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HomeMy WebLinkAbout09-2334IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, /? _ V. No. Oq - an4 (1'v l ?erm LINDA DEITZ, 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 PARA DEFENDER Conforme a PA RCP Num. 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 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. 0 q-02. 3 ?f ?1 LINDA DEITZ, Defendant 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 Linda Deitz ("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 942 Oak Hill Road, Lewisberry, Pennsylvania 17339. 3. On or about May 3, 2007, Defendant applied for the admission of her great-aunt, Betty Fitzer, to Plaintiffs skilled nursing facility. 4. At the time Defendant's great-aunt 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 great-aunt with skilled nursing services in exchange for Defendant's promise to pay a specific monetary fee from her great-aunt's assets and the assignment to Plaintiff of her great-aunt's right to apply for and obtain Medical Assistance benefits in the event that she became insolvent. In furtherance of that assignment, Defendant agreed to cooperate fully and secure Medical Assistance benefits for her great-aunt. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. After Defendant's great-aunt became a resident of Plaintiff's skilled nursing facility, she 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 great-aunt 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 great-aunt's 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 great-aunt's application is approved. 11. Upon information and belief, at all times material hereto, Defendant's great-aunt was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her 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. Dated: 9/0 -///L 7 By: Respectfully submitted, ScHuTjER BOGAR LL G 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 Plaintiff 4 APR-03-2009(FRI) 15:14 P.006/006 VERIFICATION 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 1$ Pa. C. S. § 4904, relating to unworn falsification to authorities. Dated: -4- I ' Q .,NrLi on Sharon Cramer, SR Billing/ AR Specialist, Church of God Home, Inc. EXHIBIT,','A,f,l (ro cow) CHURCH OF GOD HOME, INC'. ADMISSION AND CARE AGREEMENT TABLE OF CONTENTS PAGE 1. PROVISION OF SERVICES 26 2. RECURRING CHARGES . . . . . . . . . . . . . . . . . . .26 3. NON-RECURRING CHARGES .27 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES . . . . . 27 5. ADMISSION .. ', 28 6. PERIODIC BILLINGS AND PAYMENT DUE DATE .. 28 7. CHANGES IN CHARGES 28 8. PARTICIPATION.-IN MEDICARE/MEDICAID PROGRAMS 28 9. OBLIGATIONS OF RESPONSIBLE-PARTY .29 10. READMISSION - BED/ACCOMMODATION HOLD POLICY...: .. 2.9 11. REFUNDS 29 12. PERSONAL, FINANCES . . . . . . . . . . . . . . .. . . 29 13. TERMINATION, TRANSFER OR DISCHARGE -30 14. THIRD-PARTY PAYMENTS ... 31 15. PERSONAL PROPERTY 32 16. RESPONSIBILITIES OF RESIDENT .32 17 MISCELLANEOUS PROVISIONS .. ... 32 CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this day of by and between The Church of God Home, Inc., cal a "Facility," a Pennsylvania non-profit corporation located at 0 North Hanover Street, CarlAsle, Cumberland County, Pennsylvania, and and called "Resident" called "Responsible Party". The Resident and the Mesponsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and. understand that the submission of false information may constitute grounds to terminate this Agreement.' The Resident has applied for admission to the Facility and the Facility has approved the. Application for Admission. Therefore, the Facility, The Resident and Responsible Party agree to the following terms-6 1. PROVISION OF SERVICES. The Facility will provide Resident with: (a) Skilled nursing care, i.e. professionally supervised nursing care and related health services under a plan of services regularly provided under a plan of care supervised by licensed personnel and, as required by the Resident's.medical condition, assistance with activities of daily living. (b) Accommodations consistent with the level of care provided to the Resident including heat, air conditioning,.electricity and hot and cold water. (c) Bed, bedding, blankets and laundered bed linens,. towels and wash cloths. (d) Three meals each day, except as-otherwise medically indicated. (e) Activity programs and social services. 2. RECURRING CHARGES. In exchange for the above services, the Resident shall pay the following recurring charges: (a) For skilled nursing care: $,?.?? -dollars.per day. Admission and Care Agreement - continued -3r. NON-RECURRING CHARGES. The Resident shall pay the following non-recurring charges: (a) A security deposit in the amount of thirty-one (31) .times the current daily rate for the level of care required by the resident, will be billed after a iss?on day. The amount of the security deposit is $ No interest will be paid on the security deposit. A security deposit will not be charged to residents who are receiving benefits for room and board provided by Medicare, until the Medicare benefit concludes. An applicant who is covered by Medicaid is not required to pay a security deposit. (b) The cost for enrollment in the community a ce and ALS (Advance Life Support) Unit is $ This fee must be paid prior to admission and wftl be billed annually to the.-Resident. 4. MISCL7J ANEOUS CHARGES AND OUTSIDE SERVICES. Resident is responsible ._to pay for other services provided by the- Facility which are not covered by the daily rate/charge.' A list of such services/charges . is attached to this Agreement on the '"Chart of Costs." The services of a licensed physician and dentist, a registered' pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, and- diagnostic services, will be made available at the Resident's expense. THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER OWN PHYSICIAN OR ANY OTHER SERVICE PROVIDER SO LONG AS THE PHYSICIAN OR OTHER SERVICE PROVIDER IS PROPERLY LICENSED OR REGISTERED UNDER THE LAW, AND THAT ALL APPLICABLE GOVERNMENT RULES AND POLICIES OF THE-FACILITY ARE MET. In addition to the Facility's charges, the Resident is responsible to pay -all fees and costs 'for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement. The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist,'. therapist, diagnostic or test ing:laboratory; pharmacist, pharmacy, hospital, or any other person,' facility or entity providing services or goods to or for the Resident, and for all drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or services for the Resident. -.__.SU_CH_ FEES AND COSTS. ARE. _NOT__.INCLUDED. _IN -THE._ HOME'S DAILY RATE/CHARGE. Admission and Care Agreement - continued 5. ADMISSION. The Resident will be ad?tt d, or a bed will be reserved for Resident, beginning on ,0,7 All pre-admission charges will be billed after admission, and recurring charges will begin to accrue as of the above -date. The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily rate for the reserved bed will continue to accrue and be payable until the reservation is terminated,- even if the Resident does not enter the-Rome for whatever reason, including illness, injury, incapacity or death. 6. PERIODIC BILLINGS AND PAYMENT DUE DATE. (a) on the first of.each month, Resident will be billed the current daily rate for Resident's current level of care times the number of days in the month, The bill is due and payable-upon receipt. (b) Miscellaneous charges (refer to "Chart 'of Costs" attached to this Agreement) such as hair care, personal laundry, incontinency, supplies, etc., are. additional charges above the. daily rate. These miscellaneous charges will be added to, and included with,. your monthly bill. (c) Pharmacy charges will be billed as a separate part of the Facility, s; monthly bill, and will require a separate check.. (d) outside providers-will bill directly and separately- 7. CHANGES IN CHARGES. From time to time,the Facility -may change the amount of its charges. In addition, from time to time, the Facility may change how and when its charges are -computed, billed or become due. The Facility reserves the right to make*any such changes at any time., Written notice of any such changes will be given to the - Resident thirty (30) days in advance of implementation, unless the- change is required earlier under any federal. or state law or assistance program. • 8. PARTICIPATION IN -MEDICARE/MEDICAID" PROGRAMS. The Facility participates in the Medicare program administered pursuant to Title XVIII .of the Federal Social Security Act and the Pennsylvania Medical Assistance Program ("Medicaid") administered pursuant to the Pennsylvania state plan and Title XIX -of the Federal Social Security. Act. However, the Facility reserves the right to withdraw from the Medicare/Medicaid-programs at any time in accordance with the law. Admission and Care Agreement - continued -c}, OBLIGATIONS OF RESPONSIBLE PARTY. The Responsible Party is responsible for services and supplies that are billed through the Facility or billed directly to the Resident or Responsible party by any other provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. 10. READMISSION - BED HOLD POLICY. If the Resident leaves the Facility for a period of hospitalization, therapeutic .leave, or any other reason, other than the Resident's death, and if the Resident is not. eligible for, or receiving medical assistance, the Resident's bed will be reserved and charges for the reserved bed will continue to accrue, unless the Resident or Responsible Party -otherwise directs in writing. If the Resident or Responsible Party elects not to reserve a bed, then the Resident will be eligible for readmission upon the availability of the first bed suitable for .the Resident's level of care. If the Resident is receiving medical assistance benefits and - the Resident • leaves , the Facility for - a period of hospitalization or therapeutic leave, the Resident's bed will be reserved for the applicable maximum number of days paid for the reserved bed under the Pennsylvania-Medical Assistance, Program. The current bed reservation period is fifteen (15) days for hospitalization, regardless of level of care, fifteen (15) days for therapeutic leave for residents receiving skilled nursing care,.. and thirty (.3()) days for therapeutic leave for residents receiving intermediate care. The bed reservation period may be subject to change in-accordance with any changes in the-Medical Assistance Program. If the period of hospitalization or therapeutic leave ends within the reservation period under the Medical Assistance Program, the Resident may return to the Facility. if the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania. Medical Assistance Program, the'Resident• must wait until a suitable bed becomes available for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time of readmission, the Resident requires the services provided by the Rome. 11. REFUNDS. The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Resident's. discharge from the Facility or death. Those Nursing Residents on Medical Assistance will receive their refund, if any due,' within ninety (90) days. There will be no other refunds, in the absence of an overpayment, under this Agreement.. 12.. PERSONAL FINANCES. The Resident has the right to manage his/her personal funds. The Resident is and will be responsible to provide his/her- personal funds. If the Resident elects, the Resident may designate, in writing, that the Facility hold and manage the Resident's personal funds-_ If the Resident Admission and Care Agreement - continued designates someone other than the Facility to manage his/her personal funds, the Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to make any designation, and Is responsible for his/her own personal funds unless such designation is made. The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal funds by providing the Facility a written notice signed and dated by the Resident or Responsible Party. If the Resident transfers to the Home, responsibility to -manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which - is - provided - at the time of your admission, and the Facility's personal .funds management policy. The Facility may deduct, at any time, charges due to the Facility under. this agreement from. the Resident's personal funds managed by the Facility. 13. TEMINATION. TRANSFER OR DISCSARGE. (a) By the Resident: The- Resident may terminate this Agreement upon thirty (30) days written notice to the Facility. If the Resident leaves the -Facility for any reason other than a medical emergency or his/her death, the- Resident must give written notice to the Facility at least thirty (30) - days in advance of the departure/ transfer/discharge or termination of the Agreement. If advance written notice is not given to the Facility, there will be due to the Facility its daily and other charges then in effect for the Resident's current level of care for the required ,thirty (30) day notice period. The charge applies whether or not the Resident remains at the'Facility during the thirty. (30) day period. (b) By the Facility: The - Facility may terminate the Resident's stay and transfer or discharge the Resident if: (I) the transfer or discharge is necessary. to meet the Resident's welfare which cannot be. met by the Facility; (II) the Resident's health or condition has improved sufficiently that *the Resident no longer needs the services. provided by the Facility; (III) the safety or health " of individuals in the Facility is or otherwise would be endangered; Admission and Care Aereement- continued IV. The charges or other amounts due to the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf by Medical Assistance under the Medical Assistance Program or by Federal Medicare benefits under Title XVIII of the Federal Social Security Act; or V. The Facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none, a family member or legal representative of the Resident, if known to the Facility, at least thirty (30) days in advance of such a transfer or discharge. However, in any case, describe in subparagraph (I), (II) and (Ill) above, or if the Resident has not resided at the Facility for at least thirty (30) days, the Facility will give such notice before transfer or discharge as is practicable under the circumstances. 14. THIRD PARTY PAYMENTS- The Resident may be or may become eligible to receive financial assistance, reimbursement or other benefits from third- parties, such as through private "Insurance, employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident, the Resident/Responsible Party shall, at all times, cooperate fully with the Facility and each third-party payments. Cooperation includes, when requested, providing information, signing and delivering documents, and having the Facility designated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other governmental assistance, reimbursement or benefits to the extent of all charges due the Facility. The Resident irrevocably authorizes the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law, the Resident hereby assigns now or hereafter payable to the extent of all charges due to the endorse and turn over to the Facility any payments received from third-parties to the extent necessary to satisfy the charges under this Agreement. Admission and Care Agreement- continued 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, personal possessions, and other items of.property. The facility may limit the amount or type of property that the Resident may keep at the facility if there is insufficient space, or if medically indicated or necessary to protect the rights or welfare of others. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse regarding resident's personal property. If nametag labels are needed for clothing items, please leave them at the nursing station. 16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement and the facility's existing policies, rules and regulations which may, from time to time, be altered or amended. 17. MISCELLANEOUS PROVISIONS a. The Resident and Responsible Party acknowledge that they are adult individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by 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 assigned. c. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by competent legal authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been part of this Agreement. d. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (30) days notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. Party e 7 Facility Rei0e!kentative Date Church of God Home, inc. January 1, 2007 Fpith Wing and Love Wing Semi-Private $210.00 per day Private $258.00 per day Nursing Care Room Rates Assisted Living Room Rates Hope Wing and Peace Winn Semi-Private $89.00 per day Private $96.00 - $112.00 per day Creekside Aoartrnents Studio One Bedroom One Bedroom, Creek View One Person $125.00 per day $145.00 per day $150.00 per day Two Persons $215.00 per day $235.00 per day $275.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for rooeWevel of cars. There are no additional charges while receiving benefits under the Medicare program (except telephone, beauty and barber, laundry, transportation and name labels) Independent Living Rates LeTort Manor Apartments ADBrt(nent Monthly Fee_ Real Estate Taxes One Person Two Persons A $805 $1080 $100.12 B $760 $1020 $87.13 C - $745 $1000 $80.99 D $730 $990 $74.84 E $730 $990 $69.37 62jawn-t Type Apadment'A' Apartment 'B' Apartment 'C" Apartment 'D" Apartment 'E' 40% Refundable Rate $99,000 $87,000 $87,000 $73,500 $73,500 Independent Living Rates Creekside Apartments Non-Refundable Rate $ 'dw $69,000 $69,000 $59,000 $59,000 Apartment Monthly Fee One Person Two Persons Efficiency $1,220 $1,665 One Bedroom $1,540 $2,135 Ancillary Services Hair Care Color rinse, set $11.75 Permanents with conditioner $50.25 Cut, Men $10.00 Re-comb $ 7.50 Cut, wash, blow dry $22.00 Re-comb and curling iron $10.50 Cut, Women $10.00 Tint $25.00 Hot wax $ 6.25 Wash and Set $11.25 Men's cut and moustache trim $11.00 Wash, blow dry $1225 Oil treatrnent, shampoo, set $22.25 Wash in bed $12.25 Permanents $40.75 Wash, no blow dry $ 7.50 Permanents in bed $55.25 Wash, style, blow dry in bed $15.00 Men's Cut - Wash in bed $21.00 Men's Cut - Wash $16.50 Male wash in bed $11.50 Female wash in bed $11.50 Wash, style in bed $14.00 Transport to & from appointments $ 1.00 Bed Hold (during hospitalization or LOA) Cable Television (Nursing and Assisted Living) Cable Television (independent Living) Clothing Name Labels Guest Room (maximum stay of 5 nights) Per Diem Rate Included $22.50/month $5.50/100 1 person - $26.00/night 2 persons - $31.00/night incontinence Supplies Liners, small and large Briefs, small and large Miscellaneous supplies Laundry Service (personal clothing) Medication (self administered medication) Photocopies (copies of records) Therapy (physical, occupational, speech) 25% above cost 25% above cost 25% above cost $25.00/month $11.50/day $.10/page Actual cost unless covered under Medicare or co-payment by secondary insurance Private Telephone Purchase Telephone Set At own expense Monthly Line Fee $22.25/month Hook-up, Activation, One Outlet (one time charge) $57.75 Dietary Services (guest meals, include tax) Breakfast Dinner Supper Sundays and Holidays $4.75 $7.15 $5.80 $715 Nutritional Supplies 25% above cost Extra Dietary Service Contact your social worker Medications, Medical and adaptive equipment, special requests, etc. Transportation Services Oxygen Concentrator Usage Portable Oxygen Usage At own expense unless covered by your insurance or covered by medical assistance benefits 0-10 miles (round trip), $20.00 Over 10-50 miles (round trip), $40.00 Over 50 mites price will be determined based on destination and time required Rates are double if an escort accompanies the Resident $2.50 per day $8.00 per cylinder Church of God Home, Inc. EXTRA DIETARY SERVICES SIZE SERVES RETAIL COST W1 TAX CAKES: 9' round - 2 layers '20 $14.00 $10:00 % sheet - 9'x13' 20 $14.00 $10.00 ULM F -tor. 00 1 H " - dMes $1.00 H- 3: I. container 515.00 DW.. - 2.4 4oz. Containers :. $8.00 r $4.76 L $7.16 10 Nis p - 3 lbs. $8.00 - 3 Ibs. 58.00 Punch -1 al_ $3.18 Lemonade -1 al. $3.18 Iced Tea -1 al. $3.18 Cookies -1 doz_ an kind) j $3.00 NOTE: All of the above items include paper serving products and must be ordered 1 week in advance. Special Orders will be priced by Dietary Department Updated: 01/0612006 MEDICAL ASSISTANCE (MEDICAID} RESIDENTS 1. MEDICAL INSURANCE PREMIUMS WILL BE DEDUCTED FROM THE RESIDENTS MONTHLY INCOME AND THE BALANCE OF INCOME WILL BE APPLIED TO ROOM AND BOARD. 2. PRESCRIPTION DRUGS, PHYSICIAN VISITS, DENTAL SERVICES AND EYE EXAMINATIONS ARE COVERED UNDER MEDICAID BUT ONLY WITH PARTICIPATING DENTISTS AND OPHTHALMOLOGISTS. POTENTIAL CHARGES WILL BE DISCUSSED WITH RESPONSIBLE PARTIES ON AN INDIVIDUAL BASIS. 3. ROUTINE HAIR CARE, INCONTINENCY SUPPLIES AND PERSONAL LAUNDRY SERVICES ARE FURNISHED AT NO CHARGE TO THE RESIDENT. ROUTINE SERVICE IS THE FOLLOWING: • NORMAL SHAMPOO IS EVERY TWO WEEKS • WASHING HAIR IN BED IS ONCE PER WEEK MEN'S HAIRCUT IS ONCE EVERY FOUR WEEDS • A PERMANENT WILL BE EVERY THREE MONTHS • ANY REQUESTS BEYOND THE ABOVE ITEMS WILL BE BILLED 4. BED HOLD DAYS DUE TO HOSPITALIZATION CAN BE HELD FOR ONLY FIFTEEN DAYS. 5. ANNUAL AMBULANCE ENROLLMENT WILL BE COVERED UNDER MEDICAID. RESIDENT/RESPONSIBLE PARTY SID T DATE iwa& I FACILITY PRESENTATIVE OF THE [IR2--i °,?OTr"RY 2093 AP R 14 l : e 0 i-v $78• 60 PQ ATTY c4c: ` Q53) R- at,23&.97 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Petitioner, V. No. Oq - J-S3 f Civt !Terms LINDA DEITZ, Respondent CIVIL ACTION - EQUITY c? c C- C=Z PETITION FOR PRELIMINARY INTUNCTION AND NOW COMES Petitioner, Church of God Home, Inc. ("Petitioner" );:by and - m through its attorneys, SCHUTIER BOGAR LLC, and files the within Petition again t_ Respondent, Linda Deitz ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, ' ?PFVrt thereof, avers: 1. Respondent entered into an Admission Agreement ("Agreement") with Petitioner as a condition of the admission of her great-aunt, Betty Fitzer ("Mrs. Fitzer"), to Petitioners skilled nursing facility. See Admission Agreement attached to Complaint as Exhibit "A." 2. In the Agreement, Petitioner was assigned Betty Fitzer's rights to Medical Assistance benefits (hereinafter "the Assignment Clause"). See Complaint. 3. Accordingly, Petitioner now stands in the shoes of Betty Fitzer and has assumed her rights with respect to her 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."). 4. Petitioner cannot exercise its rights to Mrs. Fitzer's Medical Assistance benefits until the Cumberland County Assistance Office ("CAO") processes and ORIGINAL approves the application for Medical Assistance benefits, which cannot be done until Respondent provides the documentation the CAO requires. 5. Respondent's failure to secure Medical Assistance benefits for her great- aunt breaches the Assignment Clause and interferes with Petitioner's 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 Betty Fitzer'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 great- aunt - until Respondent secures Medical Assistance benefits for Betty Fitzer. 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 ownership rights in those benefits and its ability to receive compensation for the skilled nursing services it has provided and continues to provide to Betty Fitzer under the Agreement will be forever lost. 9. Petitioner's right to relief is clear. 2 10. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent and her great-aunt have been financially unable to fully compensate Petitioner for the services that it has rendered and continues to render to Respondent's great-aunt. 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. 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, Dated: e-/ /(9 SCHUTJ? OGAR LLC 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, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Linda Dietz 942 Oak Hill Road Lewisberry, PA 17339 g nq Date: William Keslar, Paralegal IN THE COURT OF COMMON PLEAS OF CHURCH OF GOD HOME, INC., PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. LINDA DEITZ, DEFENDANT 09-2334 CIVIL TERM ORDER OF COURT AND NOW, this 16 day of April, 2009, a hearing on the within petition for a preliminary injunction shall be conducted in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania on Wednesday, April 29, 2009, at 1:30 p.m. sal >- "' ( ?; 7 cv`1 .. - : ? -? j !. t,J k1..! :.J.. ...r .? : 1.f a-- ?:? ,-..,?: r- ? .? , t_? -? ? ? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 09-2334 AFFIDAVIT OF SERVICE Church of God Home, Inc. vs. Linda Deitz Commonwealth of Pennsylvania County of Dauphin as. I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 11:19 AM on 04/18/2009, I served Linda Deitz at 942 Oak Hill Road, Lewisberry, PA 17339 in the manner described below: ? Defendant(s) personally served. ® Adult family member with whom said Defendant(s) reside(s). Relationship is Robert L.eVan Spouse. ? 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 Order of Court, Notice to Defend, Complaint, Verification, Petition for Preliminary Injunction, Brief in Support of Petition for Preliminary Injunction, Certificate of Service, Plaintiffs First Request for Admissions, Plaintiff s First Set of Interrogatories and Plaintiffs First Request for Production of Documents issued in the above captioned matter. Description: Sex: Male - Age: 50 - Skin: White - Hair: Gray - Height: 5' 10" - Weight: 175 X t Sworn to and subscribed before me on this J Shinko sop 2 S nkowsky Invest' ons day of 316 Fawn Ridge N Harrisburg, PA A (800) 2 76-0202 NOTARY PUBL Atty File#: - Our File# 7093 Law Firm: Schutjer Bogar LLC Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102 Telephone: (717) 909-5925 COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL Erin M. Johnson, Notary Public Lower Paxton Township, Dauphin County My commission res November 18, 2012 ORIGINAL OF THE PPS 2009 APR 27 PH = 11 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. 09-2334 LINDA DEITZ, Defendant CIVIL ACTION - EQUITY MOTION TO RESCHEDULE HEARING ON PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES Petitioner, Church of God Home, Inc. ("Petitioner'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Motion to Reschedule Hearing on Petition for Preliminary Injunction, and in support thereof, avers: 1. On or about April 14, 2009, Petitioner filed a Complaint and Petition for Preliminary Injunction against Respondent Linda Deitz, alleging, inter alia, breach of contract. 2. The Complaint alleged, among other things, that Respondent had breeched her obligations under the Admission Agreement by failing to cooperate with the Medical Assistance process and qualify Betty Fitzer for Medical Assistance benefits. 3. On or about April 16, 2009, the Honorable Judge Bayley issued an order scheduling hearing on the Petition for Preliminary Injunction for April 29, 2009, at 1:30 p.m. ORIGINAL 4. On April 29, 2009, Petitioner and Respondent reached an agreement in principle during the hearing before Judge Bayley, wherein Respondent agreed to Stipulate to an Injunction and Authorize Petitioner to pursue Medical Assistance benefits. 5. The Stipulated Order to which Respondent agreed, merely required her to "secure, within thirty (30) days of the date of an Order adopting this Stipulation, any and all documents or verifications, in her possession or within her reasonable ability to obtain, that are required by the Cumberland County Assistance Office to obtain Medical Assistance benefits for Betty Fitzer." In fact, Petitioner modified the Stipulation to Respondent's and her Attorney's request. 6. The parties notified the Court that they had reached an agreement and the hearing was continued. 7. Immediately after the hearing, counsel for Petitioner faxed the Stipulation and Authorization Statement to Respondent's counsel for his client's signature. She failed to sign either document. 8. On May 12, 2009, counsel for Petitioner wrote to Respondent's counsel and provided the Stipulation for Injunction for signature. Once again, no signatures were provided. 9. Finally, on May 19, 2009, counsel for Petitioner left a detailed voice mail message with Attorney for Respondent indicating that if signatures were not received by the close of business, the injunction hearing would be rescheduled. Counsel for Petitioner has received no response to that message. 2 10. Despite the repeated efforts of counsel to obtain signatures on the Stipulation and Authorization to which Respondent agreed at the hearing on April 29, 2009, Respondent has inexplicably refused to abide by her agreement and the minimal obligations it imposes; she continues her pattern of failing to cooperate with Petitioner's efforts to qualify Betty Fitzer for Medical Assistance benefits. 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 Respondent's contractual duties. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 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, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Motion to Reschedule Hearing on Plaintiffs Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Wayne S. Melnick, Esquire AsoM & KUtULAKis LLP 36 S Hanover Street Carlisle, PA 17013 Counsel for Defendant Date: s 2 o o q William Keslar, Paralegal 4 FILES J; F OF THE P, :..+ ;r'NOTPR 2009 MAY 2 ( Ai"I I I* 2 6 I"r MAY 'ol 2 2009 t IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, v. No. 09-2334 LINDA DEITZ, Defendant CIVIL ACTION - EQUITY II ORDER -ttt AND NOW, this day of w , 2069, a hearing in the above-captioned matter on Petitioner's Petition for the issuance of a Preliminary Injunction is scheduled for , 2009, at . 30 o'clock U QX m. in Court Room No. a Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania. OF TNF. F THIONIC) `ARY 2009 JUN 10 Ali l1.5 3 `1 /V'og - Cop f e4 ,n'. L Lc-?, =/Yl jP4.4 MetotL e. tia- IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. 09-2334 LINDA DEITZ, Defendant CIVIL ACTION - EQUITY AFFIDAVIT OF SERVICE I, William Keslar, being duly sworn according to law, depose and say that I served Wayne S. Melnick, Esquire, with the attached Order of Court dated June 10, 2009, in the above-captioned matter, via First-Class Regular Mail, to his business address at ABOM & KUTULAKis LLP, 36 South Hanover Street, Carlisle, PA 17013 on the 11th day of June, 2009. Dated: William Keslar, Paralegal Sworn to and Subscribed before me this - I Z'- day of June, 2009. Notary Public My Commission Expires: COMMMMPAL7H OF PSNRMVAM kRIAL SEAT. BRM..- HEARS,?WARY PUBLIC SWATAx • WNSM. DiPf & COUNTY MY COMMISSIM 1 OUN AIL 23.2011 ORIGINAL BS " 6O'"6UATJER LLC R Email: wkeslar@schutjerbogar.com Direct Dial: (717) 909-8985 June 11, 2009 Via Facsimile and Regular Mail Wayne S. Melnick, Esquire ABOM & KUTULAKIS LLP 36 South Hanover Street Carlisle, PA 17013 Schutjer Bogar LLC 417 Walnut Street 4th Floor Harrisburg, PA 17101 Fax (717) 909-5925 www.schutjerbogar.com Re: Church of God Home, Inc. v. Linda Deitz; Docket No. 09-2334 Dear Attorney Melnick: Enclosed please find an Order dated June 10, 2009, scheduling a hearing for June 19, 2009 at 9:30 a.m. in Court Room No. 2, Cumberland County Courthouse, Carlisle, Pennsylvania. If you should have any questions, please do not hesitate to contact Brandon S. Williams at (717) 909-5922. Thank you. Sincerely, William Keslar Paralegal Enclosure HARRISBURG, PA PHILADELPHIA, PA PITTSBURGH, PA COLUMBUS, OH PRINCETON, NJ BALTIMORE, MD ARLINGTON. VA IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. 09-2334 LINDA DEITZ, Defendant CIVIL ACTION - EQUITY ORDER AND NOW, this 1D? , day of , 2009, a hearing in the above-captioned matter on Petitioner's Petition for the issuance of a Preliminary Injunction is scheduled for,, fa&?_, 19 , 2009, at 4 ; _?n o'clock a.m. in Court Room No. I- , Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania. CORI roOivi h 0%JF1U ??? 1'ect}4. ' ; ???+er9ot, i t? onto set my hard fe sw& 61 sad! at Ca?Se. Pa, 7F TH? 2009 JUN 15 F'i't 3: I .J t?t lL'; CHURCH OF GOD HOME, INC.,: IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - EQUITY LINDA DEITZ, Defendant NO. 09-2334 CIVIL TERM IN RE: AGREEMENT Proceedings held before the HONORABLE EDGAR B. BAYLEY, J., Cumberland County Courthouse, Carlisle, Pennsylvania, on June 19, 2009, in Courtroom Number Two. APPEARANCES: KIRK S. SOHONAGE, Esquire For the Plaintiff WAYNE S. MELNICK, Esquire For the Defendant June 19, 2009, 9:52 a.m. Carlisle, Pennsylvania 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 THE COURT: What are we doing? MR. SOHONAGE: Your Honor, this is obviously the matter of Church of God Homes versus Deitz. Mr. Melnic and I have spoken beforehand. We've come to an agreement. They have executed an authorization statement which in essence is going to give us the authority we were seeking through the hearing. As well, his client has agreed to put on the record a statement that she will continue to cooperate to whatever extent is necessary; and at that point, Your Honor, I think the matter has resolved itself. THE COURT: Okay. MR. MELNICK: That's correct, Your Honor. She's already been cooperating with me in trying to locate documents that are needed, and she's going to continue as necessary. THE COURT: I am glad it is resolved that and it should be. Hopefully that cooperation will result the Home being able to secure as much benefit as it can given the circumstances. MR. SOHONAGE: Thank you, sir. MR. MELNICK: Thank you, Your Honor. (Agreement concluded at 9:53 a.m.) 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CERTIFICATION I hereby certify that the proceedings are contained fully and accurately in the notes taken by me on the above cause and that this is a correct transcript of same. C, a?"4 Pamela R. Sheaffer Official Court Report The foregoing record of the proceedings on the hearing of the within matter is hereby approved and directed to be filed. .. Edgar B?Baylrey, J. Ninth Judicia District 3 ;, .. 4_?1 _ ?? ,r. ?? ?? Y ?J U J ?. I C v. 4 f i i i ,. ?,/ 4 ? ?..