HomeMy WebLinkAbout09-1779
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.
Plaintiff,
V. No.
SHARON L. POTTEIGER,
Defendant CIVIL ACTION - EQUITY
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims
set forth in the following pages, you must take action within twenty (20) days after this
complaint and notice are served, by entering a written appearance personally or by
attorney and filing in writing with the court your defenses or objections to the claims set
forth against you. You are warned that if you fail to do so the case may proceed without
you and a judgment may be entered against you by the court without further notice for
any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A
LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
AVISO PARR DEFENDER
Conforme a PA RCP Ndm.1018.1
USTED HA SIDO DEMANDADO/ A EN CORTE. Si usted desea defenderse de
las demandas que se presentan mas adelante en las siguientes paginas, debe tomar
accion dentro de los proximos veiente (20) dias despues de la notificacion de esta
Demanda y Aviso radicando personalmente o por medio de un abogado una
ORIGINAL
comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee
a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de
tomar accion como se describe anteriormente, el caso puede proceder sin usted y un
fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra
reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya
por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros
derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A
CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOME
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166
(800) 990-9108
V
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.
Plaintiff,
V.
SHARON L. POTTEIGER,
Defendant
No. 09- /77 f &;?-! 7-z,-
CIVIL ACTION - EQUITY
COMPLAINT
AND NOW COMES Plaintiff, Church of God Home, Inc. ("Plaintiff'), by and
through its attorneys, SCHUTJER BOGAR LLC, and files the within complaint against
Sharon Potteiger ("Defendant"), and in support thereof, provides as follows:
1. Plaintiff is a foreign corporation licensed to do business in the
Commonwealth of Pennsylvania, with its principal offices located at 801 North
Hanover Street, Carlisle, Pennsylvania 17013.
2. Defendant is an adult individual who currently resides at 478 Wolf Bridge
Road, Carlisle, Pennsylvania 17013.
3. On or about December 5, 2008, Defendant applied for the admission of her
father, Robert Musgrave, to Plaintiffs skilled nursing facility.
4. At the time Defendant's father was admitted to Plaintiff's facility, Plaintiff
and Defendant entered into a written Admission Agreement ("Agreement"), pursuant
to which Plaintiff agreed to provide Defendant's father with skilled nursing services in
exchange for Defendant's promise to pay a specific monetary fee from her father's
assets and the assignment to Plaintiff of her fathers right to apply for and obtain
Medical Assistance benefits in the event that he became insolvent. In furtherance of
that assignment, Defendant agreed to cooperate fully and secure Medical Assistance
benefits for her father. A true and correct copy of the Agreement is attached hereto as
Exhibit "A."
5. After Defendant's father became a resident of Plaintiff's skilled nursing
facility, he apparently became insolvent. As a result, pursuant to the Agreement,
Plaintiff notified Defendant that she needed to apply for Medical Assistance benefits.
6. Defendant refused to file an application for Medical Assistance benefits,
prompting Plaintiff to file an application on or about February 11, 2009.
7. If Defendant fails to provide the Cumberland County Assistance Office
("CAO") with the information necessary to qualify her father for Medical Assistance
benefits, the application will be denied and Plaintiff will be precluded from receiving
the Medical Assistance benefits that have been contractually assigned to it.
COUNTI
BREACH OF CONTRACT/ SPECIFIC PERFORMANCE
8. The allegations contained in Paragraphs 1 through 7 are incorporated
herein by reference as if fully set forth at length.
2
9. Defendant breached her Agreement with Plaintiff by failing to act in
accordance with the terms of the same, as she has failed to apply for Medical Assistance
benefits and has failed to provide necessary documentation required to process and
approve her fathers application for Medical Assistance benefits. By doing so,
Defendant has interfered with Plaintiff's right to receive the Medical Assistance benefits
that have been contractually assigned to it.
10. Plaintiff is entitled to the aforementioned Medical Assistance benefits and
cannot exercise its rights under the Assignment clause to receive payment until
Defendant's father's application is approved.
11. Upon information and belief, at all times material hereto, Defendant's
father was financially unable to fully compensate Plaintiff for the services that it has
rendered and continues to render to him in accordance with the terms and conditions of
the Agreement.
12. Defendant's breach of her Agreement with Plaintiff has irreparably
harmed Plaintiff.
13. Only a decree of specific performance will adequately protect the interests
of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
3
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders
specific performance of the Agreement between the parties.
Respectfully submitted,
Dated: ?a O
ScHugm BoGAR LLC
f,
By:
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Anthony T. Lucido
Attorney I.D. No. 76583
(717) 909-0353
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
417 Walnut Street, 411, Floor
Harrisburg, PA 17101
Fax No.: (717) 909-5925
Attorneys for Plaintiff
4
The undersigned hereby verifies that the statements of fact in the foregoing
document 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. 9 4904, relating to unworn falsification to authorities.
Dated: `, laian L
Sharon Cramer. M BMtg "Specialist
Church of God I dome, Inc.
EXHIBIT "A"
CHURCH OF GOD HOME, INC.
ASSISTED LIVING ADMISSION AGREEMENT
THIS AGREEMENT made this day of 20.07
by and between Church o odd Home, c., a Pennsyl ania non-profit corporation,
(called "Facility") and [NAME OF RES
(calle esident") and [NAME OF NSIBL
P SO OR GUARANTOR], if any, of
[ADDRESS], Resident's legal
representative and/or the individual who has lawful access to Resident's income and
financial resources available to pay for personal care services (called "Responsible
Person" or "Guarantor"). The Responsible Person is liable.only up to the amount of the
Resident's financial resources. The Guarantor is personally liable for all of the financial
obligations of the Resident under this Agreement. The Facility utilizes the terms
"personal care" and "assisted living" interchangeably so any reference to "assisted
living" has the same meaning as "personal care" and visa versa.
Resident has the right to identify a Designated Person who shall be entitled to
receive notice in the event of an emergency, termination of service, personal care home
closure or other situations as indicated by Resident or as required by law. Resident is
not lrequired t ame a Designat d person. Resident elects to name
of
jh-6
e Designate Perso he Designated Person may also be the Responsible Person
or Guarantor if Resident so chooses.
Resident, having applied for admission, and, if applicable, Responsible Person or
Guarantor, if any, affirm that the information, including all financial information,
provided in the Admission Application is true and correct, and acknowledge that the
submission of any false information may constitute grounds to terminate this
Agreement.
Therefore, Facility, Resident, and if applicable, Designated Person and/or
Responsible Person or Guarantor, if any, agree to the following terms and conditions:
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1. PROVISION OF SERVICES.
1.1. Basic Services. Facility will provide Resident with:
(a) assistance with or supervision in activities of daily living
and/or instrumental activities of daily living. The Fee
Schedule identifies those activities of daily living and/or
instrumental activities of daily living, which are available to
Resident as Basic Services and which are included in the
Daily Rate. The Fee Schedule is attached hereto as
Attachment "A" and is s 'ect to change from time to time;
(b) private semi-private accommodations;
(c) blankets, pillows, bed linens, towels, wash cloths, and
soap;
(d) laundering of linens and towels;
(e) three meals each day, except as otherwise medically
indicated;
(f) furnishings consisting of a bed, chair, storage area for
clothing (i.e., chest of drawers and closet), bedside
table/shelf, mirror and lamp. Resident, with the approval of
Facility, may also supply his/her own furnishings; and
(g) certain activity programs and social services.
1.2 Ancillary Services. Facility will provide ancillary services, at the
option and upon the request of the Resident, in exchange for additional charges as those
charges are reflected in the Fee Schedule attached to this Agreement and incorporated
by reference.
1.3 Assisted Livin Services Based on Outcome of Support Plan.
Facility shall provide Resident with assistance with activities of daily living and/or
instrumental activities of daily living consistent with Resident's Support Plan which
shall be developed and implemented within thirty (30) days after admission as specified
in Section 4.6 of this Agreement. The Support Plan shall be attached to this Agreement
and may be subject to change from time to time. Some of the activities of daily living
and/or instrumental activities of daily living specified in the Support Plan may not be
included in the Daily Rate and Resident may be subject to an additional charge for such
Ancillary Services as reflected on the Fee Schedule, which is attached hereto and may be
amended from time to time by Facility.
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2. CHARGES.
2.1 Security Deposit. Prior to admission, Resident and/or the
individual specified in Section 2.6 of this Agreement shall pay a security deposit in the
amount of initials].
2.2 Recurring
60, /periodic Charges for Basic Services. Resident and/or
the individual specified in Section 2.6 of this Agreement shall pay, in advance, in
exchange for the Basic Services the Daily Rate in effect at the time the service is
rendered as such rate is reflected on the Fee Schedule, which may be amended from
time to time by Facility upon notice to Resident. the time of execution of this
Agreement, the Daily Rate is initials], which fee is subject to
change from time to time. 1
2.3 Additional Charges for Ancillary Services and Supplies. Resident
and/or the individual specified in Section 2.6 of this Agreement shall be responsible to
pay for other services and supplies provided by or through Facility which are not
covered by the Daily Rate. Resident and/or.the individual specified in Section 2.6 of
this Agreement shall pay in exchange for Ancillary Services or Supplies the charges in
effect at the time such Ancillary Services or Supplies are rendered, as such charges are
reflected on the Fee Schedule. Any items not identified on the Fee Schedule ordered by
a physician will be provided at charges established by Facility.
2.4 Charges for Reserving Resident's Assisted Living Room. Resident
and/or the individual specified in Section 2.6 of this Agreement shall pay the full Daily
Rate applicable at the time of Resident's absence for reserving Resident's assisted living
room for any days or periods of hospitalization, transfer or any other absences from the
Facility. Resident's room is automatically reserved unless Resident indicates in writing
Resident's intent not to reserve the room.
2.5 Method of Payment for Char es for Lon Distance Tale hone Calls.
Resident and/or the individual specified in Section 2.6 of this Agreement shall pay the
charge as assessed by Facility for all long distance telephone calls. The charges for long
distance telephone calls will appear on the monthly statement provided to Resident by
the Facility.
2.6 Party Responsible for Payment. The following individual(s) are
responsible for payment, and are req to pay all applicable charges in accordance
with this Agreement: -X ?-_ Resident 11 initials];
initials]; Guarantor [ initials]. Responsible Person [
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3. PERIODIC BILLINGS AND PAYMENT DUE DATE.
3.1 Monthly Statements and Other Billings. Resident and, if
applicable, the Responsible Person and/or Guarantor will receive each month a billing
statement reflecting ancillary charges for the previous month and the amount due for
Basic Services one month in advance. All bills are due and payable upon receipt.
3.2 Modification of Charges. Facility reserves the right to change from
time to time the amount of its charges as reflected in the Fee Schedule or how and when
its charges are computed, billed or become due. Facility shall provide thirty (30) days
advance written notice of any changes in its Daily Rate or any changes in the prices of
Ancillary Services.
3.3 Late Charges and Cost of Collection. Any bills unpaid after the
tenth (101:h) day of the month of issue are subject to a late charge of one and one-half
percent (1.5%) per month, and Resident, and if applicable, Responsible Person or
Guarantor are obligated to pay any late charges. In the event Facility initiates any legal
actions or proceedings to collect payments due from Resident under this Agreement,
Resident, and if applicable, Responsible Person or Guarantor shall be responsible to pay
all attorneys' fees and costs incurred by Facility in pursuing the enforcement of
Resident's financial obligations under this Agreement.
3.4 Billing Information. Statements shall be sent to;
Resident and/or Responsible Person or Guarantor agrees
to notify the Facility within ten (10) days of any change in the billing address.
3.5 Obligations of Resident's Estate and Assignment of Property.
Resident and, if applicable, Responsible Person or Guarantor acknowledge the charges
for services provided under this Agreement remain due and payable until fully
satisfied. In the event of Resident's discharge for any reason, including death, this
Agreement shall operate as an assignment, transfer and conveyance to Facility of so
much of Resident's property as is equal in value to the amount of any unpaid
obligations under this Agreement. This assignment shall be an obligation of Resident's
estate and may be enforced against Resident's estate. Resident's estate shall be liable to
and shall pay to Facility an amount equivalent to any unpaid obligations of Resident
under this Agreement.
4. STANDARDIZED SCREENING, ASSESSMENTS AND MEDICAL
EVALUATION.
4.1 Pre-Admission Screening and Medical Evaluation. Admission to
Facility is conditioned upon Resident completing to the satisfaction of Facility a pre-
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admission screening, including a mobility assessment, within thirty (30) days prior to
admission, which indicates that the needs of Resident can be met by the services
provided by Facility. Resident also shall have a medical evaluation and have a licensed
physician, physician's assistant or certified registered nurse practitioner complete and
sign an acceptable medical evaluation form within sixty (60) days prior to or within
thirty (30) days after admission.
4.2 Initial Assessment. Resident shall have a written initial assessment,
including a mobility assessment, completed by the Administrator or a designee of the
Administrator or, subject to Facility approval, completed by a qualified human service
agency within fifteen (15) days of admission.
4.3 Cost of Medical Evaluations. Resident is responsible for paying the
cost of all medical evaluations and diagnostic tests whenever medical evaluations and
diagnostic tests are required.
4.4 Purpose and When Required. The purpose of the screening
process, initial assessment and medical evaluation is to provide basic information about
the care needed by Resident. Additional assessments, including mobility assessments,
are required: (a) annually; (b) if the condition of Resident significantly changes prior to
the annual assessment; or (c) at the request of the Department of Public Welfare upon
cause to believe that an update or revised assessment is needed. Resident shall have a
medical evaluation: (a) annually; or (b) if the medical condition of Resident changes
prior to the annual medical evaluation.
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4.5 Results of Screening and Medical Evaluation. In the event that a
screening, assessment or medical evaluation indicates that Resident's care needs exceed
the capabilities of Facility, Resident shall be transferred or discharged under the terms
and conditions set forth in this Agreement.
4.6 Support Plan. Facility shall develop and implement a written
Support Plan for Resident within thirty (30) days after admission to Facility. The
Support Plan shall describe the care, service or treatment needs of Resident. Resident
may participate in the development and implementation of Resident's Support Plan,
and may include Resident's Designated Person, if any, in making decisions about the
services to be provided to Resident. Resident's Support Plan shall be revised within
thirty (30) days upon: (a) completion of the annual assessment; or (b) changes in
Resident's needs as indicated on the current assessment. The Support Plan, upon initial
completion and any subsequent revisions, shall be attached to this Agreement.- The
service needs addressed in the Support Plan shall be available to Resident every day
during Resident's stay in Facility, unless the Support Plan provides otherwise.
4.7 Level of Care Transfer Determination. The level of care required
for Resident is initially determined and periodically reevaluated by Facility. If it is
determined by Facility that Resident, due to a change in Resident's condition, requires a
higher level of care than Facility provides, Resident and, if applicable, the Designated
Person agree to the transfer of Resident to an appropriate, higher level of care facility
within Community or a Special Service Facility to meet Resident's care needs in
accordance with the terms and conditions specified under Section 10.5 of this
Agreement.
5. PERSONAL FUNDS.
5.1 Personal Needs Allowance. The Resident and/or Responsible
Person or Guarantor agree(s) to provide such personal funds, clothing and effects as
needed, required or desired by the Resident. Resident shall retain the minimum
amount of Resident's own funds per month for personal expenditures as required by
the Department of Public Welfare, which amount currently is sixty dollars ($60.00). If
Responsible Person or Guarantor manages Resident's funds, then Responsible Person or
Guarantor shall provide Resident with at least sixty dollars ($60.00) per month for
personal expenditures.
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6. SSI PROVISIONS. The following restrictions apply in this Agreement for
residents who receive or are eligible for SSI benefits:
6.1 Monthly Charges. SSI Residents shall be obligated to pay monthly
charges, but shall not pay more than the SSI Resident's actual current monthly income
reduced by a minimum personal needs allowance determined by the Department of
Public Welfare. This provision shall not be construed to prohibit Facility from obtaining
a third party guaranty for payment of the balance of the monthly charges above the
Resident's allowable SSI amount.
6.2 Restrictions on Charges. If Resident is an SSI recipient or eligible
for SSI benefits, the Resident shall receive the following items or services as needed:
a. Necessary personal hygiene items, such as a comb,
toothbrush, toothpaste, soap and shampoo. Cosmetic items
are not included.
b. Laundry services for personal laundry, bed linens and towels, but
not including dry cleaning or other specialized services.
C. Assisted living services such as assistance or supervision
with dressing, bathing, hygiene, medication prescribed for
self-administration, arrangements for special diets if dietary
restrictions exist, and weekly housekeeping.
6.3 Restrictions on Supplemental Funds. If Resident is an SSI recipient
or eligible for SSI benefits, payment for rent and other services shall not include funds
received as lump sum awards, gifts or inheritances, gains from the sale of property or
retroactive government benefits. Facility may seek and accept payments from funds
received as retroactive awards of SSI benefits/.but only to the extent that the retroactive
awards cover periods of time during which Resident actually resided in Facility for
which full payment has not been received.
7. OBLIGATIONS OF RESPONSIBLE PERSON/ GUARANTOR.
7.1. Non-SSI Recipients.
(a) Responsible Person. Responsible Person may be required to
enter into and sign a separate "Responsible Person Agreement" to evidence Responsible
Person's financial obligations. When applicable,
Responsible Person shall be
responsible to pay from Resident's financial resources and shall be liable only up to the
amount of Resident's resources.
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(b) Guarantor. Guarantor may be required to enter into and
sign a separate "Guaranty and Suretyship Agreement, to evidence Guarantor's
financial obligations. When applicable, Guarantor shall be jointly and severally liable
for all of Resident's financial obligations under this Agreement and shall guarantee
payment in the event Resident does not pay Facility for all charges incurred under this
Agreement within thirty (30) days of the payment due date.
7.2 SS_I Recipients. If Resident enters into an agreement with
Guarantor, and Resident enters Facility as an SSI recipient or becomes an SSI recipient
during Resident's stay, then Guarantor shall be primarily liable for all unpaid charges
incurred under this Agreement, except those charges associated with food, clothing and
shelter. In such situations, Guarantor shall enter into and sign a separate "Third-Party
Payment Agreement" to evidence Guarantor's financial obligations.
8. RENT REBATE BENEFITS.
Resident may apply for any benefits to which Resident may be entitled
under the Senior Citizens Rebate and Assistance Act. Facility may not seek or accept in
excess of one-half of any rent rebate monies received by Resident under the Senior
Citizens Rebate and Assistance Act.
9. FINANCIAL MANAGEMENT.
9.1 Authorization Requirements. Resident has the right to manage his
or her own personal funds. Resident may deposit personal funds with Facility, and if
Resident so elects, authorize Facility, in writing, to hold and manage Resident's
personal funds so deposited. If Resident designates someone other than Facility to
manage his or her personal funds, Resident or, if applicable, Designated Person and/or
Responsible Person or Guarantor shall notify Facility promptly. Resident may revoke at
any time the authorization for Facility to hold. and manage his or her personal funds by
providing Facility a written notice signed and dated by the Resident or, if applicable,
the Designated Person and/or Responsible Person or Guarantor.
9.2 Facility Obligations. If assistance with financial management is
offered by Facility and elected by Resident, Facility shall comply with the financial
management policies established in the Assisted Living Handbook, which are subject to
change from time to time.
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10. TERMINATION, TRANSFER OR DISCHARGE.
10.1 Facility Initiated. Facility may terminate this Agreement and
Resident's stay, and transfer or discharge Resident if:
a. It is determined by Resident's physician or Facility's
Administrator or a designee that Resident's functional level
has advanced or declined so that Resident's needs cannot be
met by Facility; or
b. Resident is a danger to himself/herself or others; or
c. If the Facility chooses to voluntarily close all or a portion of
Facility; or
d. Violation of Facility's rules, regulations, policies or
procedures; or
e. Resident has failed to pay after reasonable efforts by Facility
to obtain payment; or
f• Meeting Resident's needs would require a fundamental
alteration in Facility's program or building site, or would
create an undue financial or programmatic burden on
Facility; or
g. Closure of Facility is initiated by the Department of Public
Welfare.
10.2 Notice. If Facility initiates a transfer or discharge of Resident, or
Facility closes, thirty (30) days prior written notice, except as is provided in Section 10.3,
shall be provided to Resident and/or Designated Person, if any, and the referral agency,
if any, citing the reasons for the discharge or transfer. Facility will notify Resident and
and/or Designated Person, if any, (or if none, a family member or legal representative
of the Resident, if known to Facility) at least thirty (30) days in advance of transfer or
discharge.
10.3 Waiver of Notice for Facility Initiated Discharge or Transfer. If a
delay in discharge or transfer would jeopardize the health or safety of Resident or
others in the Facility, as certified by a physician or the Department of Public Welfare, or
both; the thirty (30) day notice period may be waived, and Facility shall give only such
notice as is reasonable and practicable under the circumstances.
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10.4 Facility Closure. In the event of a partial or complete closure,
Facility shall submit to each affected resident at least thirty (30) days before closure, a
written statement of the intent to close and the projected date. Copies shall be provided
to the Department of Public Welfare; the Resident and his/her Designated Person, if
any; any agencies which participated in referral of the Resident to the Facility; and any
agencies currently providing services to the Resident.
10.5 Level of Care Transfer to a Nursin Facilit . There is no guarantee
or assurance that a nursing care bed in the Church of God Home's Nursing Facility will
be available at such time as Resident may need to transfer to a nursing facility for the
provision of a higher level of care than Facility provides. In order to transfer to the
Church of God Home's Nursing Facility, Resident must meet all the criteria for
admission, including the financial requirements, and sign a separate admission
agreement. In the event that there is no bed available in the nursing facility, or Resident
fails to meet the requirements for admission to the nursing facility at such time as
Resident needs to be transferred, Resident may be transferred to another nursing
facility duly licensed to provide nursing care by the Pennsylvania Department of
Health. The expense of such transfer and care, including the cost of transport service,
shall be the obligation of the Resident.
10.6 Transfer to Hospital or Other Outside Facilit . In the event of
illness or deterioration in the physical or mental condition of Resident requiring a
higher level of care than provided by Facility, Resident shall be transferred to an
appropriate health care provider. The expense of such transfer and care, including the
cost of transport service, shall be the obligation of Resident.
10.7 Documentation. The date and reason for the discharge or transfer,
and the destination of the Resident, if known, shall be recorded in Resident's record.
10.8 Resident Initiated. Resident may terminate this Agreement upon
thirty (30) days written notice to Facility. If Resident leaves Facility for any reason other
than a medical emergency or death, Resident must give written notice to Facility at least
thirty (30) days in advance of transfer, discharge or termination of this Agreement. If
Resident fails to give thirty (30) days advance written notice to terminate or Resident,
after giving notice to terminate, leaves Facility before the expiration of the required
thirty (30) day notice period, Resident shall remain responsible for payment of the Daily
Rate and other charges then in effect for Resident's stay and care for the entire thirty
(30) day notice period, whether or not Resident resided in Facility during that time.
10.9 _Withdrawal Against Advice. In the event Resident withdraws from
Facility without the consent of Facility and against the advice of his/her attending
physician and/or the Medical Director, all of Facility's responsibilities for the care of
Resident are terminated.
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11. DEATH OF RESIDENT.
11.1. Facility Responsibility. Facility assumes no responsibilities or
obligations, which may arise upon the death of Resident except notice to Resident's
proper representative. All funeral arrangements and expenses are the obligation of the
Resident's Estate and/or those individuals responsible by law. Unless otherwise
agreed, Facility will assume no responsibility for life insurance policies or benefits for
any deceased resident. Resident's survivors shall be responsible for making application
for survivor benefits.
11.2 Transfer. In the event of Resident's death, Facility is authorized to
arrange for the transfer of Resident's body to the Funeral Home designated by Resident
at the time of admission. Facility shall notify the person(s) designated by Resident in
the event of Resident's death. Resident's Estate or those individuals obligated by law
are responsible for the payment of all costs associated with the transfer and funeral.
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12. REFUNDS.
12.1 Refunds of Personal Funds. Any personal funds being managed or
held by Facility on behalf of Resident will be refunded within two (2) business days
from the date that Resident's room is cleared of Resident's property, subject to
deductions for outstanding bills or other amounts due the Facility. In the event of
Resident's death, the refund will be made to the duly authorized representative of
Resident's Estate, to the Responsible Person or Guarantor designated under this
Agreement, or to other persons entitled to property under current law. If Resident is
permanently transferred to the Church of God Home's Nursing Facility, then Facility,
upon the written request of Resident or, if applicable, upon the written request of the
Designated Person, Responsible Person or Guarantor, if any, may continue to hold
Resident's personal needs allowance or any funds held in a bank account as opposed to
issuing a refund as previously specified under this Section.
12.2 Security Deposit and Advance Pa ments. The security deposit and
any funds paid in advance for Basic Services, subject to deductions for payment of
outstanding bills, costs incurred to restore or repair Resident's assisted living room or
other amounts due the Facility, will be refunded to Resident within thirty (30) working
days after the permanent transfer or discharge of Resident from the Facility, and
termination of this Agreement. In the event of Resident's death, Facility shall refund to
Resident's Estate or to such parties or persons entitled to the property under current
law the security deposit and any unused portion of advance payments for Basic
Services made by Resident or Responsible Person and held by Facility after deductions
for payment of any outstanding bills, costs incurred to restore or repair Resident's room
or other amounts due the Facility, within thirty (30) days from the date that Resident's
personal property is removed from Resident's room.
13. FACILITY RULES, REGULATIONS, POLICIES, AND PROCEDURES.
13.1 Source of Rules. Resident shall comply fully with all governmental
laws and regulations, the provisions of this Agreement, and Facility's rules, regulations,
policies and procedures as published in the Assisted Living Handbook or other
documents or publications made available by the Facility. Facility reserves the right to
amend or change its rules, regulations, policies and procedures. A copy of the Assisted
Living Handbook containing an explanation of Facility's rules, regulations, policies and
procedures shall be provided to Resident upon admission. The Facility's rules,
regulations, policies and procedures shall not be construed as imposing any contractual
obligations on Facility or granting any contractual rights to Resident, and are subject to
change from time to time.
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132 Sm_ okin$. The Facility does not permit smoking inside the Facility;
however, smoking is permitted outside but only in designated areas.
13.3 Pets. Pets are not permitted.
14. PERSONAL AND OTHER PROPERTY.
14.1 Responsibility for Maintenance and Loss. Resident is responsible
for furnishing and maintaining his or her own clothing, jewelry and possessions and
other items of property as needed or desired. Facility shall provide Resident with a lock
box in which Resident can keep his/her cash or other personal valuables. Facility shall
not be responsible for cash or other personal valuables, which are not kept in a lock box.
Resident may obtain at his/her own expense, casualty insurance to cover potential
damage to or loss of personal property. If damage or loss occurs to Resident's property,
the Facility will investigate each incident of loss or damage to determine liability and
assess responsibility depending on the facts and circumstances of each incident. The
Facility shall be responsible for only such losses or damages as are attributed by the
Facility to the negligence or fault of the Facility.
14.2 Disposition and Stora a Uyon Resident's
Resident's death, Facility shall contact Resident's authorized reprDeath. Upon the
esentative within
twenty-four (24) hours to arrange for an inventory of Resident's personal property.
Facility is authorized to transfer Resident's personal property to a duly authorized
representative of Resident's Estate or to such parties or persons entitled to the property
under current law. The duly authorized representative of Resident's Estate or other
persons entitled to property under current law must acknowledge, in writing, the
receipt of the personal property transferred to his or her custody by Facility. After
Resident's death, Facility may keep Resident's personal property in Resident's assisted
living room for a period of time up to thirty (30) days or until the property is claimed b
an authorized representative of Resident's Estate or any parties or persons entitled to
the property under current law, whichever is sooner. The room rate may continue to be
charged until all of the Resident's property is removed from the Resident's assisted
living room. After completing an inventory, Facility, in its sole discretion, may move
and place Resident's personal property into storage at Facility's expense. If property
held in storage is not claimed within thirty (30) days, Facility shall send a notice to the
authorized representative via certified mail that if items in storage are not removed
within fourteen (14) days, Facility may dispose of Resident's property.
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14.3 Disposition and Storage Upon Resident's Transfer or Discharge. If
Resident's personal property is not claimed or removed within twenty-four (24) hours
of Resident's permanent transfer or discharge, Facility shall move and place Resident's
personal property in storage until claimed. In its sole discretion, Facility may permit a
longer time for removal of Resident's possessions in exchange for payment at the Daily
Rate. If Resident's personal property remains unclaimed for thirty (30) days after
permanent transfer or discharge, Facility may dispose of Resident's property. Resident
or Resident's Estate shall be obligated to pay all costs of storage or disposition and shall
bear the risk of loss or damage to the property. Resident shall be obligated to pay a
storage fee for each day of storage as reflected on the Fee Schedule.
14.4 Damage to Room or Facility Pro erty. Resident or Resident's
Estate is responsible for any damages caused to Facility property beyond normal wear
and tear, and shall pay for the repair and replacement of damaged property, based on
such reasonable charges as may be assessed by Facility for such repair or replacement.
15. RESIDENT RECORDS.
Resident consents to the release of Resident's personal and medical
records maintained by the Facility for treatment, payment and operations as
determined reasonably necessary by the Facility. Any such release may be to the
Facility's employees, agents and to other health care providers from whom the Resident
receives services, to third-party payors of health care services, to any Managed Care
Organization ("MCO") in which Resident may be enrolled, or to others deemed
reasonably necessary by the Facility for purposes of treatment, payment and operations.
Release of records for other purposes shall be.done in accordance with applicable law,
with a specific authorization from the Resident where required. Authorized agents of
the state or federal government, including the Long Term Care Ombudsman, may
obtain Resident's records without the written consent or authorization of Resident.
16. ASSISTED LIVING SERVICES AUTHORIZATION.
Resident authorizes Facility to provide assisted living services consistent
with the terms of this Agreement.
17. ADVANCE DIRECTIVES.
If Resident has executed an advance directive in the form of a living will
relating to the provision of health care services in the event of terminal or other illnesses or
conditions, Resident shall provide a copy of the living will or advance directive to Facility,
and a copy of any revisions or changes made to the document during Resident's stay at
Facility.
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18. DURABLE FINANCIAL POWER-OF-ATTORNEY.
Resident is strongly encouraged to furnish to Facility, no later than the
date of admission, a durable Power-of-Attorney executed by Resident as Principal
designating someone other than the Facility or a representative or affiliate of Facility as
Agent, for the limited purpose of financial decisions and payment of services. In the
event Resident fails to designate an Agent under a Power-of-Attorney, Resident, as
specified in Section 19 of this Agreement, shall be responsible to pay for any
guardianship proceedings related to the appointment of someone or a legal entity to
make decisions on behalf of Resident, if and when Resident lacks capacity to make such
decisions as determined by Facility.
19. CAPACITY OF RESIDENT AND GUARDIANSHIP.
If Resident is or becomes unable to understand or communicate, and is
determined prior to or after admission to be partially or completely incapacitated, then,
in the absence of Resident's prior designation of an authorized legal representative, or
upon the unwillingness or inability of the legal representative to act, Facility shall have
the right to commence a legal proceeding to adjudicate Resident incapacitated and to
have a court appoint a guardian for Resident. The cost of the legal proceedings,
including attorneys' fees, shall be paid by Resident or Resident's Estate.
20. NOTICE.
Wherever written notice is required to be given to Facility under this
Agreement, it shall be sufficient if notice is provided by personally delivering it or by
first-class mail, return receipt requested, addressed to:
Church of God Home, Inc.
801 N. Hanover Street
Carlisle, PA 17013
Notice to Resident will be provided by personal delivery to Resident's
assisted living room, or where applicable, by first-class mail to Responsible Person or
other Designated Person.
4?!A /I (RESPONSIBLE PERSON/ DESIGNATED PERSON, if any
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21. INDEMNIFICATION.
Resident shall indemnify and hold the Facility harmless from and against,
and is responsible to pay for, any damages, including attorneys' fees and reasonable
costs, including those incident to establishing the right to indemnification for injury to
or death of any person or other resident, or for damage to or loss of the property of any
person or resident caused by the acts or omissions of Resident, to the fullest extent
permitted by law.
22. FACILITY'S GRIEVANCE PROCEDURE.
22.1 Reyorting Complaints. If Resident or Designated Person, if any,
believe(s) that Resident is being mistreated in any way or Resident's rights have been or
are being violated by staff or another resident or in any other way, Resident and/or
Designated Person may file a complaint with Facility. Resident and/or Designated
Person may also file a complaint with the Department of Public Welfare's personal care
home regional office, local ombudsman or protective services unit in the area agency on
aging, Pennsylvania Protection & Advocacy, Inc., or law enforcement agency. The
procedure for filing a complaint with Facility. or one of the aforementioned entities is
described in the "Notice of Complaint Procedures", which is attached to this Agreement
as Attachment "B". The complaint procedures described in Attachment "B" do not
impose any contractual obligations on the Facility nor do they grant any private
contractual rights to Resident.
22.2 Voluntary Mediation. Mediation is a form of alternative dispute
resolution whereby an impartial person facilitates communication between the parties.
The goal of mediation is to resolve the dispute promptly, amicably, and without
incurring significant time and expense. Mediations are non-binding in nature. This
Agreement provides for voluntary mediation whereby the parties may, upon mutual
agreement, engage in mediation before resorting to arbitration. If the parties mutually
agree to mediate any dispute that may arise between them, then the mediation will be
conducted at a site selected by Facility, which shall be at Facility or at a site within a
reasonable distance of Facility. The costs of the mediation shall be borne equally by
each party, and each party shall be responsible for their own legal fees. If the parties are
unable to resolve their dispute through mediation, then the dispute may only be
resolved by arbitration as provided in this Agreement. If the parties do not mutually
agree to mediate any dispute that may arise between them, then they may proceed
directly to arbitration.
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22.3 Mandatory Binding Arbitration. Arbitration is a specific process of
dispute resolution utilized instead of the traditional state or federal court system.
Instead of a judge and/or jury determining the outcome of a dispute, a neutral third
party ("Arbitrator(s)") chosen by the parties to this Agreement renders the decision,
which is binding on both parties. Generally an Arbitrator's decision is final and not
open to appeal. The Arbitrator will hear both sides of the story and render a decision
based on fairness, law, common sense and the rules established by the Arbitration
Association selected by the parties. When Arbitration is mandatory, it is the only legal
process available to the parties. Mandatory Arbitration has been selected with the goal
of reducing the time, formalities and cost of utilizing the court system.
(a) Contractual and/or Property Damage Dis utes. Unless
resolved or settled by mediation, any controversy, dispute, disagreement or claim of
any kind or nature, arising from, or relating to this Agreement, or concerning any rights
arising from or relating to an alleged breach of this Agreement, with the exception of (1)
guardianship proceedings resulting from the alleged incapacity of the Resident; (2)
collection actions initiated by the Facility 'for nonpayment of stay or failure of
Responsible Person or Guarantor to fulfill their obligations under this Agreement, the
Responsible Person Agreement, Guaranty and Suretyship Agreement or the Third-
Party Payment Agreement, which results in a financial loss to the Facility; and (3)
disputes involving amounts in controversy of less than Eight Thousand Dollars ($8,000),
shall be settled exclusively by arbitration. This means that the Resident will not be able
to file a lawsuit in any court to resolve any disputes or claims that the Resident may
have against the Facility. It also means that the Resident is relinquishing or giving up
all rights that the Resident may have to a jury trial to resolve any disputes or claims
against the Facility. It also means that the Facility is giving up certain rights that it may
have to a jury trial or to bring claims in a court against the Resident. Subject to the
provisions of Section 22.3(f), the Arbitration shall be administered by ADR (Alternative
Dispute Resolution) Options, Inc., in accordance with the ADR Options Rules of
Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in
any court having appropriate jurisdiction. Resident and, if applicable, Designated
Person and/or Responsible Person or Guarantor acknowledge(s) and understand(s)
that there will be no jury trial on any claim or dispute submitted to arbitration, and
Resident and, if applicable, Designated Person and/or Responsible Person or Guarantor
relinquish and give up their rights to a jury trial on any matter submitted to arbitration
under this Agreement.
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(b) Personal Iniury or Medical Malpractice. Unless resolved or
settled by mediation, any claim that the Resident may have against the Facility for any
personal injuries sustained by the Resident arising from or relating to any alleged
medical malpractice, inadequate care, or any other cause or reason while residing in the
Facility, shall be settled exclusively by arbitration. This means that the Resident will not
be able to file a lawsuit in any court to bring any claims that the Resident may have
against the Facility for personal injuries incurred while residing in the Facility. It also
means that the Resident is relinquishing or giving up all rights that the Resident may
have to a jury trial to litigate any claims for damages or losses allegedly incurred as a
result of personal injuries sustained while residing in the Facility. Subject to the
provisions of Section 223(f), the Arbitration, shall be administered by ADR Options,
Inc., in accordance with the ADR Options Rules of Procedure, and judgment on any
award rendered by the arbitrator(s) may be entered in any court having appropriate
jurisdiction. Resident, and if applicable, Designated Person and/or Responsible Person
or Guarantor acknowledge(s) and understand(s) that there will be no jury trial on an
claim or dispute submitted to arbitration, and Resident, and if applicable, Designated
Person and/or Responsible Person or Guarantor relinquish and give up the Resident's
right to a jury trial on any claims for damages arising from personal injuries to the
Resident which are submitted to arbitration under this Agreement.
(c) Exclusion From Mandato Arbitration. Those disputes
which have been excluded from mandatory arbitration (i.e., guardianship proceedings,
collection actions initiated by the Facility, and disputes involving amounts in
controversy of less than $8,000) may be resolved through the use of the judicial system.
In situations involving any of the matters excluded from mandatory arbitration, neither
you nor the Facility are required to use the arbitration process. Any legal actions
related to those matters may be filed and litigated in any court which may have
jurisdiction over the dispute.
(d) Right to Leal Counsel. Resident has the right to be
represented by legal counsel in any proceedings initiated
under this arbitration provision. Because this arbitration
provision addresses important legal rights, the Facility
encourages and recommends that Resident obtain the advice
and assistance of legal counsel to review the legal
significance of this mandatory arbitration provision prior to
signing this Agreement.
(e) Location of Arbitration. The Arbitration will be conducted
at a site selected by the Facility, which shall be at the Facility or at a site within a
reasonable distance of the Facility.
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(f) Time Limitation for Arbitration. Any request for arbitration
of a dispute must be requested and submitted to ADR Options, Inc., with notice to the
other party, prior to the lapse of two (2) years from the date on which the event giving
rise to the dispute occurred. In the event ADR Options, Inc., is unable or unwilling to
serve, then the request for Arbitration must be submitted to Facility within thirty (30)
days of receipt of notice of ADR Options, Inc.'s, unwillingness or inability to serve as a
neutral arbitrator. Facility shall select an alternative neutral arbitration service within
thirty (30) days thereafter and the selected Arbitration Agency's procedural rules shall
apply to the arbitration proceeding. The failure to submit a request for Arbitration to
ADR Options, Inc., or an alternate neutral arbitration service selected by Facility, within
the designated time (i.e., two (2) years) shall operate as a bar to any subsequent request
for Arbitration, or for any claim for relief or a remedy, or to any action or legal
proceeding of any kind or nature, and the parties will be forever barred from arbitrating
or litigating a resolution to any such dispute. Contact information for ADR Options,
Inc., is as follows:
Two Commerce Square, Suite 1100
2001 Market Street
Philadelphia, PA 19103-7044
Phone: (215) 564-1775 / (800) 364-6098
Fax: (215) 564-1822
Website: www.adroptions.com
(g) Limitation of Damages for Arbitration. The costs of the
arbitration shall be borne equally by each party, and each party shall be responsible for
their own legal fees.
(h) Limited Resident Right to Rescind this Mandatory
Arbitration Clause (Sections 22.3(a-h) of this Agreement). Resident or, in the event of
Resident's incapacity, Resident's authorized representative have the right to rescind this
arbitration clause by notifying the Facility in writing within thirty (30) days. Such
notice must be sent via certified mail to the attention of the Administrator of the
Facility, and the notice must be post-marked within 30 days of the execution of this
Agreement. The notice may also be hand-delivered to the Administrator within the
same 30-day period. The filing of a claim in a court of law within the 30 days provided
for above will automatically rescind the arbitration clause without any further action by
Resident or Resident's authorized representative.
23. MISCELLANEOUS PROVISIONS.
23.1 Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the Commonwealth of Pennsylvania and shall
be binding upon and inure to the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
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23.2 Severability. The various provisions of this Agreement shall be
severable one from another. If any provision of this Agreement is found by a court or
administrative body of proper jurisdiction and authority to be invalid, the other
provisions shall remain in full force and effect as if the invalid provision had not been a
part of this Agreement.
23.3 Entire Agreement. The Admission Agreement consists of this
Agreement, the Admission Application and, if applicable, the Responsible Person
Agreement, the Guaranty and Suretyship Agreement or the Third-Party Payment
Agreement. This Admission Agreement represents the entire Agreement between the
parties, and it supersedes, merges and replaces, all prior negotiations, offers, warranties
and previous representations, understandings or agreements, oral or written, between
the parties.
23.4 Modifications. Facility reserves the right from time to time to
modify unilaterally the terms of this Agreement consistent with law. Facility also
reserves the right to request a change in the terms of this Agreement. Facility will give
Resident and Resident's Designated Person, if any, thirty (30) days advance written
notice of any such modifications or any such proposed modifications.
23.5 Waiver of Provisions. Facility reserves the right to waive any
obligation of Resident under the provisions of this Agreement in its sole and absolute
discretion. No term, provision or obligation of this Agreement shall be deemed to
have been waived by Facility unless such waiver is in writing by Facility. Any such
waiver by Facility shall not be deemed a waiver of any other term, provision or
obligation of this Agreement, and the other obligations of Resident under this
Agreement shall remain in full force and effect.
23.6 Rescission Period. Resident or Designated Person has the right to
rescind this Agreement for up to seventy-two (72) hours after the initial dated signature
of this Agreement. Resident or Designated Person must notify Facility in writing of the
decision to rescind this Agreement. The notice of the rescission must be received by
Facility or be post-marked before the lapse of the seventy-two (72) hour rescission
period. In the event Resident or Designated Person rescinds this Agreement, Resident
shall pay only for services received.
24. ACKNOWLEDGMENTS.
24.1 Fee Schedule. Resident and, if applicable, Designated Person
and/or Responsible Person or Guarantor acknowledge(s) the receipt of a copy of the
Fee Schedule and the opportunity to ask questions about Facility's charges. The Fee
Schedule is attached to this Agreement and incorporated by reference.
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24.2 Resident Rights and Complaint Procedures
applicable, Designated Person acknowledge being info. Re
orally and de wr h and,
of
Resident's Rights and the right to lodge complaints without intimidation, retaliation or
threats of retaliation of Facility or its staff persons against Resident and acknowledge
having an opportunity to ask questions about those rights/ complaint procedures.
Resident and, if applicable, Designated Person acknowledge receiving a copy of the
Notice of Resident Rights", which is attached to this Addendum as Attachment "C",
and a copy of the "Notice of Complaint Procedures", which is attached to this
Addendum as Attachment "B". The Resident Rights and Complaint Procedures
described in each "Notice" are granted by regulation and are regulatory in nature and
origin and they should not be construed as private contractual rights. The "Notice of
Resident Rights" and the "Notice of Complaint Procedures" do not impose an
contractual obligations on the Facility nor do they grant any private contractual rights
to Resident.
24.3 Agreement. Resident and, if applicable, Designated Person and/or
Responsible Person or Guarantor acknowledge(s) that they have read and understand
the terms of this Agreement, that the terms have been explained to them by a
representative of Facility, and that they have had an opportunity to ask questions about
this Agreement. A copy of the signed Agreement shall be provided to Resident and a
copy shall be included in the Resident's record.
24.4 Assisted Livin Handbook. Resident and, if applicable, Designated
Person and/or Responsible Person or Guarantor, if any, acknowledge(s) receipt of a
copy of the Assisted Living Handbook and the opportunity to ask any questions about
Facility's rules, regulations, policies, and procedures. The Facility's Assisted Living
Handbook shall not be construed as imposing any contractual obligations on Facility, or
granting any contractual rights to Resident, and is subject to change from time to time.
24.5 Personal Care Regulations. Resident and, if applicable, Designated
Person and/or Responsible Person or Guarantor, if any, acknowledge having been
informed of the location of the Department of Public Welfare Personal Care Home
Regulations posted in the Facility.
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r R
IN WITNESS WHEREOF, the parties, intending to be legally bound, have signed
this Agreement on the date written below.
Ment,,
oonsibl7eersonn, if any
Date
//-/,5--07
Date
Guarantor, if any
Designated Person, if any
Date.
Date
Church of God Home, Inc.
By Y- A1,A#
-X-?-? - /P-/ --
Administr o or Designee
Date
108664
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r 4 •
CHURCH OF GOD HOME, INC.
RESPONSIBLE PERSON AGREEMENT
This Responsible Person Agreement (hereinafter referred to as "Agreement") is
e between C rc of Home, Inc., (hereinafter referred to as "Facility") and
the
legal in 'vid al here' after erred to as "Responsible eSPersolne of representative
the Resident,
(hereinafter referred to as "Resident").
RECITALS:
WHEREAS, the Responsible Person and Facility enter into this Agreement to
facilitate the provision of care to the Resident.
WHEREAS, the Responsible Person may be the Guardian, the Agent under a
valid Power of Attorney, or any person authorized by Resident to serve as Resident's
Responsible Person.
WHEREAS, Facility shall discuss and consult with Responsible Person regarding
pertinent decisions related to Resident's stay and care at the Facility.
THEREFORE, Facility and Responsible Person agree to the following terms and
conditions:
1. Responsible Person affirms that the information provided in the
Admission Application and related documents are true and correct to the best of his or
her knowledge. If Responsible Person submits any false information, fails to disclose
information or misrepresents information during the application process, Responsible
Person shall be personally liable for any such misrepresentations.
2• If the Resident selects a Responsible Person, then said Responsible Person
shall sign this Agreement and the Admission Agreement in recognition of this
designation with the intent to be legally bound by this Agreement and the Admission
Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of
the Resident imposed by the Admission Agreement in accordance with the law
governing fiduciary duties. Facility may petition a court to appoint a Guardian and
take other legal action if Facility reasonably believes that the Resident's needs are not
being properly met or the duties imposed by the Admission Agreement are not being
fulfilled by the Responsible Person. Resident, Resident's estate, or Responsible Person
shall pay the cost of such Guardianship proceedings, including attorneys' fees.
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3. Responsible Person affirms that he or she has access to Resident's income
and resources and that Resident's income and resources are available to pay for
Resident's care in the Facility. The Responsible Person shall provide payment from
Resident's income and resources for such care. Responsible Person shall apply
Resident's income and resources to the costs and charges incurred during Resident's
stay unless and until such costs are paid by private insurance or other benefits such as
Medicare or Veteran's Health Insurance.
4. Responsible Person is obligated to pay Facility from Resident's financial
resources for services and supplies provided to Resident in accordance with the
Admission Agreement. If the Responsible Person withholds or misappropriates
Resident's financial resources for personal use or gifts, or otherwise does not use the
Resident's financial resources to fulfill Resident's financial obligations to Facility for
services and supplies provided to Resident in accordance with the Admission
Agreement, then Responsible Person shall be personally liable for payment up to the
dollar value of Resident's financial resources. Responsible Person is also obligated to
pay Facility for all losses or damages in by Facility by the failure of the
Responsible Person to fulfill his/her duties under the Admission Agreement. Failure to
do so will result in legal action by Facility to assure payment for amounts that are
Resident's obligations. In the event that Facility initiates any legal actions or
proceedings to collect payments due from Resident and Responsible Person under this
Agreement, or to enforce Responsible Person's obligations under the Admission
Agreement, then Resident and Responsible Person shall pay all damages, attorneys'
fees and costs incurred by Facility in pursuing the enforcement of Resident's and/or
Responsible Person's financial or other obligations under the Admission Agreement.
5. If Responsible Person fulfills Responsible Person's obligation under this
Agreement to use Resident's resources to pay for the room, board, care and services
provided to Resident, then Responsible Person shall not be held personally liable for the
Resident's charges. If, however, Responsible Person does not fulfill Responsible
Person's obligation under this Agreement, then Responsible Person shall be liable to
Facility for whatever loss Facility sustains as a result of the Responsible Person's breach
of this Agreement. This Agreement shall not be construed or operate as a third part
guaranty and Responsible Person is liable hereunder in an amount up to the dollar
value of Resident's financial resources.
6. This Agreement shall bind Responsible Person and Responsible Person's
executors, heirs, administrators and assigns, and the benefits hereof shall inure to
Facility, its successors and assigns.
7. Responsible Person is obligated to perform all provisions in the
Admission Application related to Responsible Person.
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8. The Responsible Person attests that the information set forth in the
Application Agreement is true and correct to the best of his or her knowledge,
information and belief.
9. The Responsible Person acknowledges that he or she has received a co
of the Admission Agreement and understands the terms and conditions contained
therein.
10. Responsible Person acknowledges he or she has reviewed this
Responsible Person Agreement and understands the information set forth herein.
IN WITNESS WHEREOF, the parties, intending to b legally bou d hereb , have
signed this Responsible Person Agreement on this
20x7 day of
Witness
Resp sible
Person
Witness --1? /
?7
Authorized Representative Facility's
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e
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
V. No. 2009-1779 Civil Term
SHARON L. POTTEIGER,
Respondent CIVIL ACTION - EQUITY
PETITION FOR PRELIMINARY RYTUNCMON
AND NOW COMES Petitioner, Church of God Home, Inc. ("Petitioner"), by and
through its attorneys, SCHUTJER BOGAR LLC, and files the within Petition against
Respondent, Sharon L. Potteiger ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in
support thereof, avers:
1. Respondent entered into an Admission Agreement ("Agreement") with
Petitioner as a condition of the admission of her father, Robert Musgrave ("Mr.
Musgrave"), to Petitioner's skilled nursing facility. See Admission Agreement attached
to Complaint as Exhibit "A."
2. In the Agreement, Petitioner was assigned Robert Musgrave's rights to
Medical Assistance benefits (hereinafter "the Assignment Clause"). See Complaint.
3. Accordingly, Petitioner now stands in the shoes of Robert Musgrave and
has assumed his rights with respect to his Medical Assistance benefits. See Horbal v.
Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) ("[A]ssignee stands in the shoes of the
assignor and assumes the rights of the assignor.").
ORIGNAL
r
4. Petitioner cannot exercise its rights to Mr. Musgrave"s Medical Assistance
benefits until the Cumberland County Assistance Office ("CAO") processes and
approves the application for Medical Assistance benefits, which cannot be done until
Respondent provides the documentation the CAO requires.
5. Respondent's failure to provide the documentation that the CAO requires
to process and approve her father's application for Medical Assistance benefits breaches
the Assignment Clause and interferes with Petitioners rights to the Medical Assistance
benefits.
6. The very nature of Respondent's breach presents an issue of immediate
and irreparable harm to Petitioner, as Petitioner cannot realize the benefit of the bargain
promised to it under the Assignment Clause - specifically, its right to Robert
Musgrave's Medical Assistance benefits, and by extension, its right to be compensated
for the skilled nursing services it has provided and continues to provide to
Respondent's father - until Respondent provides the CAO the documentation it needs
to process and approve her father's application.
7. The requested injunction would restore the parties to the status quo as it
existed immediately prior to Respondent's breach of the Agreement.
8. Greater injury would result from the denial of the requested injunction
than from the granting of the same. Absent the injunction, without the documentation
necessary to secure Medical Assistance benefits, the Cumberland County Assistance
Office will deny the application for Medical Assistance benefits, and Petitioner's
2
s
ownership rights in those benefits and its ability to receive compensation for the skilled
nursing services it has provided and continues to provide to Robert Musgrave under
the Agreement will be forever lost.
9. Petitioner's right to relief is clear.
10. Petitioner lacks an adequate remedy at law, as upon information and
belief, at all times material hereto, Respondent and her father have been financially
unable to fully compensate Petitioner for the services that it has rendered and continues
to render to Respondent's father.
11. A bond in the amount of $100.00 should be adequate in the event that it is
later determined that the issuance of the instant petition was in error.
[REMANDER OF PAGE INTENTIONALLY LEFT BLANK]
3
WHEREFORE, Petitioner respectfully requests that the Court schedule a hearing
on its request for injunctive relief and thereafter issue a decree ordering specific
performance of the contractual duty of Respondent.
Respectfully submitted,
SCHUTJER Boot LLC
Dated: 3 -z? O
BY. LIZ
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Anthony T. Lucido
Attorney I.D. No. 76583
(717) 909-0353
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No.: (717) 909-5925
Attorneys for Petitioner
4
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GJ`S
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CASE NO.: 09-1779
AFFIDAVIT OF SERVICE
Church of God Home, Inc.
VS.
Sharon L. Potteiger
Commonwealth of Pennsylvania
County of Dauphin ss.
I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 6:58 PM on
04/06/2009, I served Sharon L. Potteiger at 478 Wolf Bridge Road, Carlisle, PA 17013 in the manner described
below:
® Defendant(s) personally served.
Adult family member with whom said Defendant(s) reside(s).
Relationship is
? Adult in charge of Defendant(s) residence who refused to give name and/or relationship.
? Manager/Clerk of place of lodging in which Defendant(s) reside(s).
? Agent or person in charge of Defendant's office or usual place of business.
? Other:
an officer of said Defendant's company.
a true and correct copy of Notice to Defend; Complaint issued in the above captioned matter.
Description:
Sex: Female - Age: 50 - Skin: White - Hair: Black - Height: 5' 07" - Weight: 165
X
Sworn to and sub cribd before me on this J n Shinkowsky
-VftN day of 10 20( ' inkowsky Inve ti tions
316 Fawn Ridge or. h
Harrisburg, PA 110
(800) 276-0202
NOTARY PUBLIC
Atty File#: - Our File# 6841
Law Firm: Schutjer Bogar LLC
Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102
Telephone: (717) 909-5925
COMMONWEALIH OF PENNSYLVANIA
NOTARIAL SEAL,
Erin M. Johnson, Notary Public
Lower Paxton Township, Dauphin County
M commission ex Tres November 18, 2012
ORIGINAL
DOFF
OF TH PPo n-;(.1NOTARY
21199 APR 15 PM 3: `0 1
PrN
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
V. No. 2009-1779 Civil Term
SHARON L. POTTEIGER,
Respondent CIVIL ACTION - EQUITY
STIPiJLATION FOR ENTRY OF EWUNCTION
Church of God Homes, Inc. ("Petitioner') and Sharon L. Potteiger
("Respondent") stipulate and agree to the following:
1. On or about March 20, 2009, Petitioner filed a Complaint against
Respondent.
2. The Complaint sets forth a single claim against Respondent based on her
failure to specifically perform the terms of the Admission Agreement ("Agreement")
entered into with Petitioner. See Complaint Exhibit "A." Specifically, the Complaint
alleges that Respondent failed to secure the Medical Assistance benefits on behalf of her
father, Robert Musgrave ("Mr. Musgrave"), pursuant to the Agreement.
3. An application for Medical Assistance benefits was filed on behalf of Mr.
Musgrave and that application currently is pending before the Cumberland County
Assistance Office of the Department of Public Welfare.
4. The parties agree to the entry of an Order directing Respondent to provide
any and all records within their possession or control as required by the Cumberland
County Assistance Office to determine the eligibility of Respondent for Medical
ORIGINAL
..r
Assistance benefits within fifteen (15) days of the date of the Order adopting this
Attorney for Petitioner
Stipulated Injunction. The parties also agree that Respondent will work diligently to
secure any and all other documents or verifications required by the Cumberland
County Assistance Office to obtain Medical Assistance benefits, and will obtain those
documents within thirty (30) days of the date of the Order adopting this Stipulated
Injunction. The Order is attached as Exhibit "A."
5. Petitioner agrees to withdraw, without prejudice, its Petition for a
Preliminary Injunction.
6. The parties agree that failure to abide by the terms of this Stipulation and
the Order adopting the same constitutes contempt of Court and may result in sanctions
imposed by the Court.
Dated: 5 7 10?
Dated: J L116
By:
Respectfully submitted,
By:
Sharon L. ttiger
2
' Brandon S. Williams,
00
ExHIBIT""Alf
(TO STIPULATION FOR ENTRY OF INJUNCTION
-4--
IN THE COURT OF COMMON FLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
V.
SHARON L. POTTEIGER,
Respondent
No. 2009-1779 Civil Term
CIVIL ACTION - EQUITY
ORDER
AND NOW, this day of
2009, in consideration of the
parties' Stipulated Agreement, it is hereby ORDERED AND DECREED that within
fifteen (15) days of the date of this Order, Sharon L. Potteiger shall provide any and all
records in her possession that are required by the Cumberland County Assistance
Office for the pending application to determine the eligibility of Robert Musgrave for
Medical Assistance benefits. Sharon L. Potteiger shall also diligently work to secure any
and all other documents or verifications required by the Cumberland County
Assistance Office in order to obtain benefits on behalf of her father, Robert Musgrave,
within thirty (30) days.
BY THE COURT
1•
OF THE ? 0-NOTARY
2009 MAY-8 Pty 12; 52