HomeMy WebLinkAbout09-2031Q/
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2009- aU31 CIVIL TERM
SANDRA L. DIEUDONNE,
Defendant
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
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
SANDRA L. DIEUDONNE,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2009- a o 31
CIVIL TERM
COMPLAINT
NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a
Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets
forth the following:
1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Sandra L Dieudonne, is an adult individual with a residence address of
2 Lumber Street, Apt. 1, Littlestown, Adams County, Pennsylvania 17340.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
4. On or about September 23, 2008, Sandra L. Dieudonne sought to be admitted to
the Shippensburg Health facility.
5. On or about September 23, 2008, Sandra L. Dieudonne executed an Admission
Agreement. A true and correct copy of the Admission Agreement is attached hereto as Exhibit
"A" and is incorporated.
6. Pursuant to the Admission Agreement, Sandra L. Dieudonne would be
responsible to pay any costs of care which were not covered by a third party payer.
7. On or about September 23, 2008, Sandra L. Dieudonne became a resident of the
Shippensburg Health facility and remained a resident until February 1, 2009.
8. As of February 1, 2009, Sandra L. Dieudonne owed Shippensburg Health the sum
of $25,190.32 for the costs of care provided by Shippensburg Health to her. A true and correct
copy of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is
incorporated.
9. Demand has been made upon Sandra L. Dieudonne to pay the amount due.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. SANDRA L. DIEUDONNE
10. Plaintiff incorporates by reference paragraphs one through nine as though set
forth at length.
11. Sandra L. Dieudonne has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
12. As a consequence of that breach, Shippensburg Health is owed the sum of
$25,190.32 to February 1, 2009.
13. The accrued debt consists of the private pay obligation of Sandra L. Dieudonne.
14. The Admission Agreement bound Sandra L. Dieudonne 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 1.5% per month. These finance charges total $1,179.13 as of March
11, 2009 and continue to accrue.
16. The Admission Agreement provides for the recovery of reasonable attorney fees
and costs incurred by Shippensburg Health to collect a debt due and owing to Shippensburg
Health.
WHEREFORE, Plaintiff requests judgment in its favor and against Sandra L. Dieudonne
for the sum of $25,190.32 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 v. SANDRA L. DIEUDONNE
17. Plaintiff incorporates by reference paragraphs one through sixteen as though set
forth at length.
18. During the period of her residency at the facility, Sandra L. Dieudonne enjoyed
the benefit of care and services provided to her by Shippensburg Health.
19. Sandra L. Dieudonne has failed and refused to pay for the costs of her care and
services provided by Shippensburg Health.
20. Sandra L. Dieudonne has been unjustly enriched by her use and enjoyment of the
services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Sandra L. Dieudonne
for the sum of $25,190.32 plus interest, costs and expenses, late fees and any additional amount
coming due to the date of award and attorney fees and costs.
Respectfully submitted,
O EN, B &
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/dieudonne/complaint. pld
VERIFICATION
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they 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 unworn falsifications to authorities.
DATE: t?-o2G -O 9 /C1?/?
Deb Black
Business Office Coordinator
SHIPPENSBURG HEALTHCARE CENTER
ADMISSION AGREEMENT
THIS AGREEMENT, made this 4.3 day of ,
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
rx?,c.? . JtC
"SHIPPENSBURG") and
(hereafter "Resident"), previously residing at (Street Address and Post Office
Box)
and
(hereafter
"Legal Representative"), residing at (Street Address and Post Office Box)
The Legal
Representative's relationship with the Resident is that of
The staff of SHIPPENSBURG will take whatever time is necessary to answer
all of your questions. Please continue to ask questions
until you are sure that you understand.
1. PROVISION OF SERVICES
A. NURSING SERVICES: SHIPPENSBURG will provide the Resident with
routine nursing services, semi-private accommodations, three meals each day
(except as otherwise medically indicated), blankets, bed linens, towels and
wash cloths, laundering of blankets, linens, towels, and wash cloths,
housekeeping services, and activity programs and social services as
established by the facility, as identified on the Rate Schedule. The Rate
Schedule is attached to this Agreement and is incorporated herein as if set forth
in full. The Rate Schedule sets forth the list of supplies and services included in
SHIPPENSBURG's daily rates, those supplies and services which are not
covered by the daily rates for which the Resident will be separately charged,
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EXHIBIT "A"
and those supplies and services covered by the Medicare and/or Medicaid
programs for enrolled Residents.
Federal and state laws and regulations change regularly and frequently
require changes related to the care and services SHIPPENSBURG provides.
Additionally, other financial factors may require SHIPPENSBURG to make
changes related to provision of its care and services. On this basis, the Rate
Schedule may be changed, upon notice to the resident.
B. ANCILLARY SERVICES AND SUPPLIES: SHIPPENSBURG will also
provide ancillary services and supplies as set forth in the Rate Schedule, and
private accommodations upon the direction of the Resident's physician. The
ancillary services and supplies are subject to change from time to time at the
discretion of SHIPPENSBURG.
C. OUTSIDE PROVIDERS AND NON-FACILITY SERVICES:
SHIPPENSBURG makes available, from time to time, the services of outside
providers and non-facility services. These services will be available under
SHIPPENSBURG's policies and procedures, and at the Resident's sole
expense unless the charges for such services are covered by a third party
payer. Should the Resident arrange for the services of outside providers, the
providers must be properly licensed or registered under state and federal law,
and must comply with all SHIPPENSBURG policies and procedures, including,
but not limited to, providing SHIPPENSBURG with documented proof of their
legally required liability insurance coverage. All outside providers must be
approved in writing by SHIPPENSBURG before providing any services. At
SHIPPENSBURG's sole discretion, only providers deemed by
SHIPPENSBURG to fulfill all of the requirements set forth in federal and state
law, as well as SHIPPENSBURG's policies and procedures, may provide
services to Residents.
The Resident recognizes and agrees that all outside providers, including
those designated by SHIPPENSBURG, are independent contractors. The
Resident recognizes and agrees that such providers are not associates or
agents of SHIPPENSBURG, and that SHIPPENSBURG is not liable for any
outside provider's acts or omissions. The Resident shall be solely responsible
for payment of all charges of any provider who renders care to the Resident in
SHIPPENSBURG, unless the charges are covered by a third party payer.
Furthermore, the Resident agrees to confirm that any Resident initiated,
approved outside provider (i.e. private duty nurse, etc.) has worker's
compensation insurance coverage as required by law, as well as liability
insurance. To the extent that the outside provider does not have the legally
required worker's compensation insurance coverage, the Resident will provide
and pay for such coverage.
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11. RESIDENT'S RIGHTS
SHIPPENSBURG welcomes all persons in need of its services
and does not discriminate on the basis of age, disability, race, color,
national origin, ancestry, religion, or sex. Furthermore, SHIPPENSBURG does
not discriminate among persons based on their sources of payment.
A. Conent for Treatment
1. SHIPPENSBURG SERVICES: By signing this Agreement,
the Resident consents to SHIPPENSBURG providing routine nursing and other.
health care services and administering all medication as directed by the
attending physician, or when the attending physician is unavailable,
SHIPPENSBURG's Medical Director. SHIPPENSBURG is not obligated to
provide the Resident with any medications, treatments, special diets or
equipment without specific orders or directions from the Resident's physician or
SHIPPENSBURG's Medical Director. From time to time SHIPPENSBURG may
participate in training programs for persons seeking licensure or certification as
health care workers. In the course of this participation, care may be rendered
to the Resident by such trainees under supervision as required by law.
Consent to routine nursing care provided by SHIPPENSBURG shall include
consent for care by such trainees.
2. PHYSICIAN SERVICES: The Resident acknowledges that
he or she is under the medical care of a personal attending physician, and that
SHIPPENSBURG provides services based on the general and specific
instructions of that physician, or when unavailable, SHIPPENSBURG's Medical
Director. The Resident has a right to select his or her own attending physician.
If, however, the Resident does not select an attending physician, or is unable to
select an attending physician, an attending physician may be designated by
SHIPPENSBURG or in accordance with state law. All attending physicians
must meet and conform with all of SHIPPENSBURG's policies and procedures,
and are subject to the terms set forth in the Outside Providers and Non-facility
Services section of this Agreement.
3. RIGHT TO REFUSE TREATMENT: The Resident has the
right to refuse treatment and to revoke consent for treatment. The Resident
also has the right to be informed of the medical consequences of such refusal
or revocation of consent, and to be informed of alternate treatments available.
Where, in the opinion of the attending physician or by judgment of a court of
law, the Resident is determined to be mentally incompetent to make a decision
regarding refusal of treatment, the decision to refuse treatment may be made by
a Legal Representative or other surrogate decision-maker, subject to state and
federal law.
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B. Resident's Personal Proaertv
SHIPPENSBURG strongly discourages the keeping of valuable jewelry,
papers, large sums of money, or other items considered of value in
SHIPPENSBURG. However, the Resident shall be permitted to retain and use
personal clothing and possessions as space permits, unless to do so would
infringe upon the right of other residents or unless determined medically
inadvisable as documented by the Resident's physician in the Resident's
medical record. SHIPPENSBURG shall make reasonable efforts to properly
handle and safeguard the Resident's personal property in SHIPPENSBURG.
The Resident agrees to inform SHIPPENSBURG of all valuable property upon
admission. If, at any time during the Resident's stay, new items of value are
added to the Resident's possessions in SHIPPENSBURG, the Resident agrees
to so inform SHIPPENSBURG's Administrator or designee.
The Resident is responsible for obtaining at his or her own expense any
insurance coverage necessary to cover potential damage to or loss of any of
Resident's personal property. SHIPPENSBURG shall not be liable for damage
to or loss of any of Resident's personal property. Should the Resident lose his
or her property, or believe that his or her property has been otherwise removed
from his or her possession, the Resident agrees to follow SHIPPENSBURG's
procedure for filing reports of lost or stolen property.
In the event that Resident is transferred or discharged from
SHIPPENSBURG, or if the Resident expires, the Resident hereby authorizes
SHIPPENSBURG to transfer the Resident's personal property to the Resident's
Legal Representative, or to any duly authorized representative of Residents
estate. If the Resident's personal property is not claimed or removed within
twenty four (24) hours of the Resident's transfer or discharge, or expiration, the
Resident authorizes SHIPPENSBURG to place his personal property into
storage until claimed. Standard daily storage charges will continue while the
Resident's property remains in SHIPPENSBURG.
Should the Resident's property fail to be claimed within fourteen (14)
days of the Resident's transfer, discharge, or expiration, the Resident and
SHIPPENSBURG hereby agree to a storage and sale arrangement. Under this
arrangement, SHIPPENSBURG agrees to bear any and all costs of the storage
of the Resident's property, not including any insurance thereon. However, in
consideration of SHIPPENSBURG's storage of the Resident's property, should
the Resident's property fail to be claimed within thirty (30) days of placement by
SHIPPENSBURG into storage, the Resident hereby agrees that
SHIPPENSBURG may dispose of the Resident's property with and at
SHIPPENSBURG's discretion, including retaining all proceeds from any sale
thereof.
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C. Resident's Records
1. CONFIDENTIALITY: Information included in the Residents
medical records is confidential. Unauthorized persons shall not be allowed to
review these records without the Resident's written consent, except as required
or permitted by law.
2. CONSENT TO RELgA E BY SHIPP NS13URG: The Resident
authorizes SHIPPENSBURG to release all or any part of the Residents medical
or financial records to any person or entity which has or may have a legal or
contractual obligation to provide the Resident with medical services, or to pay
all or a portion of the costs of care provided to the Resident, including but not
limited to hospital or medical services companies, insurance companies,
workers' compensation carriers, welfare funds, and/or the Resident's employer.
The Resident also authorizes release of information from medical or financial
records to any medical professional or institution responsible for the Residents
medical or nursing care when the Resident is transferred or discharged from
SHIPPENSBURG. The Resident hereby releases SHIPPENSBURG from any
liability for damages or other loss suffered in or incurred by the Resident and
arising out of or directly or indirectly related to the reliance by the facility upon
the foregoing authorization.
3. PHOTOGRAPHS: The Resident authorizes SHIPPENSBURG to
photograph or videotape the Resident as a means of identification or for health
related purposes. The photographs or videotapes may also be used to help
locate the Resident in the event of an unauthorized absence from
SHIPPENSBURG, but shall otherwise be kept confidential. If SHIPPENSBURG
intends to use the photograph or videotape for purposes other than those noted
above, SHIPPENSBURG shall get written permission from the Resident in
advance of such use (SHIPPENSBURG sometimes requests Resident to permit
the use of their photograph and written impressions about SHIPPENSBURG in
marketing and other public information materials). The Resident retains the
right to refuse the taking of a photograph at any particular time.
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D. RESIDENT'S RESPONSIBILITIES
1 • RULES AND REGULATIONS: The Resident agrees that
SHIPPENSBURG may, to maintain orderly and economical operations, adopt
reasonable rules and regulations to govern the conduct and responsibilities of
the Resident. These rules and regulations include that SHIPPENSBURG is a
SMOKE FREE CAMPUS, with no smoking or use of smokeless tobacco
products permitted in all its buildings, grounds and parking areas, for new
residents, their visitors, staff, vendors, physicians, contractors, and volunteers.
The Resident agrees to follow those rules and regulations. It is understood that
these rules and regulations may be amended from time to time as
SHIPPENSBURG may require. Any changes to the rules and regulations shall
be given to the Resident in writing. NOTE: Some residents admitted prior to the
effective date of the SMOKE FREE CAMPUS Policy will be allowed to continue
smoking in special designated areas as required by Federal regulations.
2. DIET: The Resident understands that his or her diet is medically
prescribed and, therefore, must be monitored by SHIPPENSBURG. The
Resident agrees to consult with Nursing or Dietary staff when food or
beverages are brought into SHIPPENSBURG.
3. MEDICATIONS: No medications or drugs may be brought upon
SHIPPENSBURG premises unless the medications or drugs are labeled
according to the requirements of state and federal law. Packaging of
medications must be compatible with SHIPPENSBURG's medication
distribution system. No drugs or medications may be brought into
SHIPPENSBURG unless they are delivered directly to the nurses' station.
. 4. CARE OF SHIPPENSBURG'S PROPERTY: To preserve the
value of SHIPPENSBURG's property for future residents' use, the Resident
agrees to use due care to avoid damaging SHIPPENSBURG's property and
premises. The Resident shall be responsible for the costs of repair or
replacement of SHIPPENSBURG's property damaged or destroyed by the
Resident. However, the Resident shall not be responsible for such damage as
is to be expected from ordinary wear and tear.
5. CARE OF THE RESIDENT'S ROOM: SHIPPENSBURG
encourages the Resident to have a SHIPPENSBURG-like environment, and will
attempt to accommodate all reasonable requests to individualize resident
rooms. For safety reasons, SHIPPENSBURG must approve any addition or
rearrangement of furniture, hanging of pictures, posters, or other similar
activities.
L
6. INDEMNIFICATION: The Resident hereby agrees to indemnify
and hold harmless SHIPPENSBURG, its officers, directors, agents, and
employees from and against any and all claims, demands or causes of action
for injury or death to person or damage to property, including all costs and
attorneys fees incurred in defending any claim, demand or cause of action
which Is caused by the Resident and which is not caused by any willful or
negligent action of SHIPPENSBURG. This indemnification includes, but is not
limited to, all claims, demands or causes of action stemming from the acts or
omissions of the Resident, including but not limited to Resident's refusal of any
nursing care, medical or other treatment, or any other item or service deemed
necessary by SHIPPENSBURG or any other treating health professional.
111. POLICY REGARDING THE IMPLEMENTATION
OF THE PATIENT SELF-DETERMINATION ACT
The following information is being provided to the Resident as a result of
a federal law which requires certain health care institutions, including
SHIPPENSBURG, to disclose to the Resident his or her rights under federal
and state law to make decisions regarding his or her health care.
A. INTRODUCTION.
1. SHIPPENSBURG recognizes and appreciates the dignity and value
of each Resident's life, and the right of each Resident to make decisions
regarding his or her care.
2. SHIPPENSBURG recognizes the Resident's right to have these
decisions made on his/her behalf by a substitute decision-maker in accordance
with state law when the Resident is no longer able to make them.
3. SHIPPENSBURG recognizes the right of each Resident to utilize
those health care advance directives recognized under state law, and will honor
such advance directives developed and implemented in accordance with state
law and consistent with the level of care SHIPPENSBURG is licensed to
provide. A health care advance directive is a written document that states
choices for health care and/or names or precludes those individuals who the
Resident wishes to make those choices. These choices may include the refusal
of certain types of care. A Living Will and a Durable Power of Attorney for
Health Care are examples of such advance directives.
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PENNSYLVANIA LAW PERMITS SHIPPENSBURG TO REFUSE TO
HONOR DECISIONS BY THE INDIVIDUAL YOU APPOINT AS YOUR
AGENT IN AN ADVANCE DIRECTIVE OR BY A "HEALTH CARE
REPRESENTATIVE" WHO SEEKS TO MAKE SUCH DECISIONS FOR
YOU UNDER PENNSYLVANIA LAW IF SHIPPENSBURG HAS A GOOD
FAITH BELIEF THAT THE INDIVIDUAL IS NOT REALLY AUTHORIZED
TO MAKE DECISIONS FOR YOU UNDER THE LAW OR THAT THE
DECISIONS BEING MADE ARE NOT CONSISTENT WITH THE RULES
FOR SUCH INDIVIDUALS TO MAKE DECISIONS ON YOUR BEHALF
ESTABLISHED BY PENNSYLVANIA LAW.
B. HEALTH CARE ADVANCE DIRECTIVE. A health care advance
SHIPPENSBURG. However. If the Resident has a health care advance
directive. he or she must provide a validly executed original advance directive
to HIPPENSBURG's Administrator or desi4nee so that it can be reviewed and
made a part of his or her medical record. It is essential that SHIPPENSBURG
receives a validly executed, orioinal document or documents to ensure that it is
authorized to follow the directives therein.
RECENT CHANGES IN PENNSYLVANIA LAW (discussed further below
in Subsection C) PROVIDE SOME ADDITIONAL REASONS TO
CONSIDER HAVING AN ADVANCE DIRECTIVE.
WHILE SHIPPENSBURG WILL REQUIRE A "HEALTH CARE
REPRESENATIVES" TO CERTIFY THAT THEY HAVE KNOWLEDGE
OF THE INCAPACITATED PERSON'S PREFERENCES, VALUES,
AND MORAL AND RELIGIOUS BELIEFS, THE LAW PERMITS THEM
TO MAKE SOME DECISIONS BASED ON THEIR OWN EVALUATION
OF THE INFORMATION ABOUT THE INCAPACITATED PERSON'S
CONDITION WHERE INSTRUCTIONS FROM THE INCAPACITATED
PERSON IS LACKING.
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C. HEALTH CARE REPRESENTATIVE. PENNSYLVANIA LAW PERMITS
AN INDIVIDUAL QUALIFYING AS A "HEALTH CARE REPRESENTATIVE"
UNDER 20 PA. C.S. § 5461 TO MAKE HEALTH CARE DECISIONS FOR
INCAPACITATED PERSONS, WHO HAVE AN END-STAGE MEDICAL
CONDITION OR ARE PERMANENTLY UNCONSCIOUS, WITHOUT THAT
AN ADVANCE DIRECTIVE CAN PROVIDE SPECIFIC INSTRUCTIONS
FOR AND ALSO LIMIT WHO CAN QUALIFY AS A "HEALTH CARE
REPRESENTATIVE" OR CAN PROVIDE THEM WITH ADDITIONAL
AUTHORITY TO ACT ON ONE'S BEHALF. IF A RESIDENT WISHES
TO PLACE SUCH LIMITS ON THE ABILITY OF OTHERS TO ACT AS
THEIR "HEALTH CARE REPRESENTATIVE" OR TO PROVIDE
ADDITIONAL INSTRUCTIONS FOR THEM, THE RESIDENT SHOULD
CONSIDER HAVING A WRITTEN ADVANCE DIRECTIVE THAT
STATES THEIR WISHES; AND, THE RESIDENT MAY WISH TO
CONSULT WITH THEIR FAMILY AND LEGAL COUNSEL ON THIS
QUESTION.
D. ASSISTANCE AVAILABLE.
1. Questions about SHIPPENSBURG's policies regarding health care
decision-making and/or advance directives may be presented to
SHIPPENSBURG's Administrator.
2. Questions negarding whether and how to execute health care
advance directives and about their content should be discussed with the
Resident's family, ahysician and attorney.
3. SAMPLE HEALTH CARE ADVANCE DIRECTIVE FORMS
included in the current Pennsylvania Living Will Statute accompanies this
Agreement for the Resident's information.
4. Resident should consult with their family, physician, and
attorney before using any Advance Directive Forms.
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IV. CAPACITY OF RESIDENT AND GUARDIANSHIP
If the Resident is or becomes unable to understand or communicate, and
is determined to be incapacitated by the Resident's physician, in the absence of
the Resident's prior designation of an authorized Legal Representative, or upon
the unwillingness or inability of the Legal Representative to act,
SHIPPENSBURG shall have the right to commence a legal proceeding to
adjudicate the Resident incapacitated. As a result of such a legal proceeding
SHIPPENSBURG shall have a court appoint a legal guardian for the Resident.
SHIPPENSBURG also shall have the right to commence a legal proceeding to
have a court replace an authorized Legal Representative with a new one or with
a legal guardian when SHIPPENSBURG has a good faith belief that the Legal
Representative is not acting in the best interests of the Resident. The cost of
the legal proceedings, including attorney's fees and costs, if not covered by the
Commonwealth, shall be paid promptly by the Resident or the Resident's
estate.
V. FINANCIAL ASPECTS OF THE AGREEMENT
A. Local Reipre"ritative
1. STATUS. While not legally required, if the Resident is unable to make
decisions for himself or herself, a Legal Representative should be available to
make certain decisions on behalf of the Resident. For the purposes of this
Agreement, the Resident's Legal Representative is the person selected by the
Resident and defined under state and federal law as the Resident's responsible
person, or as the person recognized under state law as having the authority to
make health care and/or financial decisions for the Resident. The Legal
Representative may or may not be court appointed, may be an attomey-in-fact
acting under a durable power of attorney for health care, guardian, conservator,
next-of-kin, or other person allowed to act for the Resident under state law. If
Legal Representative status has been conferred by a court of law or through
appointment by the Resident, verification of such status must be provided to
SHIPPENSBURG at the time of Admission. Such verification includes providing
SHIPPENSBURG with a certified copy of any court order, or a validly executed
original Power of Attorney or other legal document.
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2. REQUIREMENTS. For purposes of this Agreement, LEGAL
REPRESENTATIVES ARE REQUIRED TO SIGN THIS AGREEMENT FOR
ADMISSION, AND AGREE TO DISTRIBUTE TO SHIPPENSBURG, FROM
THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR
ITEMS/SERVICES PROVIDED TO THE RESIDENT. Legal Representative is
contractually bound by the terms of this Agreement and may become personally
liable for failure to perform their fiduciary duties under the Agreement. Legal
Representatives are also required to produce financial documentation as proof
of the Resident's ability to pay for charges when due. Wherever this
Agreement refers to the Resident's financial obligations under this
Agreement, the term "Resident" shall be construed to include the
obligations of any Legal Representative to act on behalf of Resident.
B. Financial Arranceme ts
1. INCOME AND ASSETS/ CHANGES TO INCOME AND ASSETS: It
is essential that the Resident advise SHIPPENSBURG of the Resident's
income and assets, and to communicate changes in the Resident's income or
assets to SHIPPENSBURG as quickly as possible. The Resident hereby
agrees to notify SHIPPENSBURG ninety (90) days prior to the time when the
Resident has reason to believe that his income and assets will no longer be
sufficient to fulfill his financial obligations under the terms of this Agreement.
2. MEDICAL ASSISTANCE. Generally, when private funds are
depleted, residents apply for Medical Assistance benefits under Title XIX of the
Social Security Act and Article IV of the Pennsylvania Public Welfare Code.
The Medical Assistance application process can be complicated, and the
processing time can be lengthy. SHIPPENSBURG is experienced in the
Medical Assistance Application process, and can be of great assistance to the
Resident in this process. To be of assistance, SHIPPENSBURG must have
accurate record of the history and depletion of the Resident's income and
significant assets.
3. DISCLOSURE FORM. On this basis, please set forth the
Resident's income and assets below:
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Income
Social Security:
Account Number:
Monthly Income:
-*At IV
?cr
(p3 oc--6
Payee:
Pension:
Account Number:
Monthly Income:
Financial Institution:
Payee:
Trusts:
Account Number(s):
Monthly Income:
12
Financial Institution(s):
Beneficiary(s):
Type of Trust(s):
Other Income (please describe): (r
I'll
Payee(s):
Assets
ResidenggMe All Estate: n 15
Address:
13
I hicle(g):
Year, Make and Model
State of Registration:
Bank Accounis•
Account Number(s):
Financial Institution(s):
Insurance policies:
Account Number(s):
Financial Institution(s):
Beneficiary:
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Other Slanificant Assets (please describe):
Liabilities
Describe nature and extent:
Has a Will been completed?:
If yes, Executor's Name:
Yes No
Executor's Address:
15
S. Receipt of Income/ Representative Payee. Many Residents find
security in appointing SHIPPENSBURG as the "Payee" or "Representative
Payee" of the Resident's income, including social security income. By
appointing SHIPPENSBURG as the "payee" or the "Representative Payee", the
Resident directs that his or her income be directed to SHIPPENSBURG for the
purposes of paying for the Resident's care and services. Any excess funds
accumulated are refunded to the Resident or the Resident's Legal
Representative on or before the tenth (10) day of the month following the
receipt of the benefits. This is not required. However, if the Resident is
interested in aaaointina SHIPPENSBURG as the Resident's "Payee" or
"Representative Payee". please notify SHIPPENSBURG's Administrator or _the
Administrator's designee. SHIPPENSBURG will assist you in making these
arrangements.
6. PRIVATE RESIDENTS: A Resident is considered private (or private pay)
when no state or federal program is paying for the Resident's room and board.
A private-pay Resident may have private insurance or another third party, which
pays all or some of his or her charges.
a.) Daily Rate. The Resident agrees to pay SHIPPENSBURG's private
pay per diem rate as described in the Rate Schedule. The Resident agrees to
pay SHIPPENSBURG in advance for one month's private daily rate. For each
additional month's stay, the Resident agrees to pay SHIPPENSBURG in
advance on or before the tenth (10th) day of the month. Any unused advance
payment shall be refunded to the Resident ninety (90) days after the Resident's
discharge if the Resident becomes covered by Medicaid or Medicare, or leaves
SHIPPENSBURG before the end of the month.
b.) Rate Adjustments. SHIPPENSBURG may occasionally need to
increase the daily rate or optional service charges. If this happens, the
Resident shall receive thirty (30) days advance written notice of the rate
adjustment. SHIPPENSBURG shall provide notice to the Resident, and if
known, the Resident's Legal Representative. When a notice of a rate
adjustment is received, the Resident can choose to end this Agreement by
providing written notice to the Administrator. If the Resident fails to leave
SHIPPENSBURG prior to the effective date of the rate adjustment, the Resident
shall be considered to have consented to the increase.
16
0 Private Insurance. Even when there is private insurance coverage,
the Resident remains primarily responsible for Davina all of SHIPPENSBURG's
charges.- Where the Residents private insurer is a managed care plan with
which SHIPPENSBURG has a contract, SHIPPENSBURG agrees to invoice the
managed care plan directly for the Resident's care and services. However, all
charges that are not covered by the managed care plan are the responsibility of
the Resident. These non-covered charges include but are not limited to any
coinsurance and/or deductible amounts which the managed care plan requires
the Resident to pay, to the extent allowed under federal and state laws. Where
the Residents private insurer is not a managed care plan with which
SHIPPENSBURG has a contract, SHIPPENSBURG will invoice the Resident,
who is primarily responsible for payment of the invoice.
7. MEDICAL ASSISTANCE (MEDICAID) RESIDENTS: A Medicaid Resident is
one who receives benefits from the state Medicaid program for all or a majority
of his or her room and board charges. The services currently covered by
Medicaid are set forth in the attached Rate Schedule, which is subject to
change. SHIPPENSBURG makes no guarantee of any kind that the
Resident's care will be covered by Medicare, Medicaid, or any third party
Insurance or other reimbursement source. SHIPPENSBURG, its agents
and associates are hereby released from any liability for the Resident's
potential claim for any failure to obtain such coverage.
With respect to applying for and receiving Medical Assistance through the
Medicaid Program, SHIPPENSBURG will assist the Resident in the application
process. The Resident agrees to the following:
a.) Qualifying for Medicaid Assistance. If the Resident elects coverage
under the Medicaid Program, the Resident agrees to act as quickly as possible
to establish and maintain eligibility for Medicaid. These actions must include,
but are not limited to, taking any and all steps necessary to ensure that the
Resident's assets and income are within the required limits and that these
assets and income remain within allowable limits for Medicaid.
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b.) Providing Application Information. The Resident agrees to provide
all financial and other information required for completion of the Medicaid
application accurately and truthfully, as requested by applicable state/county
agencies. Additionally, the Resident agrees to provide this information in the
manner requested by the applicable agencies, and in compliance with any
deadlines set by the applicable agencies. Furthermore, the Resident agrees to
attend any and all interviews necessary for completion of the Medical
Assistance eligibility process, as requested by the applicable state%ounty
agencies. Failure to provide all financial and other information required for
completion and support of the Medicaid application accurately and truthfully, as
requested by applicable statelcounty agencies, may result in personal liability
for SHIPPENSBURG's charges.
c.) Keeping SHIPPENSBURG Informed. The Resident agrees to keep
SHIPPENSBURG informed of the status and progress of the Medicaid
application. The Resident agrees to provide SHIPPENSBURG with copies of
any financial and other information related to the Medicaid application, including
a copy of the completed application.
d.) Transferring Assets. If the Resident transfers assets, this transfer may
disqualify the Resident for Medicaid and/or cause a discontinuance of the
Resident's Medicaid benefits. The Resident acknowledges that this may result
in discharge of the Resident due to non-payment, and personal liability for
SHIPPENSBURG's charges.
e.) Legal Representative Controlling Resident's Funds. If the
Resident's Legal Representative has control of or access to the Resident's
income and/or assets, the Legal Representative agrees to use these funds
solely for the Resident's welfare. This includes, but is not limited to, making
prompt payment for care and services provided to the Resident as specked
and required by the terms of this Agreement. Failure to use these funds solely
for the Resident's welfare may result in personal liability for SHIPPENSBURG's
charges.
f.) Providing Financial Information. The Resident certifies that any
financial information regarding the Resident's income and assets required by
SHIPPENSBURG and provided by the Resident is complete and accurate.
g.) Daily Rate Payment. The Resident agrees to pay the costs or
SHIPPENSBURG's per diem rate as described in the Rate Schedule.
18
h.) Termination or Denial of Coverage. The Resident may remain in
SHIPPENSBURG for as long as he or she is certified eligible for Medicaid
coverage, or for as long as any share of cost owed by the Resident is paid as
due. A Resident who remains in SHIPPENSBURG after Medicaid coverage
has been denied and a final determination has been made must pay
SHIPPENSBURG charges as a private resident. In this event, the Resident will
pay based on the private rates, charges, and terms in effect at the time of
service. Where the Resident fails to pay the private rates and charges, the
Resident agrees to seek immediate placement at an alternate facility at the
earliest possible time. Residents who have not already been determined
any charges that are not covered by Medical Assistance or other third-party
pavors.after the Resident's eligibility for and effective date of Medicaid coverage
has been finally determined. Resident is expected to make pa ent to
SHIPPENSBURG while any application for Medical Assistance benefits is
pending final determination of at least their monthly income (e.g. Social
Secunty. pension) less the amount established by law for the Resident Personal
Funds Allowance (the current amount is listed on the attached Rate Schedule
Any refunds due to the Resident after the final determination of Medicaid
coverage will be made within ten (10) business days of SHIPPENSBURG's
receipt of notice of such coverage.
I.) Resident's Share of Cost. The Medicaid program reviews the available
monthly income of all persons requesting Medicaid. Based on this review, the
Medicaid program requires most Medicaid residents to pay for a reasonable
share of the cost of their care. The amount of the Resident's share of the cost
of their care can change based upon the services the Resident chooses, and
the Medicaid program can adjust the amount of the Resident's share of the cost
of their care based upon changes in the Resident's income. Payment of that
share is the responsibility of the Resident.
D Appeal of Finding of Ineligibility. Where the Resident applies for
Medical Assistance benefits, the applicable state/county agency may deny or
limit benefits. While Resident retains all legal responsibility for obtaining his or
her benefits, Resident authorizes SHIPPENSBURG to assist Resident in
making any claims and to take all other actions necessary to secure the
Resident's benefits, including, but not limited to, assisting the Resident in
appealing any state/county agency determination and requesting Interim
Assistance benefits. The Resident agrees to provide SHIPPENSBURG with all
information related to obtaining benefits upon receipt, including, but not limited
to, notices of denial. This paragraph shall not create any responsibility on
behalf of SHIPPENSBURG to obtain benefits or any portion of benefits, nor any
liability for failure to obtain same. To facilitate this authorization, but not in lieu
thereof, the Resident agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION - MEDICAID statement attached to this Agreement.
19
B. MEDICARE RESIDENTS: A Medicare Resident is one who receives
benefits from the federal Medicare program for his or her SHIPPENSBURG
care. The services currently covered by Medicaid are set forth in the attached
Rate Schedule, which is subject to change. Some additional items and services
may be also covered by Medicare. SHIPPENSBURG makes no guarantee of
any kind that the Resident's care will be covered by Medicare, Medicaid,
or any third party insurance or other reimbursement source.
SHIPPENSBURG, its agents and associates are hereby released from any
liability for the Resident's potential claim for any failure to obtain such coverage.
a.) Continuing Payment of SHIPPENSBURG Charges Pending
Eligibility. Where the Resident is not currently covered by Medicare,
the Resident agrees that while coverage is being pursued the Resident
shall pay the private pay rate as a private pay resident as described
within this Agreement. If the Resident is unable to pay the private pay
rate, the Resident agrees to pay SHIPPENSBURG an amount that is at
least equal to the Resident's monthly income from all of the Resident's
income sources. This amount, minus any amount not covered by
Medicare, shall be refunded to the Resident within thirty (30) days of
payment by Medicare should the Resident be found eligible by Medicare.
Once the Resident is determined to be eligible for Medicare, the amount
of the Resident's share of cost not covered by Medicare shall be paid to
SHIPPENSBURG on or before the tenth (10"') day of each month.
Furthermore, the Resident shall immediately pay to SHIPPENSBURG any
amount the Resident is in arrears. If payment of any outstanding amount
cannot be made immediately, the Resident shall immediately discuss same
with SHIPPENSBURG's Administrator or the Administrator's designee, and
shall make arrangements to bring his or her account into balance within the
shortest possible time.
b.) Daily Rate Payment. The Resident agrees to pay the costs of
SHIPPENSBURG's per diem rate as described in the Rate Schedule for those
supplies and services not paid for by the Medicare program.
c.) Coinsurance and Deductibles. The Resident is responsible for
payment of any Medicare coinsurance and/or deductibles that are not paid to
SHIPPENSBURG by the Medicaid program or private insurance.
d.) Limited Coverage. The Resident understands that Medicare coverage
is established by federal guidelines and not by SHIPPENSBURG. Medicare
coverage is limited in that only a specified level of care is covered for a
specified number of days (benefit period). If the Resident no longer meets
Medicare coverage criteria, coverage can be ended before the use of all allotted
days in the current benefit period.
20
e.) Expiration of Benefits. Prior to admission, the Resident must be able
to demonstrate the ability to pay SHIPPENSBURG (either privately or through
Medicaid) for services rendered after Medicare benefits expire. When Medicare
coverage expires, the Resident may remain in SHIPPENSBURG if private pay
or other payment arrangements have been made. If the Resident wishes to be
discharged from SHIPPENSBURG upon expiration of Medicare benefits, he or
she must so advise SHIPPENSBURG at the time of the Resident's admission.
If the Resident intends to become private pay when Medicare benefits expire,
the Resident agrees to pay in advance for one month's private daily rate when
the Resident changes to private pay status. No advance payment is required
from Medicare Residents who are eligible for Medicaid coverage.
C) Appeals of Denials of Coverage. Where the Resident applies for
Medicare benefits, the applicable intermediary, carrier or government agency
may deny the Resident these benefits or some portion of these benefits. Where
a denial occurs, the Resident retains all responsibility for obtaining his or her
benefits. However, the Resident authorizes SHIPPENSBURG to assist the
Resident in making all claims and to taking all other actions necessary to
secure his or her benefits, including, but not limited to, appealing any initial or
subsequent adverse determinations, including requests for Reconsideration.
The Resident agrees to provide SHIPPENSBURG with all information related to
obtaining benefits upon receipt, including, but not limited to, notices of denial.
This paragraph does not apply to benefits for which SHIPPENSBURG has
determined the Resident is not eligible, and does not affect the Resident's right
to have a Demand Bill filed. This paragraph shall not create any responsibility
on behalf of SHIPPENSBURG to obtain any portion of benefits, nor any liability
for failure to obtain same. To facilitate this authorization, but not in lieu thereof,
the Resident hereby agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION - MEDICARE statement attached to this Agreement.
8. MANAGED CARE ORGANIZATIONS: Where the Resident enrolls in or
switches the Resident's enrollment to any managed care organization
(hereafter "MCOJ, including MCOs that provide Medicare or Medicaid benefits,
the Resident agrees as follows:
a.) The Resident shall advise SHIPPENSBURG prior to enrolling in or
switching the Resident's enrollment to any MCO.
b.) The Resident acknowledges that SHIPPENSBURG is not responsible
for and has made no representations regarding the actions or decisions of any
MCO with which SHIPPENSBURG is a participating provider, including
decisions relating to a denial of coverage.
21
C-) SHIPPENSBURG will accept payment from the MCO as payment in
full only for those services and supplies covered by the MCO. The Resident is
responsible for any co-payments or other costs assigned to the Resident under
the managed care plan, or not covered by the MCO under the terms of the
managed care plan. If the Resident utilizes services which the MCO refuses to
pre-authorize, the Resident shall pay SHIPPENSBURG for those services.
Further, the Resident shall pay SHIPPENSBURG for services for which the
MCO has denied payment because the Resident failed to supply information to
the MCO, or for services which are denied subsequently by the MCO.
d.) SHIPPENSBURG reserves the right to withdraw as a participating
provider in any MCO at any time and for any reason. In the event that
SHIPPENSBURG withdraws as a participating provider, the Resident may
convert his or her coverage to a health plan in which SHIPPENSBURG is a
participating provider. Effective the date of SHIPPENSBURG's withdrawal from
the Resident's MCO, the Resident is obligated to pay for services and supplies
provided to the Resident as a private pay resident. If possible,
SHIPPENSBURG will provide the Resident with advance written notice of its
withdrawal from the Resident's MCO thirty (30) days before SHIPPENSBURG's
withdrawal.
10. ASSIGNMENT OF THIRD PARTY PAYMENTS: The Resident irrevocably
authorizes SHIPPENSBURG to make claims and to take all other actions to
secure receipt of third party payments to reimburse SHIPPENSBURG for its
charges. To the fullest extent permitted by law, and as security for payment of
SHIPPENSBURG's charges, the Resident hereby assigns to SHIPPENSBURG
all of the Resident's rights to any third party payments now or subsequently
payable to the extent of all charges due under this Agreement. Resident shall
promptly endorse and deliver to SHIPPENSBURG any payments received from
third parties to the extent necessary to satisfy the charges under this
Agreement. To facilitate this assignment, but not in lieu thereof, the Resident
hereby agrees to properly execute the ASSIGNMENT OF THIRD PARTY
PAYMENTS statement attached to this Agreement.
11. FINANCIAL POWER OF ATTORNEY: The Resident agrees that upon
admission the Resident, if able, will supply SHIPPENSBURG with a fully
executed and legally valid original Financial Power of Attorney appointing an
individual chosen at the Resident's sole discretion to be his financial attorney-
in-fact should the Resident become medically incompetent. If not able, the
Resident agrees to work with SHIPPENSBURG to pursue guardianship. This
Power of Attomey need only become effective if the Resident becomes
medically Incompetent. If, in the judgment of the Resident, no such individual is
available, the Resident agrees to appoint such an individual when one becomes
available. Judgment of the Resident's incompetence shall not require a court
22
adjudication, but shall require the written order of Resident's physician plus
confirmation by a second examining physician. The Resident's financial
attorney-in-fact shall be granted the authority to make financial decisions for the
Resident, including the unlimited power to pay SHIPPENSBURG's charges and
invoices from the Resident's income, and from the proceeds of the attorney-in-
fact's sale of the Resident's assets.
The selection of this attomey-in-fact serves at the complete discretion of
the Resident. However, should the Resident revoke the power of his or her
appointed attorney-in-fact, or should the Power of Attorney become inoperable
for any reason, the Resident hereby agrees to immediately appoint a successor
attorney-in-fact for the financial purposes set forth herein, if such an individual is
available. Upon receiving a duly executed copy or facsimile of this Agreement
noting the Resident's appointed financial attomey-in-fact, SHIPPENSBURG
may act hereunder. Revocation of the attomey-in-fact shall be ineffective as to
SHIPPENSBURG unless and until written or actual notice or knowledge of such
revocation is received. The attomey-in-fact's power shall continue in full force
and effect and may be relied upon by SHIPPENSBURG despite purported
revocation until written notice of revocation is received by SHIPPENSBURG.
Residents should first consult with his or her family and attorney
before executing any Financial Power of Attorney form.
VI. PAYMENT INFORMATION
A. DUE DATES AND THE OBLIGATION OF TIMELY PAYMENT:
SHIPPENSBURG's charges for services provided shall be billed on a monthly
basis to the Resident. These charges are due and payable by the tenth (10th)
day of each month. If payment is not received by the fifteenth (15th) day of each
month, the account balance is considered past due, and SHIPPENSBURG may
add late charges to the Resident's account. These late charges shall be
assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one
and one-half percent) or the maximum amount permitted by law. This late
charge does not alter any obligations of SHIPPENSBURG or Resident under
this Agreement.
The Resident recognizes that SHIPPENSBURG does not offer credit or
accept installment payments. SHIPPENSBURG's acceptance of a partial
payment does not limit SHIPPENSBURG's rights under this Agreement to full
payment for the care and services provided.
23
B. BILLING ADDRESS: All of SHIPPENSBURG's invoices are to be mailed to
the folbwing address for prompt payment (either Resident's address or Legal
Representative's address, when applicable):
C. FAILURE TO PAY AND DEFAULT OF AGREEMENT: SHIPPENSBURG's
due date for its payments falls on the fifteenth (15th) day of each month.
Resident's failure to remit a required payment within twenty-one (21) days of
the due date constitutes DEFAULT of this Agreement, and SHIPPENSBURG
may require the Resident to vacate SHIPPENSBURG after appropriate
advance notice. If the Resident is required to vacate SHIPPENSBURG for
failure to pay, SHIPPENSBURG shall provide advance notice as set forth in
Termination section of this Agreement. SHIPPENSBURG retains the right
under federal law and social security regulations to request the regional social
security field office to change the name of Representative in the event of
DEFAULT of this Agreement or the Representative Payee is consistently late
with payments.
24
D. VENUE. It is hereby agreed that this Admission Agreement is a
transaction entered into and accepted by the parties herein at the offices
of SHIPPENSBURG, in Cumberland County, Pennsylvania. Resident
agrees that, in event of DEFAULT, SHIPPENSBURG may bring a civil
action in the Court of Common Pleas of Cumberland County,
Pennsylvania, to collect any amounts owed to SHIPPENSBURG under the
teens of this Agreement.
E. ATTORNEY'S FEES AND COSTS OF POLLECTION: In the event that
SHIPPENSBURG institutes and is a prevailing party in litigation in court against
any party to this Agreement arising from DEFAULT or other non-payment under
Agreement, SHIPPENSBURG shall be entitled to receive from the losing party
reasonable attorneys' fees and costs of collection.
F. FEE FOR RETURNED CHECKS: A service fee of $25.00 (twenty-five
dollars) or the actual fee charged by the bank, whichever is greater, will be
charged for any returned check.
0. OBLIGATIONS OF RESIDENT'S ESTATE AND ASSIGNMENT OF
PROPERTY: This Agreement shall operate as an assignment, transfer and
conveyance to SHIPPENSBURG of as much of the Resident's property as is
equal in value to the amount of any unpaid obligations under this Agreement,
and this assignment shall be an obligation of the Resident's estate and may be
enforced against the Resident's estate. The Resident's estate shall be liable to
and shall pay SHIPPENSBURG an amount equivalent to any unpaid obligations
of the Resident under this Agreement. This assignment shall apply whether or
not the Resident is residing in SHIPPENSBURG at the time of the Resident's
death.
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VII. BED HOLDS
A. TICE. The Resident may need to be absent from SHIPPENSBURG
temporarily for hospitalization or therapeutic leave. The Resident may request
that SHIPPENSBURG hold open the Resident's bed during this time. This is
known as a "bed hold." The Resident, and if known, the Resident's Legal
Representative shall be given notice of the bed hold option at the time of
hospitalization or therapeutic leave. A schedule of charges for bed holds is
located on the Rate Schedule attached to this Agreement.
B. MEDICAID RESIDENTS: If the Resident's care is paid under the
Medicaid Program, Medicaid currently pays for up to 15 consecutive bed hold
days for each hospitalization and for up to 30 bed hold days each year for
therapeutic leave. If the Medicaid Resident's hospitalization or therapeutic
leave exceeds the bed-hold period, paid under the Medicaid program, the
Resident may request an additional bed hold period from SHIPPENSBURG by
agreeing to pay the daily additional bed hold amount listed in the attach6 Rate
Schedule. Otherwise, the Resident shall be readmitted upon the first availability
of a bed in a non-private room as long as the Resident requires the services
provided by SHIPPENSBURG and is eligible for Medicaid benefits.
C. PRIVATE AND MEDICARE RESIDENTS: Any Private or Medicare
Resident may request a bed hold from SHIPPENSBURG. The Resident's
private insurance may or may not pay for bed holds. The Medicare program
does not pay for bed holds. However, W the Medicare Resident is also eligible
for Medicaid, and if proven to the satisfaction of SHIPPENSBURG, Medicaid
pays for 15 bed hold days. Otherwise, a Private or Medicare Resident
requesting a bed hold must pay SHIPPENSBURG's bed hold rate set forth in
the Rate Schedule for the bed being held during the bed hold period.
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VIII. PERSONAL FUNDS
A. RESIDENT FUND AUTHORIZATION. The Resident has a right to
manage his or her own personal funds. If the Resident wants assistance with
management of personal funds, and requests so in writing through a Resident
Fund Authorization form, SHIPPENSBURG will hold, safeguard, manage, and
account for these funds. A Resident Fund Authorization form can be obtained
from SHIPPENSBURG's Administrator or designee.
B. PROCEDURES. Resident personal funds deposited with
SHIPPENSBURG shall be handled as follows:
1. SHIPPENSBURG shall deposit funds in excess of fifty dollars ($50.00) in
an interest-bearing account insured by the Federal Deposit Insurance
Corporation (FDIC) that is separate from any SHIPPENSBURG operating
accounts. All interest earned on the Resident's funds shall be credited to his
or her account. SHIPPENSBURG shall have the option of depositing funds
of less than fifty dollars in a non-interest bearing account, an interest bearing
account, or a petty cash fund. SHIPPENSBURG shall inform the Resident
as to how his or her funds are being held. SHIPPENSBURG's policy is to
maintain all resident funds in a separate account, except for a nominal
amount maintained in a petty cash fund for the Resident's convenience.
2. SHIPPENSBURG shall have a system that ensures a complete and
separate accounting, based on generally accepted accounting principles, of
the personal funds deposited with SHIPPENSBURG by each Resident or on
his or her behalf. This system shall also ensure that the Resident's funds
are not commingled with SHIPPENSBURG's funds or with any other funds
besides those of other residents. In addition to the required quarterly
accounting, SHIPPENSBURG shall provide individual financial records at
the written request of the Resident.
3. The personal fund balance a resident receiving Medicaid benefits must
remain within a certain dollar range for the Resident to continue to receive
benefits. SHIPPENSBURG shall notify a Medicaid resident if his or her
account balance is within two hundred dollars ($200.00) of the federal
Supplemental Security Income (hereafter °SSI") limit. SHIPPENSBURG
shall also notify the Resident if the account balance, in addition to the
Resident's known non-exempt assets, reaches the SSI resource limit.
Furthermore, SHIPPENSBURG shall notify the Resident if the account
balance, in addition to the Resident's known non-exempt assets, reaches
the resource limits for Medicaid eligibility. A balance in excess of this limit
may cause the Resident to lose eligibility for Medicaid or SSI.
4. If a Resident who has personal funds deposited with SHIPPENSBURG
expires, SHIPPENSBURG shall refund the Resident's personal account
27
balance within thirty (30) days, and provide a full accounting of these funds
to the individual, probate jurisdiction administering the Resident's estate, or
other entity as required by state law or regulation. However, any
outstanding balance owed to SHIPPENSBURG for the Resident's care and
services shall first be deducted from the Resident's personal account as
permitted by law.
5. SHIPPENSBURG shall ensure the security of all resident personal funds
deposited with SHIPPENSBURG, and shall not take money from a Medicare
and/or Medicaid resident's personal funds for any item or service for which
payment is covered by Medicare and/or Medicaid.
IX. FUNERAL ARRANGEMENTS
SHIPPENSBURG assumes no financial responsibility for the funeral or
funeral related expenses associated with a Resident's passing.
SHIPPENSBURG recognizes the emotional hardship that such an event may
have on the Resident's family and loved-ones. To assist during this difficult
time, SHIPPENSBURG will convey the Resident's wishes, as expressed below,
concerning arrangements to a designated funeral director.
Funeral Arrangements:
Funeral Director:
Burial Fund:
Cemetery Lot Location:
Person Assuming
Responsibility for Burial:
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X. TERMINATION OF AGREEMENT
A. RIGHT TO TERMINATE: An explanation of the Resident's rights
concerning termination, transfer, and discharge is contained in the Statement of
Resident Rights, which is attached to but separate from this Agreement.
B. RESIDENT INITIATED: Notice of resident initiated termination is
required for proper discharge planning. Other than in the case of a medical
emergency or death, the Resident will provide SHIPPENSBURG with written
notice two (2) business days before the Resident's termination of this
Agreement.
C. REFUNDS: NDS: If a Resident has personal funds deposited with
SHIPPENSBURG upon termination of this Agreement, SHIPPENSBURG shall
refund the Resident's personal account balance within thirty (30) days, and
provide the Resident or the Resident's estate with a full accounting of these
funds. However, any outstanding balance owed to SHIPPENSBURG for the
Resident's care and services shall first be deducted from the Resident's
personal account as permitted by law.
XI. RESIDENT GRIEVANCE/ COMPLAINT RESOLUTION
A. RESIDENT GRIEVANCES:
1.) All Residents, family members, and Resident representatives are
urged to bring any grievances concerning SHIPPENSBURG to the
attention of the SHIPPENSBURG Administrator or the Administrator's
designee.
2.) In addition to bringing grievances to the attention of
SHIPPENSBURG Administrator or designee, residents may also contact
the outside representative of his or her choice. Outside representatives
include the Governor's Action Line at (800) 932-0784, the Department of
Health Hot Line at (800) 254-6154, the Long Term Care Ombudsman
located within the Local Area Agency on Aging, and the Legal Services
Program. The telephone number of the local Long Term Care
Ombudsman and the Legal Services Program is located within the
Resident's Bill of Rights accompanying this Agreement.
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B. ARBITRATION OF NONPAYMENT DISPUTES UNDER THIS
(a) UNLESS OTHERWISE MUTUALLY AGREED UPON IN WRITING,
SHOULD GRIEVANCE PROCEDURES FAIL, THE RESIDENT AND
SHIPPENSBURG AGREE THAT ALL DISPUTES ARISING UNDER
THIS AGREEMENT, WITH THE EXCEPTION OF DISPUTES
CONCERNING DEFAULT (AS DEFINED ABOVE IN SECTION VI-C)
OR OTHER NON-PAYMENT FOR SERVICES RENDERED, SHALL BE
RESOLVED BY BINDING ARBITRATION BEFORE A NEUTRAL
ARBITRATOR, ASSIGNED TO THE MATTER IN ACCORDANCE WITH
THE AMERICAN HEALTH LAWYERS ASSOCIATION (AHLA)
ALTERNATIVE DISPUTE RESOLUTION SERVICE RULES OF
PROCEDURE FOR ARBITRATION.
(b) SUCH ARBITRATION SHALL TAKE PLACE AT SHIPPENSBURG
AT A MUTUALLY AGREED UPON TIME. ANY TIME A DISPUTE
ARISES, ANY PARTY MAY REQUEST THE APPOINTMENT OF AN
ARBITRATOR TO RESOLVE THE DISPUTE.
(c) THE REQUESTING PARTY SHALL NOTIFY THE OTHER PARTY
IN WRITING A MINIMUM OF SEVEN (7) BUSINESS DAYS PRIOR TO
REQUESTING THE APPOINTMENT OF THE ARBITRATOR.
(d) THE COSTS OF THE ARBITRATOR AND ALL COSTS
ASSOCIATED WITH THE ARBITRATION, INCLUDING ATTORNEY'S
FEES, COSTS, AND EXPENSES SHALL BE BORNE BY THE LOSING
PARTY.
(e) THE DECISION OF THE ARBITRATOR WILL BE FINAL AND
BINDING, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT
HAVING COMPETENT JURISDICTION.
30
XII. MISCELLANEOUS PROVISIONS
A. CLINICAL FINANCIAL INFORMATION: With and at
SHIPPENSBURG's discretion, the Resident hereby authorizes
SHIPPENSBURG to obtain all of the necessary clinical and/or financial
documentation from the Resident prior or transferring hospital or nursing facility.
B. SOLE AGREEMENT: This Agreement, along with any documents
attached or included by reference, is the only agreement between
SHIPPENSBURG and parties. Changes to this Agreement are valid only if
made in writing and signed by all parties. If changes in state or federal law
make any part of this Agreement invalid, the remaining terms remain valid and
enforceable.
C. NON ASSIGNABLE AGREEMENT: The Resident agrees that the right
of the Resident to reside at SHIPPENSBURG is personal and not assignable.
The Resident may not transfer his or her rights under this Agreement to any
other person.
D. GOVERNING LAW: This Agreement shall be govemed by and construed
by the laws of the Commonwealth of Pennsylvania, and shall be binding upon
and shall be for the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
E. SEVERABILITY: The Resident and SHIPPENSBURG agree that each
separate obligation contained in this Agreement shall be deemed a separate
and independent agreement. If any term, condition, clause or provision of this
Agreement shall be determined or declared to be void or invalid in law or
otherwise, then only that term, condition, clause or provision shall be stricken
from this Agreement, and in all other respects this Agreement shall be valid and
continue in full force, effect and operation.
F. CAPTIONS: The captions used in this Agreement are inserted only for
the purpose of reference. Such captions shall not be deemed to govern, limit,
modify or in any manner affect the scope, meaning or intent of the provisions of
this Agreement. The captions shall be given no legal effect.
G. WAIVER: A waiver by either party at any time of any of the terms,
conditions, or covenants of this Agreement, or of any default or breach shall not
be deemed or taken as a waiver at any time thereafter of the same or any other
term, condition or covenant herein contained, nor of the strict and prompt
performance thereof.
31
H. MODIFICATIONS: SHIPPENSBURG reserves the right to unilaterally
modify this Agreement to the extent necessary to conform the Agreement with
subsequent changes in law or regulation. SHIPPENSBURG will notify the
Resident thirty days (30) before such modification, if possible.
XIII. ACKNOWLEDGMENTS
A. RAZE SCHEDULE: The Resident and the Resident's Legal Representative
hereby acknowledge the receipt of a copy of the Rate Schedule and sufficient
opportunity to ask questions about the Rate Schedule to answer all of their
questions about SHIPPENSBURG's charges. The Resident and the Legal
Representative hereby acknowledge that SHIPPENSBURG can and will alter
the Rate Schedule from time to time, and that Resident will be subject to those
changes. The Resident and the Resident's Legal Representative hereby agree
to be subject to those changes as provided in this Agreement.
B. STATEMENT OF RESIDENT'S RIGHTS: The Resident and the Residents
Legal Representative hereby acknowledge being informed orally and of
receiving a written copy of the Resident's Rights, as set forth in this Agreement,
and as further set forth in the accompanying SHIPPENSBURG's Statement of
Resident's Rights. Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Resident's rights and have received appropriate responses.
The Resident and the Resident's Legal Representative hereby acknowledge
that the accompanying Statement of Resident's Rights is subject to change
from time to time, and shall not be construed as imposing any contractual
obligations on SHIPPENSBURG or granting any contractual rights to the
Resident.
C. COMMONWEALTH'S ADMISSIONS NOTICE PACKET: The Resident and
the Resident's Legal Representative hereby acknowledge being informed orally
and of receiving a written copy of the Commonwealth's Admissions Notice
Packet, accompanying this Agreement. Furthermore, the Resident and the
Resident's Legal Representative hereby acknowledge having sufficient
opportunity to ask questions about the Resident's rights and have received
appropriate responses. The Resident and the Resident's Legal Representative
hereby acknowledge that the Commonwealth's Admissions Notice Packet is
subject to change from time to time, and shall not be construed as imposing any
contractual obligations on SHIPPENSBURG or granting any contractual rights
to the Resident.
32
D. LACY ACT STATEMENT - HEALTH CARE RECORDS; The Resident
and the Resident's Legal Representative hereby acknowledge being informed
orally of and receiving a written copy of the Privacy Act Statement - Health
Care Records, in compliance with the Privacy Act of 1974. Furthermore, the
Resident and the Resident's Legal Representative hereby acknowledge having
sufficient opportunity to ask questions about the Privacy Act Statement and
have received appropriate responses.
E. HEALTH CARE ADVANCE DIRECTIVES: The Resident and the Resident's
Legal Representative hereby acknowledge being informed orally and in writing
about health care advance directives, including receiving a copy of the
Commonwealth's Medical and Treatment Self-Directive Statement, and of
SHIPPENSBURG's policy concerning health care advance directives and
medical treatment decisions. Furthermore, the Resident and the Resident's
Legal Representative hereby acknowledge having sufficient opportunity to ask
questions about advance directives, the Commonwealth's Medical and
Treatment Self-Directive Statement, and SHIPPENSBURG's policy thereon,
and have received appropriate responses to all of their questions.
F. STATEMENT OF PRIVACY PRACTICES: The Resident and the Resident's
Legal Representative hereby acknowledge having been informed orally of and
receiving a written copy of SHIPPENSBURG's Statement of Privacy Practices,
in compliance with the Health Insurance Portability and Accountability Act of
1996 (HIPAA). Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Statement and have received appropriate responses.
G. AGREEMENT: The Resident and the Resident's Legal Representative
hereby acknowledge that they have carefully read and understand the terms of
this Agreement, and that the terms have been explained to them by a
representative of SHIPPENSBURG. Furthermore, the Resident and the
Resident's Legal Representative hereby acknowledge having sufficient
opportunity to ask questions about the Agreement and have received
appropriate responses.
33
IN WITNESS WHEREOF, INTENDING TO BE LEGALLY BOUND, the
parties hereto have executed this Agreement the ar-&.-d day of
U•&= 6'-'e , and same shall be
considered binding upon all parties, and shall remain in full force and effect
unless and until cancelled according to the terms of this Agreement.
Resident Date
Legal Representative
S IPPENSBURG Representative
)U-44r?.
Witness
Date
9t?-4r
Date
N3-o8
Date
Date
34
1
Sandra Dieudonne
Interest on Outstanding 18%
10/8/2008 Barber & Beauty $12.00
10/812008 Adjustment $3,200.00
1011512008 Barber & Beauty $35.00
10/27/2008 Barber & Beauty $12.00
10/31/2008 Room Charges $2,668.68
Total $5,927.68
11/112008 Cable $10.00
11/1/2008 Adjustment $512.00
11/112008 Room Charge $3,558.24
11/912008 Bed Hold Charge $816.00
11/1312008 Room Charge $6,337.36
11125/2009 Bed Hold Charge $408.00
11/30/2008 Interest $88.92
Total $16,658.20
12/3012008 Barber & Beauty $36.00
12/30/2008 Cable $10.00
12/31/2008 Room & Board $2,040.00
12/31/2008 Co Insurance $15.77
12/3112008 Interest $249.87
Total $19,009.84
113112009 Room & Board $6,324.00
1/31/2009 Cable $10.00
1/3112009 Co Insurance $185.27
1131/2009 Interest _ $285.15
Total $25,814.26
2/2812009 Interest $387.21
Total $26,201.47
3/13/2009 Interest $167.98
Total $26,369.45
Total Charges $25,190.32
Interest $1,179.13
Total Due $26,369.45
EXHIBIT "B"
?
?
n
C7??
F L I) -! s=ri E
w
HOAR- 1 13:
cult
o#7i-sv 4'?j
fi?:A
as ?s?
Sheriffs Office of Cumberland County
R Thomas Kline oyti?v of ctretrbcr? Edward L Schorpp
Sheri { Solicitor
f rt - I,
Ronny R Anderson Jody S Smith
Chief Deputy OFF-cE s"QRIFF Civil Process Sergeant
SHERIFF'S RETURN OF SERVICE
04/01/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and
inquiry for the within named defendant, to wit: Sandra L. Dieudonne, but was unable to locate her in his
bailiwick. He therefore deputized the Sheriff of Adams County, PA to serve the within Complaint and
Notice according to law.
04/09/2009 Adams County Return: And now, April 9, 20091, James W. Muller, Sheriff of Adams County,
Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for Sandra L.
Dieudonne the defendant named in the within Complaint and that 1 am unable to find her in the County of
Adams and therefore return same NOT FOUND. The defendant has not resided at 2 Lumber Street, Apt.
1 Littlestown, Adams County, Pennsylvania 17340 for approximately three years. The Littlestown Post
Office has nothing on file for the defendant.
SHERIFF COST: $42.42
April 15, 2009
SO ANSWERS,
R THOMAS KLINE, SHERIFF
2009-2031
Perini Services
VS,
Sandra L. Dieudonne
"IARY
OF ?'r i"
2009 OR 20 AM 8: 47
C at v, u"N ty
MASON DIXON BUSINESS FORMS, INC. 33000026
DATE RECEIVED
SHERIFF'S DEPARTMENT
ADAMS COUNTY, PENNSYLVANIA
COURTHOUSE, GETTYSBURG, PA 17325
DATE PROCESSED
INSTRUCTIONS: See "INSTRUCTIONS FOR SERVICE OF PROCESS BY
SHERIFF SERVICE THE SHERIFF" on the reverse of the last (No. 5) copy of this farm. Plsaee
PROCESS RECEIPT, and AFFIDAVIT OF RETURN tyfre or print 1ooft. tiring rwaaft of am copies.
Do not detach any copies. AM IJIY.x
1. PLAINTIFFS/ 2. COURT NUMBER
PERINI SERVICES/SOUTH HAMP'T'ON MANOR, L.P. 2009-2031 Civil Term
3. DEFENDANT/W
SANDRA L. DIl
41* i 41 a 0
4. TYPE OF WRIT OR COMPLAINT:
Zomplaint in Civil Action
UpVE 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC., TO SERVICE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED OR SOLD.
r Sandra L. Dieudonne
-? S. ADDRESS (Strsst or RFD, Apartment No., City, Boro, Twp., State and ZIP CODE)
AT 2 Lumber Street, Apt. #1, Littlestown, PA
7. INDICATE UNUSUAL SERVICE: ? PERSONAL ? PERSON IN CHARGE ? DEPUTIZE ? CERT. MAIL ? REGISTERED MAIL ? POSTED ? OTHER
Now, , I, SHERIFF OF ADAMS COUNTY, PA., do hereby deputize the Sheriff of
County to execute this Writ and make return therof according to taw. This deputation being
made at the request and risk of the plaintiff.
SHERIFF OF ADAMS COLWTY
9. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN-Any deputy sheriff levying upon or attaching any property under within writ may leave
same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to
any plaintiff herein for any loss, destruction or removal of any such property before sheriffs sale thereof.
9. SIGNATURE of ATTORNEY or other ORKUNATOR requesting service on behalf of: 10. TELEPHONE NUMBER 11. DATE
David A. Boric ES X1 PLAINTIFF (717) 249-6873
9' ? DEFENDANT
PA BELOW FOR E F SHERIFF ONLY - O NOT WRITE BELOW THIS LINE
12. 1 acknowledge receipt of the writ SIGNATURE of Authorized ACSD Do" or Clerk and Title 13. Date Received 14. Expiration / SO= date
or complaint as indicated above. 4/6/2009 HAY 1. 2009
15. 1 hereby CERTIFY and RETURN that 1 ? have personally served, ? have served person in charge, ? have legal evidence of service as shown in "Remarks" (on reverse)
? have posted the above described property with the writ or complaint described on the individual, company, corporation, etc., at the address shown above or on the
individual, company, corporation, etc., at the address inserted below by handinglor Posting a TRUE and ATTESTED COPY therof.
1A VI 1 harahu r"Mu and raeum a NOT FOUND because I am unable to locate the individual. comma. corporation. etc.. named above. (See remarks belowl
1$j
17. Name and title of individual served 19. A parson of auk" age and discretion Read Order
==In do dsfendwd's usual
?
. ?
19. Address of where served (complete only if different than shown above) (Street or RFD, Apartment No., City, Boro, Twp., 20. Date of Service 21. Time
State and ZIP CODE)
REMWS: The defendant bas not resided at the above address in appro tely 3 yea rs. The
Littlestown Post Office bas nothing on file for the defendant
22. ATTEMPTS Data Miles Dep.int. Data Mlles Dep.int. Dab Mlle Dep.IM. Dab MNss Dep.lnt. Data Mlles Dep.hht.
23. Advance Costs 24. 25. 26. 27. Total Costs 28 =M REFUND
5D.(D $28.06 d. /14/ 1$121.94 Ck. #20182
AFFIRMED and subscribed to before me this
day
/
By MMQ[Dsp. BMrilf) (Plsese Print a Type)
Jeremy Becker
signahas of Sheriff
Data
4/9/2009
4%9/2009
SHERIFF OF ADAMS COUNTY
33000(126
SwaRWEA RLBM QE SAM"
{ ) (I The within
upon , the within nanne#
defendant by mailing to
by - mail, return receipt requested, postage
prepaid, on the
a true and attested copy theta at
The return receipt signed by
defendant on the is hereto attached and
made a part of this return.
( } { 2) Outside the Cvmmorn?reakh, pursuan$,to . R.C.Pv 405 --(c) (1) (2), by mailing a true
and,#ttes l o" lhaw at
in ft foil manner:
{ ) (a) to the defendant by ( } ragibteret ( ) certified mail, return receipt requested,
postage prepaid, addressee only on the
said receipt being returned NOT signed by defendant, but with a notation by the Postal-Authorities
that Dew refused to aoc*jA-#w same. The returned receipt and envelope is a " hereto
and huts a part of this return.
And ther
( ) (b) To the defendant by ordinary mail addressed to defendant at same address, with the return
address of the Sheriff. appearing #w-eon, on the.
1 further oertify that after fifften (I5? dayt front the m6llino- date, I have not cgeeirred
said envelope back from the Postal Authorities. A certificate of mailing is hereto attached as a
proof of mailing.
( ) (3) By publication in, the Adams Couady Lao Journal, a Mt#elity publication *( age *WW circulation in
the County of 'Adanht, CommofiWealth of Pennsylvarhia, and Ifie Gettysburg T' Imes, adaily
newspaper pW*shad in the, County of Adami toam?orMSQ" Of F ntl?+snia iltitd` ltaratidg. al
circulation in said County for
successive weeks of
The Affids he
from -said Adages County Legal nal and C,te#ys rrg Tinos, are horetetat lhsel?and made
part of this rotum.
( ) (a) By mailing to
by n*", return receipt requested. postage prepaid, .
on the
a true and attested copy thereof at _
The returl.fay thrt Real
Au?fl?;f'kR??aaa?
ii 140o iltillC' a?' uuuc
C ) C 5) Qhar
,,,
gli
In The Court of Common Pleas of Cumberland County, Pennsylvania
Perini Services
Sandra L. Dieudonne
2 Lumber Street, Apt. 1
Littlestown, PA 17340
VS.
Civil No. 2009-2031
Now, April 1, 2009, I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of
Adams County to execute this Writ, this deputation being made at the request and risk of the Plaintiff.
00 (-4
Sheriff of Cumberland County, PA
Affidavit of Service
Now,
within
upon
at
by handing to
a
and made known to
copy of the original
the contents thereof.
So answers,
Sheriff of County, PA
COSTS
Sworn and subscribed before SERVICE $
me this day of 20 MILEAGE
AFFIDAVIT
20 , at o'clock M, served the
AINnoo swdod
33183HS
SZ=1 d 9-ddyol
N
Sheriffs Office of Cumberland County
R Thomas Kline `%ov at 4+?+>>urr Edward L Schorpp
Sheriff ",to Solicitor
Ronny R Anderson Jody S Smith
Chief Deputy r'="' ``r Civil Process Sergeant
SHERIFF'S RETURN OF SERVICE
04/01/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and
inquiry for the within named defendant, to wit: Sandra L. Dieudonne, but was unable to locate her in his
bailiwick. He therefore deputized the Sheriff of Adams County, PA to serve the within Complaint and
Notice according to law.
04/09/2009 Adams County Return: And now, April 9, 2009 I, James W. Muller, Sheriff of Adams County,
Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for Sandra L.
Dieudonne the defendant named in the within Complaint and that I am unable to find her in the County of
Adams and therefore return same NOT FOUND. The defendant has not resided at 2 Lumber Street, Apt.
1 Littlestown, Adams County, Pennsylvania 17340 for approximately three years. The Littlestown Post
Office has nothing on file for the defendant.
SHERIFF COST: $42.42
April 15, 2009
SO ANSWERS,
R THOMAS KLINE, SHERIFF
2009-2031
Perini Services
VS.
Sandra L. Dieudonne
?t.,
0? ,fir TAP
2009 APR ZO At' ' B.., .f
UiY _ 4y;?i =J
r
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
SANDRA L. DIEUDONNE, :
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2009- 2031 CIVIL TERM
PRAECIPE TO ATTACH SUBSTITUTE VERIFICATION
Please attach the following Substitute Verification to the Complaint filed in this matter on
April 1, 2009.
Date: April 14, 2009
Respectfully submitted,
O'BRIEN, B RIC & S RER
l? 4
David A. Baric, Esquire
I.D. #44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.d it/shcc/dieudonne/su bstituteverification. pra
4k
VERIFICATION
I, Deb Black, verify that the statements made in the foregoing Complaint are true and
correct to the best of my knowledge, information and belief.
I hereby ratify the verification previously supplied by my attorney, David A. Baric,
Esquire and execute this verification as a substituted verification.
I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.
§4904 relating to unsworn falsifications to authorities.
Date:
Deb Black
Business Office Coordinator
e t r
ZEDS P4 r 20 C i.", di e
t
r ??
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
SANDRA L. DIEUDONNE,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2009- 2031 CIVIL TERM
PRAECIPE TO REINSTATE
TO THE PROTHONOTARY:
Please reinstate the Complaint filed in the above matter on April 1, 2009.
Respectfully submitted,
EN, BARI & S R
c
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.dir/shcc/dieudonne/reinstatecomplaint.pra
OF THE- AM
2069 APP 30 Pi''! s, 42
4?eG 3
Sheriffs Office of Cumberland County
R Thomas Kline Edward L Schorpp
Sheriff' Solicitor
14 ?'t
Ronny R Anderson Jody S Smith
Chief Deputy OFFICE -E 5?vRIFF Civil Process Sergeant
Perini Services Case Number
vs. 2009-2031
Sandra L. Dieudonne
SHERIFF'S RETURN OF SERVICE
05/01/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and
inquiry for the within named defendant, to wit: Sandra L. Dieudonne, but was unable to locate him in her
bailiwick. He therefore deputized the Sheriff of Adams County, PA to serve the within Complaint and
Notice according to law.
05/14/2009 Adams County Return: And now, May 14, 2009 I, James W. Muller, Sheriff of Adams County,
Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for Sandra L.
Dieudonne the defendant named in the within Complaint and that I am unable to find her in the ounty of
Adams and therefore return same NOT FOUND.
SHERIFF COST: $42.44 SO A
July 02, 2009 / R TH MAS KLINE, SHERIFF
? 1 L
._.?D
}
?
F .
"y
c.a
.? 'i
010100* 0*040
MASON DIXON BUSINESS FORMS, INC. 33000026
DATE RECEIVED DATE PROCESSED
SHERIFF'S DEPARTMENT
ADAMS COUNTY, PENNSYLVANIA
COURTHOUSE, GETTYSBURG, PA 17325
INSTRUCTIONS: See "INSTRUCTIONS FOR SERVICE OF PROCESS BY
SHERIFF SERVICE THE SHERIFF" on the reverse of the last (No. 5) copy of this form. Please
PROCESS RECEIPT, and AFFIDAVIT OF RETURN type or print legibly, insuring readability of all copies.
Do not detach any copies. ACSD ENV.#
1. PLAINTIFFS/ 2. COURT NUMBER
PERINI SERVICES/SOUTH HAMPTON MANOR, L.P. 2009-2031 Civil Term
3. DEFENDANTS/ 4. TYPE OF WRIT OR COMPLAINT:
SANDRA L. DIEUDONNE Reinstated Complaint
SERVE 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC., TO SERVICE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED OR SOLD.
1 Sandra L. Dieudonne
6. ADDRESS (Street or RFD, Apartment No., City, Boro, Twp., State and ZIP CODE)
AT 29 East Summit Drive, Littlestown, PA
7. INDICATE UNUSUAL SERVICE: ? PERSONAL ? PERSON IN CHARGE ? DEPUTIZE ? CERT. MAIL ? REGISTERED MAIL ? POSTED ? OTHER
Now, , I, SHERIFF OF ADAMS COUNTY, PA., do hereby deputize the Sheriff of
County to execute this Writ and make return therof according to law. This deputation being
made at the request and risk of the plaintiff.
SHERIFF OF ADAMS COUNTY
8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE.
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN-Any deputy sheriff levying upon or attaching any property under within writ may leave
same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to
any plaintiff herein for any loss, destruction or removal of any such property before sheriffs sale thereof.
9. SIGNATURE of ATTORNEY or other ORIGINATOR requesting service on behalf of: 10. TELEPHONE NUMBER 11. DATE
David A. Baric, Esq. PLAINTIFF (717) 249-6873
? DEFENDANT
SPACE BELOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS LINE
12. 1 acknowledge receipt of the writ SIGNATURE of Authorized ACSD Deputy or Clerk and Title 13. Date Received 14. Expiration atHIMdate
or complaint as indicated above. 1 .1 5/6/2009 MAY 30 2009
15. 1 hereby CERTIFY and RETURN that 1 ? have personally served, ? have served person in charge, ? have legal evidence of service as shown in "Remarks" (on reverse)
? have posted the above described property with the writ or complaint described on the individual, company, corporation, etc., at the address shown above or on the
individual, company, corporation, etc., at the address inserted below by handing/or Posting a TRUE and ATTESTED COPY therof.
16. K I hereby certify and return a NOT FOUND because I am unable to locate the individual, company, corporation, etc., named above. (See remarks below)
17. Name and title of individual served
18. A person of suitable sgs and discretion Read order
then rssidirp in the defendant's usual
place of abode. ? ?
19. Address of where served (complete only if different than shown above) (Street or RFD, Apartment No., City, Boro, Twp., 20. Date of Service 21. Time
State and ZIP CODE)
RFMAM: The people residing at the above listed address stated that S drs L. Di onne
bad not lived at that residence in over 6 years.
22. ATTEMPTS Data Mlles Dsp.lnt. Data Mlles Dep.lnt. Data Miles Dep.int. Date Mlles Dep.lnt. Data Mlles Dep.int.
23. Advance Costs 24.
$150.0D Fb.&W. #1
25. 1 26.
27. Total Costs 28. 5W5K REFVND
$25.70 Pd. 7/1/09 $124.30 Ck. #20433
AFFIRMED and subscribed to before me this
day
Public
so
By CD". Sheriff) (P-se Print or Type) Date
Jeremy Becker 5
Signature of Sheriff Data
SHERIFF OF ADAMS COUNTY
I ACKNOWLEDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE I 139. Date Received
OF AUTHORIZED ISSUING AUTHORITY AND TITLE.
PROTHONOTARY
83000026
SHERIFF'S RETURN OF SERVICE
( ) (1 ) The within
upon , the within named
defendant by mailing to
by mail, return receipt requested, postage
prepaid, on the
a true and attested copy thereof at
The return receipt signed by
defendant on the is hereto attached and
made a part of this return.
( ) ( 2 ) Outside the Commonwealth, pursuant to Pa. R.C.P. 405 (c) (1) (2), by mailing a true
and attested copy thereof at
in the following manner:
( ) (a) to the defendant by ( ) registered ( ) certified mail, return receipt requested,
postage prepaid, addressee only on the
said receipt being returned NOT signed by defendant, but with a notation by the Postal Authorities
that Defendant refused to accept the same. The returned receipt and envelope is attached hereto
and made a' part of this return.
And thereafter:
( ) (b) To the defendant by ordinary mail addressed to defendant at same address, with the return
address of the Sheriff appearing thereon, on the
i further certify that after fifteen (15) days from the mailing date, I have not received
said envelope back from the Postal Authorities. A certificate of mailing is hereto attached as a
proof of mailing.
( ) (3) By publication in the Adams County Legal Journal, a weekly publication of general circulation in
the County of Adams, Commonwealth of Pennsylvania, and the Gettysburg Times, a daily
newspaper published. in the County of Adams, Commonwealth of Pennsylvania and having general
circulation in said County for
successive weeks of
The Affidavits
from said Adams County Legal Journal and Gettysburg Times, are hereto attached and made
part of this return.
( ) (4) By mailing to
by mail, return receipt requested, postage prepaid,
on the
a true and attested copy thereof at
The returned by the Postal
Authorities marked
is hereto attached.
{ } ( 5 ) Other