA r,ni iNTY np• CtlKBZKxAzn Meg. oW. No.; 09-3-01 Mau Name: Hon. X&ROLD E. SiNDEB md..o.: 5 5 W OMAN= OT 9zX9V=WXV r PA Ta00ne; (717) 532-7676 17257-0361 FAX No. 71729 P.003 NOTIC6 7 JUOGME,?TnRANSCRIPT CIVIL CAse PLAINTIFF: M"% and ApDRM rsEIPPE1rB>dl=ci XJULLTQ CARE LMM 7 121 WALNUT x= ED SS=PPAOg(?, PA 17257 L J VS DEFENDANT: . NAME and AOORE68 THORN, MIX= -I 294 LINCOLN NA? WWT CRA PA 17101 88I)RLE! KONN L 294 LMICOLN W&T NEST Docket No.: CV-0000294-08 clam ERaDVAC, PA 17201 Date Filed: 11/13/09 THIS to TO NOTIFY YOU THAT: Judgment: 70>E PL>i1INT!>Ir (Date of Judgment) 2119/09 © Judgment was entered for: (Name) 111IMPAMMUR0 BEiLTE CARZ C T1 Judgment was entered against: (Name) HORN, =22LIM in the amount of $ 7,040.415 Defendants are jointly and severally liable. Damages will be assessed on Date & Time 0 This case dismissed without prejudibe. Amount of Judgment Subject to Attachment/42 Pa.C.S. § 8127 Portion of Judgment for physical damages arising out of reeldential lease Amount of Judgment $ 5,970.00 Judgment Costs . . S 443.231 Interest on Judgment' $ 62720 Attorney. Fees $ . 01 To1M1 :$ 1, 040.45 Post Judgment Credits $ Post Judgment Costs $ Certified Jutlgmem Total $ ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE EMERY OF JUDGMENT BY FILING A NOTICE OF APPEAL WITH THE PROTHONOTANY)CLERK OF THE COURT OF COMMON PLEAS, CIVIL DIVISION. You MUST INCLUDE A COPY OF TI-116 NOTICE OF JUDGMENT/rRANSGRIPT FORM WITH YOUR N071CE OF APPEAL. EXCEPT AS OTHERWISE PROVIDED IN THE RULES OF CIVIL PROCEDURE FOR MAGISTERIAL DISTRICT JUDGES, IF THE JUDfiMaNT MOLDER ELECTS TO ENTI IA THE JUDGMENT IN THE COURT OF COMMON PL8A1s, ALL RXITHER PROCE" MUST COME FROM THE COURT OF COMMON PLEAS AND NO FURTHER PROCESS MAY BE ISSUED BY THE MAGISTERIAL DISTRICT JUDGE. UNLI:ee THE JUDGMENT 0 ENTERED IN THE COURT OF COMMON PLEAS, ANYONE INTERESTED IN THE JUDGMENT MAY FUZ A REQUEST FOR ENTRY OF SATISFACTION WITH THE MAGISTERIAL OISTMT JUDGE IF THE JUDGMENT DEBTOR PAYS ME FULL, SETTLES, OR OTHERWISE COMPLIES WITH THE JUDGMENT. --/ ?LeI? I certify that this is a true and correct copy of the record of the procoedings eontalning the judgment. Date , Magisterial District Judge My commission expires first Monday of January, 2012 SEAL AOPC 215.07 DATE PRINK: 2/20/09 11:15:00 AN, SHI PPENSBURG HEALTH CARE CENTER, Plaintiff vs. SHIRLEY HORN, Defendant : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Oq- 173 0(`vi 1 W N . APPEAL OF UNIT, JUDGMENT PRAECIPE TO PROCEED IN FORMA PAUPERIS To the Prothonotary: Kindly allow, Shirley Horn , Defendant, to proceed in forma au ris. I, Grace E. D'Alo, attorney for the party proceeding in forma au ris, certify that I believe the party is unable to pay the costs and that I am providing free legal services to the party. 4 `oko e D'Alo J sica Diamondstone Geoffrey Biringer Attorneys for Plaintiff MidPenn Legal Services 401 E. Louther Street Carlisle, PA 17013 (717) 243-9400 alo -10 rd , no 0 ( o O 1711 1 -a !'1`I ? ID .i C r- - ? t --?L c (41 < PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE CO LAINT (This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing of the notice of appeal. Check applicable boxes.) COMMONWEALTH OF PENNSYLVANIA COUNTY OF ?Ytib.trLQgA,1C?_ : ss AFFIDAVIT: I hereby (swear) (affirm) that I served ? a copy of the Notice of Appeal, Common Pleas upon the Dist?ri?ct Justice designated therein on Gh 20 ? by personal service by (certified) (registered) mail, (date of service)?YV sender's receipt attached hereto, and upon the appellee, (name) m C ,V? W , 20 () Of ? by personal service sender's receipt attached hereto. (SWORN (FFIRMED} AND SUBSCRIBED BEFORE ME 20. THIS AY F WOWS Signature of foe whom a ? a Title of official My commission expires on w"UAL CARLWVUM W C0MMISSMN W _ 4; Q RY? , on Z by (certified) (registered) mail, COURT Of COMMON PLEAS Judicial District, County Of NOTICE OF APPEAL. FROM OSTRICT JUSTiCE J(biT It C.,? NOTICE OF APPEAL Notice is given that the appellant has filed in the above Court of Common Plena an appeal from the judgment rendered by the District Justice on the date and in the case referenced below. in Oct Ic'Ki, CV - 4+-M Tr n block will be signed ONLY when Oft notation is rewired untler'Pa R.C.P.D.J. No. 1008S. This Notice of Appeal, when received by the District Justice, will operate as a SUPERSEDEAS to the judgment for possession in this case. waa ClBiMSW (see Pa. C.P.D.J. No. 1f10'ltd) in action bed a DisWd Jus , A COMPLAINT MUST BE FILED wiftn twenty (20) days air Aiaag Me NOTICE of APPS k. PRAECIPE TO ENTER RULE TOME CQMPLANT AND RULE TO FILE (This section of form to be used ONLY **on appellant, saes,DEFENDANT (sew Pe R.C.P.D.J. No. 1001(7) in action before Drstxt Justice. IF NOT USED, dsfach from copy of'nolee of appeal to be std upon appellee. PRAECIPE: To Prothonotary Enter rule upon 1N (Common Pleas No. r / wthuo twenty (20) days 10 RULE: To' appeft*), to So a comp* t in this appeal servioe<of ruts or suffer entry of of non pros. l (1) You are no0ed that a rule is hereby entered upon low, # in 8" eppsed-W thirt twenty (20) days after the date of service of this rule upon you by personal service or bycer led or ?ilf ±wieiF (2) If you do not go a complaint wiUoin this time, a JUDGj*W OF WM PROS MAY BE ENTERED AGAMXZAW. (3) The date of see.4ce-of his nee f swvloe was by mtitis ft e 400 ome awdiiing, Date: 20 rj6 or CAM Aa. YOU ARIST PiCL: A COPY OF THE NOTICE OF JWPOOM KIPT FO" 3i AOPC 312.02 - , WHITE- COURT FILE TO BE FILED WITH PROTHONOTARY GREEN - COURT FILE YELLOW - APPELLANTS COPY PINK - COPY TO BE SERVED ON APPELLEE- GOLD -,OWY TO E SERVED ON DISTRICT AlgTICE MAGNOLIA MANAGEMENT INCORPORATED, d/b/a Shippensburg Health Care Center, Plaintiff V. SHIRLEY HORN, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 2009- 1-75 CIVIL TERM NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 MAGNOLIA MANAGEMENT INCORPORATED, d/b/a Shippensburg Health Care Center, Plaintiff V. SHIRLEY HORN, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 2009- I CIVIL TERM COMPLAINT NOW, comes Plaintiff, Magnolia Management Incorporation ("Shippensburg Health Care") by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the following: 1. Magnolia Management Incorporated is a Maryland corporation, duly authorized to conduct business in the Commonwealth of Pennsylvania, with a business address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania. 2. Magnolia Management Incorporated owns and operates a skilled care facility known as Shippensburg Health Care Center ("Shippensburg Health Care") located as 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania. 3. Defendant, Shirley Horn ("Horn"), is an adult individual with a residence address of 294 Lincoln Way West, Chambersburg, Franklin County, Pennsylvania 17201. 4. On or about January 30, 2007, Horn sought admission to the Shippensburg Health Care Center for resident skilled care. 5. In connection with the admission, Marlin Horn, deceased, the former spouse of Horn executed an Admission Agreement with Shippensburg Health Care. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A' and is incorporated by reference. 6. Upon execution of the Admission Agreement, Horn was admitted to the Shippensburg Health Care Center and remained a resident of the facility from January 30, 2007 through March 1, 2007. 7. As of her time of discharge from the facility, the sum of $5,970.00 was owned to Shippensburg Health Care for the care and services provided by Shippensburg Health Care to Horn. A true and correct copy of a Statement reflecting the balance due is attached hereto as Exhibit "B" and is incorporated by reference. 8. Pursuant to the Admission Agreement, Horn would be responsible to pay any costs of care which were not covered by a third party payer. 9. Demand has been made upon Horn to pay the amount due. COUNT I - BREACH OF CONTRACT SHIPPENSBURG HEALTH CARE v. SHIRLEY HORN 10. Plaintiff incorporates paragraphs one through nine as thought set forth at length. 11. Horn has breached her obligation to pay for the costs of care as provided by Shippensburg Health Care. 12. As a consequence of that breach, Shippensburg Health Care is owed is the $5,970.00 to February 1, 2009. 13. The accrued debt consists of the private pay obligation of Horn. 14. The Admission Agreement bound Horn to pay for the costs of her care at the facility. 15. The Admission Agreement provides for the recovery of a penalty for late payments in the amount of .5% per month. These finance charges total $686.00 as of April 1, 2009 and continue to accrue at a per diem of $0.98. 16. The Admission Agreement provides for the recovery of reasonable attorneys fees and costs incurred by Shippensburg Health Care to collect a debt due and owing to Shippensburg Health Care. WHEREFORE, Plaintiff requests judgment in its favor and against Horn for the sum of $5,970.00 plus interest, costs and expenses, late fees and any additional amount coming due to the date of award and attorney fees and costs. COUNT II - QUANTUM MERUIT SHIPPENSBURG HEALTH CARE v. SHIRLEY HORN 17. Plaintiff incorporates by referenced paragraphs one through sixteen as though set forth at length. 18. During the period of her residency at the facility, Horn enjoyed the benefit of care and services provided to her by Shippensburg Health Care. 19. Horn has failed and refused to pay for the costs of her care and services provided by Shippensburg Health Care. 20. Horn has been unjustly enriched by her use and enjoyment of the services and care provided by Shippensburg Health Care without making payment thereof. WHEREFORE, Plaintiff requests judgment in its favor and against Horn for the sum of $5,970.00 plus interests, costs and expenses, late fees and any additional amount coming due to the date of award and attorney fees and costs. Respectfully submitted, O'BRIY-N, C& S E R David A. Baric, Esquire I.D.# 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/shcc/horn/complaint.pid VERIFICATION I verify that the statements made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. This verification is signed by David A. Baric, Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as documents reviewed by the undersigned as attorney for Plaintiff. I undersigned that false statements herein are made subject to penalties of 18 Pa.C.S. §4904, relating to unsworn falsifications to authorities. (/ 0 q Dated: David A. Baric, Esquire CERTIFICATE OF SERVICE I hereby certify that on the 6th day of April, 2009, I, David A. Baric, Esquire, of O'Brien, Baric & Scherer, did serve a copy of the Complaint, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Grace D'Alo, Esquire MidPenn Legal Services 401 East Louther Street Carlisle, Pennsylvania 17013 David A. Baric, Esquire Aq';o &A _lei HEALTH CARE CENT ER 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257-9005 A.DMYSSION AGREEMENT FAX (717) 590-8304 TTY 1-800-654-5984 Tb?k agreement ire een Shippensburg Health Care Center (the "Facility" or "we" and) i, Lail (the "Resident" or "you") and, if you or the court have designated an individual to act on your behalf, or there is another individual to act on your behalf, or operation of law, f affil 4. ikm - ("your representative"). A checklist of the rights and responsibilities applicable to your representative is listed in Exhibit 1 and is incorporated into this Agreement. Paying for Your Care If you are applying to this facility as a private-pay resident, you must provide all financial information requested by us. If we later find that the information you or your representative provided was incomplete or inaccurate; we will consider that as a breach of this Agreement which gives us the right to pursue all legal remedies against you or your representative, .. Who Can Be Required to. Pay for Your Care Only you and your insurer can be required to pay for your care. No other person, (i.e, a family member, friend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care, although he or she may knowingly and voluntarily agree to guarantee payment for the cost of your care. 'We require the person responsible for making payments on your behalf to pay for your care under the terms of this contract in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your representative agrees to make all necessary payments from your funds. Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds. Private Pay Residents The items and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for items and services that are included in the daily rate is payable one month in advance and due on the first of each month. Items and services include& in your daily rate are listed in Exhibit 2.A. You will-be charged separately for additional items and services not included in our daily rates such as special nursing care, special equipment, pharmacy charges, laboratory charges, medical transportation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers. Items and services for which you will be charged are listed in Exhibit 23. Payment for these additional items and services are dueafter you have requested them, and; you have received and have been billed for them. V ithin 30 days of receiving an item or service, Exhibit "A" you have the right to ask us for an itemized financial statement that briefly but clearly describes each item and the amount charged for it. You will be given an updated listing of services and related charges, including any charges for services not covered under Medicare or by the facilities basic per diem charges, annually on or about January 1 of each year. Medicare Residents We participate in the Medicare Program. Medicare may pay for some or all of your nursing home care. For information on Medicare, see Exhibit 3. If you are eligible for Medicare, you have the right to have claims for your nursing home care submitted to Medicare. Medicaid Residents We participate in the Medicaid program. For information on Medicaid, see Exhibit 3. You are not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If your private funds are used up during your stay here and you are eligible for Medicaid; we will accept Medicaid payments although Medicaid may require you to pay some amount in addition to what Medicaid pays for your care. If you are planning on applying to Medical Assistance later, you may want to find out now if your are "medically eligible" for nursing home payment by Medicaid. You-are responsible for applying for and obtaining Medicaid benefits and we will assist you. We Than may no arge, sk-f , cep or receive any gift, money, onation or consi eration o er Medicaid reimbursement as a condition of your admission or continued stay here except that Medicaid may require you to pay certain amounts from your private funds. If you receive Medicaid, most of your nursing home charges such as room, board, and general nursing care are covered. For a list of services covered by Medicaid, see Exhibit 4.A. The local Board of Assistance will tell you whether you have to pay part of the charge for your care and, if so, how much. Some of the items and services that we offer are not covered by-Medicaid. If you want any items or services, which are not covered by Medicaid, you or your representative will have to pay for them. A list of the items and services not covered by Medicaid and the charges for them are in Exhibit 4.B. Payment for items and services that are not covered by Medicaid is due after you have requested them, and; have received and have been billed for them. Within 30 days of receiving the item or service, you have the right to ask us for an itemized statement that briefly but clearly describes each item and the amount charged for it. Increases in Charges and Fees Any time we increase a fee or charge for item or service-or add a new item or service, we will provide you and your representative with 30 days advance written notice. Penalties We may not charge you -interest if you pay your bill in time. Your payment is on time if it is made within 45 days of the date the bill is post marked, or 30 days after the end of the billing period, whichever is later. The penalty we charge is .5% of the amount due, calculated on a per day basis. If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. Private Duty Nurses Geriatric Aides If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting a person licensed and/or certified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she must meet our standards and follow our policies .and procedures. Employees of the Facility may not serve as private duty nurses or private duty geriatric aides. Holding Your Bed if You Leave the Facility If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows: A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare Program (and you are not covered under Medicaid), unless you notify us otherwise, we will hold your bed for as long as you pay for it at the daily.rate you are currently being charged. B. If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximum number of days required by this state, currently B days. If you leave for any other reason, we will hold your bed for up to the maximum number of days required by this state, currently 18 days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are liable as determined by the Medicaid Program. C. If you have applied for Medicaid, your bed will be reserved in accardance with Paragraph B. However, if you are found to be ineligible for Medicaid, then you are required to pay for the bed as a private pay resident as described in Paragraph A. D. Other third-party payers may or may not have a bed hold policy. We will discuss this if it applies to you. Your Right to Make Complaints and Suggest Changes in Policies and Services As a nursing home resident, you have many rights according to State and Federal law. These are described in detail in Exhibit 6, which is attached and is part of this Contract. You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility. You will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You may present your complaints to the facility, management company or to one of the following State agencies: Lin Tierson, NHA Administrator Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 717-530-8300 Ombudsman Office of Aging 16 West High Street Carlisle, PA 17013 717-240-6110 . 717-532-7286 Ext. 6110 Mr. John Perini President Magnolia Management, Inc. 1710 Underpass Way, Suite 201 Hagerstown, MD 21740 301-745-8700 Department of Health 100 North Cameron Street 2°d Floor Harrisburg, PA 17101 717-783-3790 Your Riaht to Make Decisions You have the right to make your own medical decisions and to manage your personal affairs.. If you become disabled, it may be necessary for someone else to make decisions for you. For this reason, we recommend that you have a living will and/or advance directive for medical decisions and a financial Power of Attorney, but you are not required to do so. See Exhibit 7 for a description of your legal rights to decide about your future medical treatment. Transfer, Relocation and Discharge You have the right to remain here, and you may not be transferred, relocated or discharged against your will, except for the following reasons: (1) A medical reason (i.e. the facility cannot provide the land of care that you need, your condition has improved so that you no longer need the care we provide, or a medical emergency arises; (2) Your welfare or the .welfare of other residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate. If we decide that you should be transferred or discharged, we ,"U notify you, and an immediate family member or legal representative, by letter 30 days in advance. If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter -Mll also tell you how you can appeal our decision to transfer or discharge you. If you are discharged involuntarily, we will attempt to make other appropriate arrangements for youi care. However, if other arrangements are not available, your representative agrees to accept you into his or her custody if it is medically appropriate. Your Right to End This Contract If you decide to end this Contract and leave the Facility, you must pay your bill before you leave. You must give us five (5) days written notice to terminate this contract. If you leave before the . end of that time, you must still pay for each day of the required notice. In the event you die while a. resident of the faci'li'ty, pour representative is responsible for making the fuaeral arrangements. We will notify your representative immediately. If vie are unable to reach your representative, we will contest the funeral ' home of your choice to, facilitate aria figements. Additional Docnments It is not possible to cover. everything that is important to your'stay in, our Facility in the body of this Contract. Therefore, we have iholuded adclidonal important documents as Exhibits. These " Eidu5its are part of this ,Contract. Please'verlfy that you received the Exhibits and that the contei?ts of the Exhibits were explained to you by placing • your initials on- the line -nest to the description of each Exhibit. F.Ambit i. Rights and Obligations of Representatives. Exhibit 2. Fot PrWate Pay Residents: ' (a) Items and- services covered by daily rate. (b) Items and'seivices not covered by daily rate. Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits. .? . ErJuibit 4. (a) Items and Services Covered by Medicaid. (c) Items and Services Not Covered by Medicaid. Extnbit 5. Physicians Who Practice at the Facility. Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment. Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your Personal Property. Exhibit 8. Services Provided by Outside Health Care Providers. Changes in Law Any provision of this Contract that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Contract. If there are services we, have agreed to provide that are later found to be impossibJ& to render as •a reg& of a change in State or Federal law, it is agreed that to the extent possible, - the Resident and the Facility will continue to fulfill our respective obligations tinder this Contrast consistent with the lavr. - WHEREOF, the parties have executed this Contract on this day of . I By: W. Scott Murray, Administrator Shippensburg Health Care Center Witness Resident if the resident has been adjudicated disabled or the Resident's doctor determines that the Resident is incapable of understanding or exercising his or her rights and responsibilities, the Facility may require the signature of another person on this contract. The other person may be: (1) An appointed healthcare agent under and advance directive for medical care; (2) A guardian or Power of Attorney of the person; (3) A surrogate or family member. With s R sponsible Parry (Name) C Title: Indicate wh er you are (1), (2) or (3) EXHIBIT 1 RIGHTS AND OBLIGATIONS OF REPRESENTATIVE The Representative shall have the right to be notified by the Facility of any event or occurrence involving the Resident, which directly affects any obligation of the Representative under this Agreement. Representative agrees to assume independently, under this Agreement, the following obligations and is entitled to the following rights, as indicated by Representative's initials accompanying any of the following provisions: Representative agrees to be responsible for ensuring that any payment from the resident to which the Facility is entitled pursuant to this Agreement shall be paid to the Facility in a. timely manner. In the event the Resident is a beneficiary of Medicare, Medicaid or any other third party payment'plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as described under this Agreement, shall be paid from the Resident's funds. Representative is subject to a civil penalty for willful violation of the agreement to distribute the Resident's funds to the facility. • (Unless the Representative voluntarily agrees to act as guarantor), Representative shall be responsible for any payments required under this Agreement only to the extent of the Resident's funds. Resident is applying for admission on private pay basis, and Representative agrees to assist the Resident in providing all financial information required by the Facility to determine the extent of the Resident's resources. If it is ever determined the Representative participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure shall be deemed a material breach of this Agreement and the Facility reserves the right to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. • Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for this representation is attached to this Agreement. • Representative is signing this Agreement on Resident's behalf, based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not possess the capability to understand his or her rights and responsibilities. • Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. (Exhibit 1, Continued) • If it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, Representative agrees to be responsible for arranging independently for those services, including ensuring any payment. Representative agrees that in the event the Resident's private funds are exhausted during the Resident's stay and the Resident is eligible to apply for benefits under the Medicaid Program, the Representative shall assist the Resident and the Facility with any application for Medicaid benefits. Representative fiuther-agrees to act, on behalf of the Resident, to facilitate any Medicare, Veterans Administration or other third-party benefits which may be available to cover the cost of Resident's care at the Facility. • In the event the resident seeks to terminate this Agreement, the Representative agrees-to ensure that all notices required under this Agreement are provided to the Facility. • In the event of an involuntary termination of this Agreement, if other arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the Resident into the Representative's custody, if medically appropriate. • Representative has the right to copies of the following documents and any amendment to them. Representative further acknowledges receipt of the following documents, which may be amended from time-to-time. 1. A copy of this Admission Agreement. 2. A list of the Facility's rates, subject to amendment on thirty-(30) days notice, and a description of charges for services not included. 3. A list of health care providers offering services at the facility. • Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBIT 2.A Private Pay Residents DAILY ROOM RATES Total Daily Room Rates Effective January 1, 2007 Special Care Program Private Rooms ........................ $200.00 $204.00 Semi-Private Rooms ................. $190.00 $199.00 Triple/Quad Rooms .................. $185.00 $189.00 A. The daily rate includes the following services: • Room • Board • Social Services • Nursing Care, including: o The administration of prescribed medications, treatments and diets o The provision of care to prevent skin breakdown, bedsores, and deformities. o The provision of care necessary to encourage the resident from accident, injury and infection. o The provisions of care necessary to encourage, assist and train the resident in self-care and group activities. The daily rate does NOT include the following items/services: • Physician Services • Medications • Specialized and/or specially ordered medical supplies/se" rices/equipment • Prescribed dietary supplements • Cable -($7.00 per month) • Telephone and telephone services • Beauty/Barber Shop Services • Disposable Diapers • Items listed on Ancillary Charge Sheet • Personal Laundry Payment: Payment is due in full and on the first day of each month. Bill is done on a monthly basis. Each monthly payment shall also include any additional fees and charges incurred in the proceeding month. EXIMIT 23 ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE The follovsviag items and services are not covered by the Facility's basic daily rate: Item or Service Physician Services Medications Prescribed Dietary Supplements Personal Dry Cleaning, Personal Linens Telephone Television Service Beauty/Barber Shop Services Clothing Sundry Pharmaceutical Ambulance Service, Medical Transportation N Therapy X-Ray Services Medical Nursing Supplies Dental, Podiatrist and Ophthalmology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized and/or specially ordered medical services/equipment Guest meals (Exhibit 23, Continued) ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE (refer to the Ancillary Charge List for additional costs) Item Charge Telephone Direct bill from telephone company Television/Cable per month $ 7.00 per month Beauty/Barber Shop Services: Permanent $35.00 Haircuts and Blow-dry $ 10.25 Hair Sets $ 8.25 Cut Only $ 8.25 Color $30.00 Personal Laundry $ 45.00 per month Personal Dry Cleaning Same as billed by cleaner Physical Therapy Service Determined by level of care required Occupational/Speech Therapy . Determined by level of care required IV Therapy Charge list will be provided by contract pharmacy prior to delivery of services Aerosol Therapy Determined by level of care required Shippensburg Health Care Center cordially invites family members, guests and friends to join our Resident's at meal times. The prices for guest trays, effective July 1, 2001 are as follows: Breakfast A $4.00 Will be served at 7:00 AM Breakfast B $4.00 ($3.77 +.23 state tax) served at 7:30 AM Lunch A $4.00 Will be served at 12:00 PM Lunch B $4.00 ($3.77 +.23 state tax) served at 12:3 0 PM Dinner A $4,00 Will be served at 5:00 PM . . Dinner B $4.00 ($3.77 +.23 state tax) served at 5:30 PM *The Resident's ug11 be assigned their meal times upon admissioin. Meals can be paid for at the Receptionists' desk.. In order to prepare sufficient quantities we require a 2-hour notice to prepare guest tray. EXAMxT 3 The following summarizes the Medicare and Medicaid programs.. It also tells you who to call for more detailed information. If you have questions, our staff will also help you. What's Covered - Medicare 1. Care in a hospital 2. 100 days of skilled care in a nursing home. Medicare provides full coverage for the first 20 days. You must make a co-payment after that. The following services are examples of skilled care: a. Injections & feedings given through an IV ,b. Tube feedings c. Application of a dressing that involved prescription medication d. Treatment of stage 3 or 4 bedsores 3. Medically necessary doctor's sen?ices. What's Covered - Medicaid Medicaid is a comprehensive program that will cover most of the costs of a nursing home stay. See Exhibit 4 for information about.covered and non-covered items. Your Contribution - Medicare Medicare does not pay 100% of the cost of covered services. You will be required to pay part of the charges. Your payment may be called a "co-payment", "deductible" or "premium', depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any payment that you are responsible for under Medicare. Your Contribution - Medicaid Depending on your income and assets, you may be required to make a contribution toward the cost of your care. The amount of any contribution will be decided by the local Board of Assistance. Who's Eligible - Medicare People 65 years old or older who are eligible to collect old-age benefits under Social Security are eligible. Persons who receive Social Security disability benefits for at least 24 months, or have been found eligible for Medicare by the Social Security Administration because they have end stage renal disease requiring regular dialysis or kidney transplant are also eligible. Who's Eligible - Medicaid Eligibility depends on whether your income and assets are below certain levels: 1. Jncome: You should consult the local Board of Assistance to find out whether your income makes you eligible. That phone number is listed on the next page. If you qualify, $30 per month of your income is protected for your personal use while in the Facility. (Exhibit 3, Continued) 2. Assets: The Cumberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualify. The following are examples of things not counted as assets. a. Your house if your spouse lives there. b. Household goods. C. A certain amount of cash. d. Personal Property in your possession in the Nursing home, e. A certain amount of money for burial arrangements. How to Apply - Medicare Contact the local Social Security Office at the following address: Social Security Office 401 E. Louther Street Carlisle, PA 17013 (800) 772-1213 (717) 243-0085 How to Apply -- Medicaid Contact the local County Board of Assistance at the following address: Board of Assistance 33 Westminster Drive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 Whom to Contact if you have a Question or Problem -Medicare If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing to: Aetna Medicare Claim Administration 501 Office Center Building Fort Washington, PA 19034 (215) 643-7200 Whom to Contact if you have a Oueston or Problem - Medicaid If your application for Medicaid is denied, your coverage is terminated, or a senrice is not covered, you may appeal in writing to: County Board of Assistance Office 33 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 (Exhibit 3, Continued). Whom to Contact if you have Incurred Medical Expenses prior to Your MA Effective Date Medicare - Not applicable. Whom to Contact if you have Incurred Medical Expenses prior to your MA Effective Date - Medicaid Medical bills that you received in the 3 months prior to receiving Medicaid may be covered by Medicaid. Contact; County Board of Assistance Office 3 3 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 EXMIT 4.A A. Items and Services Covered bT the Medicaid Per Diem Rate • . Regular room, dietary services, social services and other services required to meet certification standards, medical and surgical supplies, and the use of equipment and facilities. • General nursing services, including but not limited to, administration' of oxygen and related medications, hand feeding, incontinency care, tray service and enemas. Basis Beauty/Barber Services. The facility must provide shampooing and hair care which is considered necessary for hygiene. The facility must inform the resident of the types and frequency of the services provided. • Items furnished routinely and relatively uniformly to all residents, such as water pitchers, basins, and bedpans. • Items furnished, distributed, or used individually in small quantities such as alcohol, applicators, cotton balls, band-aids, antacids, aspirin (and other non- legend drugs ordinarily kept on hand), suppositories, and tongue depressors. • Items used by individual residents, but which are reusable and expected to be available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other durable medical equipment. • Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even if written as a prescription item by a physician. • Laundry services for other than personal clothing. • Non-emergency medical transportation services. • Other special medical services of a rehabilitative, restorative, or maintenance nature, designed to restore or sustain the resident's physical and social capacities. • Personal care items including a patient gown, shampoo, skin lotion, comb, brush, toothpaste, toothbrush, and denture cream. EXHBIT 43 B. Items and Services Not Covered by the Medicaid Per Diem Rate Medical expenses such as, but not limited to: • Health insurance premiums. • Visits by a non-participating physician other than approved by the nursing care facility. • Emergency ambulance services, if the ambulance company does not accept MA. • Over-the-counter medications, which are a particular brand not supplied by the nursing facility. For example, the nursing facility must provide aspirin, but the patient may request and buy a specific brand ofpain reliever, such as Excedrin PM, or Tylenol. • Hearing aids and batteries. • Specialized Beaut ,/Barber Shop services. • Diapers, if the resident wants a style or brand which is not provided by the nursing care facility. • Personal care items of the resident's choice if preferred instead of the items provided by the nursing care facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc. VaRBIT 5 PHYSICIANS WHO PRACTICE AT THE FACrLITY Dr. Yogindra S. Balhara, M.D. 761 Fifth Avenue Chambersburg, PA 17201 (717) 261-2583 Dr. Paul Orange, M.D. Dr. Baxter Drew Wcllmon, H, D.O., P.C. 4225 Lincoln Way East Fayetteville, PA 17222 (717) 352-3616 127 Walnut Bottom Road Shippensburg, PA 17257 (717) 532-3211 E)MBIT 6 LEGAL RIGHTS OF PENNSYLVAN ANS TO DECIDE ABOUT HEALTH CARE You Have the Right to Decide About Your health Care Adults generally have the right to decide if they want medical treatment, unless they are not competent. This right includes decisions about treatments that extend life, life-support machines, or feeding tubes. Sometimes, an accident or illness takes away a person's ability to make health care choices. But the decisions still must be made. If you are unable to make them, others will. They will decide based on your wishes or your best interests if your -Mshes are unknown. Pennsylvania law gives you the right to make many healthcare decisions in advance. One way to do this is by using a written advance directive to name an agent to make your health care decisions if you cannot. A written advance directive can also state your treatment preferences, especially about life sustaining procedures. Naming a Health Care Agent You can name anyone to be your health care agent. The only exception is that, in general, someone who works where you are receiving your care cannot be your agent. Your agent can be a family member or a friend. You choose when your agent can decide for you - right away, if you want, or only after two doctors agree that you are not able to decide for yourself. You also choose the kinds of decisions your agent can make for you. For example, if you want, you can give .your agent very broad power to decide about life-sustaining treatment. Pick our health care agent very carefully. Make sure your agent knows what you want. Your agent will then follow your 'Mshes, even if your friends of family disagree, Using Advance Directives There are many ways to use an advance directive. A living NA ill is a type of written advance directive that states your wishes on life-sustaining treatments. It usually comes into affect when a person will die very soon from an incurable condition. It can also be used when a person is permanently unconscious (in a vegetative state). You can make a broader written advance directive for other health care issues too, For example, you can decide whether you want life-sustaining treatment if you are in an end-stage condition. An end-stage condition is an advanced, progressive, and incurable condition resulting in complete dependency. What Happens If You Do Not Make an Advance Directive? No one can deny you health care because you do not have an advance directive. But you should know what happens legally if you do not. (Exhibit 6, Continued) Pennsylvania law allows a surrogate to make medical decisions for you, if you have not named a health care agent and are no longer able to decide treatment issues yourself. Then, your closest relative would be asked to make health care decisions for you.. Your spouse, adult children, parents, or adult brothers and sisters, in that order, are considered your closest relatives. If these relatives are not available, another relative or close friend can make decisions for you. A surrogate, though, might have less authority to decide against life-sustaining procedures than a health-care agent. If there is no one to be a surrogate, a court might have to appoint a guardian to make your medical decisions. The guardian might be somebody who does not know you personally. How Do You Get More Information? This summary does not cover every issue. If you have legal questions about your rights, please speak to a lawyer. Also talk to your health care provider about the medical issues involved in your care. Tell those caring for you about your decisions and give them a copy of any advance directive. For a free copy of a Living Will or Advance Directive form contact: State Representative Jeff Coy 39 West King Street Shippensburg, PA 17257 (717) 532-1707 or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 6110 (717) 240-611-0 EXHIBIT 7 POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS AND YOUR PERSONAL PROPERTY A. Your Rights: 1. You have the right to keep and use your personal property, including some furnishings and clothing, so long as there is enough space and other residents are not inconvenienced. You also have the right to security for your personal possessions. 2. You have the right to manage your financial affairs unless a court determines that you are incapacitated or the Social Security Administration selects a representative to receive Social Security funds for your use and benefit. We cannot require you to deposit your personal funds with us. You may, however, choose any person to manage your funds, including the Facility. 4. If you decide to have us manage your personal funds, you may withdraw your money that we keep in the Facility during the Facility's business hours. If we have deposited any of your funds in a bank, you may obtain those funds within three banking days, provided the funds have cleared. If you need help to perform your banking transactions, you may give the administrator of our Facility legal authority to access your account. This authority is called "representative payee." To give the administrator this authority, you -Mll need to complete a special form. 6. You and your personal representative have the right, during normal business hours, to inspect our written records that concern your personal funds. You and your personal representative have a right to file a complaint- if either of you believes that your funds, valuables. or other assets have been stolen or damaged. The agencies to contact in order to make a complaint are listed below: a. The Cumberland County Office of Aging Attn: Ombudsman Human Services Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 6110 (717) 240-6110 (Exhibit 7, Continued) b.' Cumberland County Board of Assistance 33 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 c. The Department of Health Division of Nursing Care Facilities 100 North Cameron Street 2nd Floor Harrisburg, PA 17101 (717) 783-3790 B. Our Responsibilities: 1. We will provide a reasonable amount of secure space for you to keep your clothing and other personal property. We must investigate any damage to or loss of your personal property. 2. If you want us to manage $50.00 or less of your personal funds, we will deposit this money-irra-non-interest bearing account or a petty cash fund. 3. If you want us to manage more than $50.00 of your personal funds, we will deposit this money in an interest bearing account that is insured by the federal government. This account will be separate from the accounts we use to operate the facility. In addition, we will credit you with all interest earned on your money. 4. We A ill maintain a full, complete and separate accounting of your personal funds. 1ITe will also provide you with a quarterly statement of the activity of your account. 5. If you receive Medicaid benefits, we will notify you if your account balance becomes too high. If you are to remain eligible for Medicaid, your account balance must be under a certain dollar limit that is established by the Federal government and changes periodically. 6. We may not use your personal funds to pay for an item or service that Medicare or Medicaid covers. 71 ) iTe vaill maintain adequate fire and theft coverage to protect your funds and personal property that are kept at the Facility. We shall also obtain a surety bond or otherwise assure the security of your personal funds that are deposited with the Facility. (Exhibit 7, Continued) 8. If you are discharged, there are several things we must do: a. We will ensure the return of your personal funds in our possession. If we have deposited your personal funds in a bank account, we will ensure that this money is made available to you or your authorized representative within 30 days. b. If we are your representative payee for Social Security benefits, we will promptly ask the Social Security Administration to name a new representative payee and we will transfer your money to that person. In the event of your death, there are several things we must do: a. Vire will convey your personal funds and a final accounting of those funds to the person in charge of administering your estate within 30 days. We will immediately notify any • government agency that paid for all or part of your care in our Facility. That agency shall have the right to assist us in determining what to do with your property. If a government agency did not pay for your care, we will immediately .notify your representative or neat of kin to determine what to do with your property. C. If we have your funds, valuables or other assets in our possession, we will hold them until the appointed personal representative of your estate presents a copy of the. certified Letters of Administration to us. All conveyance of personal funds will be by check made payable "To the Estate of...". d. We will make reasonable attempts to locate your personal representative and your heirs. If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we will write the State Office of the Comptroller for direction. 10. If we are in possession of your funds, valuables or other assets for more than one year from the date of your transfer or discharge, we will transfer your funds, any interest on your funds, and your valuables or other assets to the State Office of the Comptroller's Office of any account(s) in your name of which we have knowledge. EXHIBIT 8 SERVICES PROVIDED BY OUTSIDE HEALTH CARE PROVIDERS Some of the services available in the Facility, such as pharmacy services, are provided by outside health care providers. These services, and information about the providers, appear below. You are free to pick your own.provider or to use one of those listed below: Whether we have Provider's Name, a financial Address and interest in Type of Service Telephone Number the provider Physician Dr. Yogindra Balhara 761 Fifth Avenue No Chambersburg, PA 17201 (717) 264-6185 X-Ray Services Mobil X-Ray Services The Chambersburg Hospital No 112 N. Seventh Street Chambersburg, PA 17201 (717) 267-7153 Lab Services Health Network Labs 1200 Walnut Bottom Road No Carlisle, PA 17013 (877) 402-4221 Pharmaceutical Millennium Pharmacy Systems, Inc. 12450 Perry Highway, Suite 200 No Wexford, PA 15080 (866) 456-7779 Podiatrist Dr. Pinker and D. Goiec 47 Brookwood Avenue No Carlisle, PA 17013 (717) 243-2236 Hospital Chambersburg Hospital No Inpatient or Carlisle-Hospital No Emergency Futlon Co. Medical Center No Room Hershey Medical Center No Waynesboro Hospital No ?.. ?_ . ??_? Z"`??' ?r'? -? ? ., .. .tJ ? ., R'? MAGNOLIA MANAGEMENT : IN THE COURT OF COMMON PLEAS INCORPORATED, d/b/a : CUMBERLAND COUNTY, PENNSYLVANIA Shippensburg Health Care Center Plaintiff 2009-1736 CIVIL TERM V. SHIRLEY HORN, Defendant DEFENDANT'S ANSWER WITH NEW MATTER AND AFFIRMATIVE DEFENSES ANSWER 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Denied. Defendant is without information sufficient to form a belief as to the truth of the averment and demands strict proof thereof at trial. 6. Admitted. 7. Denied. The information is solely in the possession of the Plaintiff and Defendant is, therefore, without information sufficient to form a belief as to the truth of the averment and demands strict proof thereof at trial. By way of further answer, Exhibit "B" does not appear to be attached to Defendant's copy of Plaintiff's Complaint. 8. Admitted in part. By way of further answer, however, and as will be set out more fully in Defendant's New Matter with Affirmative Defenses, Plaintiff did not perform its obligations either under the Agreement or the law to assist the Defendant in obtaining benefits from a third party payer such as Medicare or Medicaid. 9. Admitted. COUNT I - BREACH OF CONTRACT SHIPPENSBURG HEALTH CARE V. SHIRLEY HORN 10. No response required. 11. Denied. As will be set out more fully in Defendant's New Matter with Affirmative Defenses, Plaintiff did not perform its obligations either under the Agreement or the law to assist the Defendant in obtaining benefits from a third party payer such as Medicare or Medicaid. 12. Denied. As will be set out more fully in Defendant's New Matter with Affirmative Defenses, Plaintiff did not perform its obligations either under the Agreement or the law to assist the Defendant in obtaining benefits from a third party payer such as Medicare or Medicaid. 13. Denied. Defendant Horn would not have had a private pay obligation to the Plaintiff if Plaintiff had followed their own agreement and the law in assisting the Defendant to obtain third-party payer benefits. 14. Admitted in part. Horn was bound to pay only for those costs that were not paid by a third party payer, which payer should have been contacted by the Plaintiff. 15. Admitted that the Agreement provides for the charges, but denied that they are due, as Plaintiff did not perform its obligations either under the Agreement or the law to assist the Defendant in obtaining benefits from a third party payer, such as Medicare or Medicaid. 16. Admitted in part. It is denied that said fees and costs are owed as is set out more fully below in New Matter and Affirmative Defenses. WHEREFORE, Defendant requests that Plaintiff's Complaint be dismissed and judgment entered for the Defendant. COUNT II - QUANTUM MERUIT SHIPPENSBURG HEALTH CARE V. SHIRLEY HORN 17. No response required. 18. Admitted. 19. Admitted, but denied that the Defendant owes for the costs of her care as is set out more fully below in New Matter and Affirmative Defenses. 20. Denied. As is set out more fully below, Plaintiff could have been paid from a third party payer, namely the Department of Public Welfare and the Medicaid Program, had they followed their own Agreements with the Defendant and the law and regulations governing their duty to assist individuals like the Defendant in acquiring payments for their care. WHEREFORE, Defendant requests that Plaintiff's Complaint be dismissed and judgment entered for the Defendant. NEW MATTER 21. Paragraphs 1-20 are incorporated herein by reference hereto. 22. Defendant believes and therefore avers, that, upon her admission to Plaintiff's facility for care, she did not receive an appropriate level of assistance in obtaining third-party financial assistance from the Pennsylvania Department of Public Welfare 23. Defendant is 59 years old and lacks the mental capacity to understand how to obtain third party payer benefits to pay for her nursing home stay. 24. Said assistance is required by the Agreement between the parties at Paragraph 10, and by the Federal Regulations at 42 CFR 483.10. 25. Defendant was already a Medicaid recipient when she entered Plaintiff's facility for care. 26. Plaintiff failed to submit a MA-51 form to the Franklin County Assistance Office on behalf of the Defendant. 27. Plaintiff's failure to submit a MA-51 form to the Franklin County Assistance on behalf of the Defendant caused Medicaid to be unaware and therefore unable to pay for the Defendant's stay at the Plaintiff's facility. 28. Plaintiff's duty, in explaining the availability of benefits and assisting in the procurement thereof was breached by the Plaintiff. 29. As a direct result of Plaintiff's failure to explain and to assist the Defendant in obtaining third-party payer benefits, Plaintiff deprived itself and the Defendant of a resource available for the costs of care they seek from the Defendant. AFFIRMATIVE DEFENSES COUNT - I - BREACH OF CONTRACT 30. Paragraphs 1-29 are incorporated herein by reference hereto. 31. In failing to assist the Defendant in obtaining Medicaid (third-party payer) benefits, Plaintiff breached their agreement with the Defendant to the Defendant's detriment. 32. Had Plaintiff followed their own agreement, Medicaid would have paid for the costs of Defendant's care. WHEREFORE, Defendant requests that judgment be entered in her favor and against the Plaintiff in the amount of $5,970, plus any other fees and costs this Court deems reasonable. COUNT - II - BREACH OF DUTY PURSUANT TO 42 CFR 483.10 33. Paragraphs 1-32 are incorporated herein by reference hereto. 34. The Federal Regulations, at Section 42 CFR 438.10 require that a facility such as that of Plaintiff's is required to furnish a written description of legal rights that include a description of the requirements and procedures for establishing eligibility for Medicaid. 35. Defendant believes, and therefore avers, that Plaintiff failed to adequately explain to her rights to third-party payer status upon her admission, and to actively assist her, in obtaining said benefits. 36. Had Plaintiff done an adequate job in explaining the right to benefits and assisting the Defendant in obtaining those benefits as required by law, Plaintiff could have obtained payment for the cost of Defendant's care and relieved her of the burden of this lawsuit. WHEREFORE, Defendant requests that this Court find in favor of the Defendant and against the Plaintiff. Respectfully submitted: A Geoffrey M. Binnger, Esquire Supreme Court I.D. # 18040 401 E. Louther Street, Suite 103 Carlisle, Pennsylvania 17013 (717) 243-9400 Attorney for Defendant VERIFICATION I, Shirley Horn, make this verification that the facts set forth in the foregoing Answer, New Matter, and Affirmative Defenses are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904 relating to unsworn falsification to authorities. Date: ? 0&? q`J -'oa 9 D Shirley orn CERTIFICATE OF SERVICE I hereby certify that on the 27`h day of April, 2009, I, Geoffrey M. Biringer, Esquire, of MidPenn Legal Services, did serve a copy of the Answer, by first class U.S. mail, postage prepaid, to the party listed below, as follows: David A. Baric, Esquire O'Brien, Baric & Scherer 19 West South Street Carlisle, Pennsylvania 17013 eoffrey . Bi ger, Esquire F1LEI;--v?F uE OF THE ppo,TRi o NOTARY 2609 APR 21 AlIM 9: 24