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HomeMy WebLinkAbout09-2428IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC V. CIVIL ACTION - EQUITY No. Dq - ,h/4 Civit-Fem CINDEE FENTON a/k/a CYNTHIA FENTON COMPLAINT Filed on Behalf of Plaintiff: Church of God Home, Inc. Counsel of Record for Plaintiff: SCHUTJER BoGAR LLC Livia F. Langton i Attorney I.D. No. 91548 (412) 281-3710 llangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, CIVIL ACTION - EQUITY No. V. CINDEE FENTON a/kla CYNTHIA FENTON, Defendant. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 EN LA CORTE DE ALEGATOS COM(JN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, CIVIL ACTION - EQUITY No. V. CINDEE FENTON a/k/a CYNTHIA FENTON, Defendant. 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 comparecencia escrita y radicando cn 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 SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Defendant. CIVIL ACTION - EQUITY No. 0,F- 2 Y,z 9' '14^ COMPLAINT AND NOW, COMES, Church of God Home, Inc. ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files this Complaint against Cindee Fenton a/k/a Cynthia Fenton ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff Church of God Home, Inc. is a domestic non-profit 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 Cindee Fenton a/k/a Cynthia Fenton, wife of William Fenton, is an adult individual who currently resides at 133 Garland Drive, Carlisle, Pennsylvania 17013. 3. On or about April 18, 2008, William Fenton was admitted to Plaintiff's skilled nursing facility. 4. Plaintiff and Defendant entered into a written Admission and Care Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide William Fenton with skilled nursing services in exchange for Defendant's promise to pay a specific monetary fee from William Fenton's resources, and Defendant assigned to Plaintiff William Fenton's "any payments received from third-parties to the extent necessary to satisfy the charges under this 1 Agreement." See a true and correct copy of the Agreement attached hereto at pages 46 to 51 of Exhibit "A." 5. After William Fenton became a resident of Plaintiffs skilled nursing care facility, he apparently became insolvent. As a result, Plaintiff notified the Defendant that she needed to apply for Medical Assistance benefits for William Fenton. 6. The Defendant failed to prepare and/or file for Medical Assistance benefits, which resulted in this Plaintiff's filing an application for Medical Assistance benefits on William Fenton's behalf. 7. The application referred to above is currently pending; however, it will be denied unless the Defendant provides the Cumberland County Assistance Office ("CAO") with the information necessary to qualify William Fenton for Medical Assistance benefits. 8. If the Defendant fails to produce the information requested by the CAO at or before the due date, the application for Medical Assistance benefits will fail and Plaintiff will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE Plaintiff v. Defendant 9. The allegations contained in Paragraphs 1 through 8 are incorporated herein by reference as if fully set forth at length. 10. Defendant breached the Agreement with Plaintiff by failing to "cooperate fully with the Facility and each third-party payments. Cooperation includes, when requested, providing information, signing and delivering documents." By not cooperating, Defendant has 2 interfered with Plaintiffs right to receive the Medical Assistance benefits that have been contractually assigned to it. 11. The law is clear that an "assignee stands in the shoes of the assignor and assumes the rights of the assignor." Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997). 12. As Defendant has failed to provide the necessary documentation to the Plaintiff and/or the CAO, as required to process and approve William Fenton's application for Medical Assistance benefits, Plaintiff is precluded from the benefits Defendant assigned to it. 13. Upon information and belief, at all times material hereto, William Fenton has been financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to him in accordance with the terms and conditions of the Agreement. 14. Defendant's breach of the Agreement with Plaintiff has irreparably harmed and continues to irreparably harm Plaintiff. 15. 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. WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. COUNT II SPECIFIC PERFORMANCE/STATUTORY DUTY OF SUPPORT Plaintiff v. Defendant 16. The allegations contained in Paragraphs 1 through 15 are incorporated herein by reference as if fully set forth at length. 17. Defendant Cindee Fenton a/k/a Cynthia Fenton is the wife of William Fenton. 18. At all times material hereto, upon information and belief, William Fenton has been indigent. 3 19. At all times material hereto, Defendant has had a statutory duty to financially support her husband, William Fenton. See 23 Pa. C.S. § 4603(a). 20. At all times material hereto, Defendant has failed to financially support her husband. 21. The statutory duty of Defendant to support her husband must reasonably include the duty to assist with securing financial support through the Medical Assistance benefits system and the duty to not actively work against Medical Assistance benefits approval. 22. At all times material hereto, Defendant has failed to care for, maintain or financially assist her husband by refusing to provide the information and documents requested by the Plaintiff and the CAO to determine the eligibility of her husband for Medical Assistance benefits. WHEREFORE, Plaintiff Church of God Home, Inc. respectfully requests that this Honorable Court order Defendant Cindee Fenton a/k/a Cynthia Fenton to specifically perform her statutory duty and obligation, and to produce the information and documents to the Cumberland County Assistance Office required to secure Medical Assistance benefits for her husband, William Fenton. [This section intentionally left blank.] 4 Respectfully submitted, SCHOTJER BoGAR LLC Dated: q 0 T By: ivia F. Langt Attorney I.D o. 91548 (412) 281-3710 llangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4`h Floor Harrisburg, PA 17101 Attorneys for Plaintiff EXHIBIT A i CHURCH Of GOD HOME -C??n?mirfrd to raring' Nursing Care Admissions Contract Information 4 s Church of God Home, Inc. 801 N. Hanover Street - Carlisle, PA 17013 P: (717) 249-5322 - F: (717) 249-8622 ' Revised 0112008 42?? CHURCH OF GOD HOME T'J"811111rrJin Coll inv' f i Dear Friend: Admission into a health care facility is a leaming experience, both for the new resident and their family. We at the Church of God Home try to make the admission process as positive, pleasant and easy as possible. Because of the number of documents that must be explained and signed upon admission, many facilities look at this as being "overwhelming'. However, both State and Federal regulations require such forms for permanent records. As we welcome the new resident, a hand is extended in friendship... an arm is offered for support ... a cheerful pat of encouragement is given... these are a few of the special touches that the Church of God Home has been offering since its doors first opened in 1948. For more then sixty years a Christian spirit has been the guiding philosophy of our Home. That's the reason our care goes far beyond just meeting the physical needs of our residents. We believe in the dignity and self-worth of each individual, and every aspect of our care reflects that belief. Our mission is to minister to the physical, spiritual, and emotional need of-each resident in order to help him or her lead a more meaningful life. In sharing these values and standards of the Church of God Home, we hope that our experience will benefit others so that, together, we will continue to find better ways to serve the needs of elderly people in our society. i Carson G. Ritchie, CPA, NHA President/CEO 2 Table of Contents 1. Welcome Letter ................................................... ....................................................................... 2 2. Statement of Vision and Mission ................................................................................._........ .......4 3. Ambulance ........................................................................................................................... .......4 4. Chart of Costs ...................................................................................................................... ... 5-7 5. Dietary Services ............................................................................. ..................................... 7-8 ... 6. DVD "A Time of Transition" .................................................................................................. .......8 7. Guest Room ..................................................................................... ................................... ....8 ... 8. Lehigh Valley Respiratory Care - Lancaster ....................................................................... .......9 9. Medicaid (Medical Assistance) ............................................................................................ . 9-10 10- Medicaid (Medical Assistance) Residents ........................................._............................._... .....11 11. Medicaid (Medical Assistance) Residents Checklist ........................................ ................... 12-13 12. Medicare ............................................................................................................................. 14-15 13. Mobile X-Ray Imaging, Inc ........................................................................................................16 14. Psychiatrist ...............................................................................................................................16 15. Smoke Free Environment .........................................................................................................17 16. Specialized Services .................................................................................................................17 17. Transportation ..........................................................................................................................17 18. Understanding Restraint Use ....................................................................................................18 19. Advance Directive Policy ......................................................................................:...................19 ' 20.. Delegation of Responsibility Form ............................................................................................ 20 21. Legal Rights Compliance ..........................................................................................................21 22. Non-Discrimination Statement ....................................................... .22 ............................ 23. Personal Cash Accounts / Depleted funds ..................... .. . 23-24 i 24. Personal Laundry Service ................................................................................................... ......25 25. Pharmacy Services............ ................................................................................................. 26-33 ` 26. Podiatry Services ................................................................................................................ ......34 27. Privacy Act Statement - Healthcare Records ..................................................................... 35-36 ` 28. Private Room Policy / Nursing ...................... .. ......37 29. Therapy .............................................................................................................................. ......38 30. Vaccinations ....................................................................................................................... 39-44 31- Valuables ............................................................................................................................ ......45 32. Admission and Care Agreement ......................................................................................... 46-51 a. Security Deposit ........................................................................................................... ......46 b. Readmission - Bed Hold Policy ................................................. .. ................................ ......48 33. Resident / Family Guide to Inquiries and Information 52-53 1 34. °Welcome" (Tel phone/Ext sion) .................................................................................... ......54 E 35. Checklist ............................................................................................................................. ......55 STATEMENT OF VISION AND MISSION Vision To provide an aging services' continuum of care that reflects the perfect love of Christ, exceeding the expectations of those we serve. Mission Church of God Home, a Continuing Care Retirement Community, is a Christian Ministry committed to caring for the body, mind and spirit of older persons. Admissions Policy It is the policy of the Church of God Home, a 'unit of the Eastern Regional Conference of The Churches of God, to admit and treat all persons without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. Only those applicants whose medical nursing care, psychological and behavioral needs can be adequately met by the staff, will be admitted or kept in this facility. In addition, all residents must meet the financial criteria of private pay, Medicaid or SSI payer source. The Board of Trustees is committed to providing housing, services and needed responsible care for older persons with priority to those who are- members of, or affiliated with, the Eastern Regional Conference of The Churches of God. The same requirements for admission are applied to all, and residents are assigned within the facility without regard to'race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. There is no distinction in eligibility for, or in any manner of, providing any resident service that is provided by or through the facility. All areas of the healthcare center are available to all persons and visitors regardless of their race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. All persons applying for admission, or who are recommending individuals to the Church of God Home, are advised to do so without regard to the person's race, color, national origin, age, ancestry, sex, handicap, disability, or religious creed. Ambulance Ambulance enrollment is recommended but is not handled by the facility. If you desire enrollment, please contact. them independently. 4 Chart of Costs Effective January 1, 2009 Faith Wing and Love Wing Semi-Privale $236.00 per day Private $290.00 per day Assisted Living Room Rates Hope Wing and Peace Wing Semi-Private $103.00 per day (Rm401-411) I Private $111.00 per day (Rm301) $121.00 per day (Rm303-313) $129.00 per day (Rm400) Creekside Apartments i I { Studio One Bedroom One Bedroom, Creek view One person $145.00 per day $165.00 per day $170.00 per day Two persons $245.00 per day $270.00 per day $315.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for roomAevel of care. In the event of a Level of Care change to a higher level the residentfresponsible party will be billed the difference between the security deposits. There are no additional charges while receiving benefits under the Medicare program while in nursing care (except telephone, hair care, personal laundry, transportation, bed hold, bed reserve and name labels). Nursing Care Room Rates Independent Living Rates LeTort Manor Apartments Apartment Monthly Fee One Person Two Persons A $905 $1,215 B $835 $1,125 - C $835 $1,125 D $820 $1,115 E $820 $1,115 Aaartment TVDe 40% Refundable Rate Non-Refundable Apartment 'A' Apartment "B' Apartment 'C" Apartment "D' Apartment "E" $109,000 $96.100 $96,100 $81,000 $81,000 Independent Living Rates Creekside Apartments Apartment Monthly Fee One person Two Persons Efficiency $1,305 $1,785 One Bedroom $1,650 $2,290 $83,000 $73,000 $73,000 $63,000 $63,000 t i i 5 Chart of Costs (continued) Bed Hold (during hospitalization or LOA) Cable Television (Nursing and Assisted Living) Cable Television (Independent Living) Cable Internet (Independent Living) Cable Modem (Independent Living) Per Diem rate Included $22.00/month $20.00/month $62.00 one time fee Clothing Name Labels Guest Room (maximum stay of 5 nights) Incontinence Supplies ' Liners Briefs / Pull-ups Miscellaneous supplies Laundry Service (personal clothing) I Medication (self administered medication) Photocopies (copies of records) Therapy (physical, occupational, speech) Cost 1 person - $28.001night 2 persons - $33.00/night 25% above cost 25% above cost 25% above cost $33.00/month $15.00/day $1.28/pg(1-20) $0.95/pg(21-60) $0.32/pg(61+) Actual cost unless covered under Medicare or co- payment by secondary insurance Private Telephone-, Purchase Telephone Set At own expense Monthly Line Fee $30.001month Hook-up, Activation, One Outlet (one lime charge) $57.75 Dietary Services (guest meals; includes tax) Breakfast Dinner Supper Sundays and Holidays Nutritional Supplies Extra Dietary Service $5.00 $7.65 $6.30 $7.65 25% above cost Contact your social worker Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Transportation Services At own expense unless covered by your insurance or covered by medical assistance benefits 0-10 Miles (round trip) .......................$22.00 11-50 Miles (round trip) .....................$44.00 51+ Miles price will be determined based on destination and time required. 'Rates are double if an escort accompanies the Resident. Oxygen Concentrator Usage $3.00/day, unless covered under Medicare Portable Oxygen Usage $12.00/cyCnder, unless covered under Medicare 6 r r 1 Chart of Costs (continued) Hair Care Color rinse, set $13.00 Cut, Men $11.00 Cut, wash, blow dry $24.50 Cut, Women $11.00 Hot wax $7.00 Men's cut and moustache trim $12.00 Oil treatment, shampoo, set $24.00 Permanents $43.00 Permanents in bed $58.25 Wash, no blow dry $8.25 Men's/Women's cut-wash in bed $26.75 Color rinse $1.00 Dietary Services Permanents w/conditioner $53.00 Re-comb $8.25 Re-comb and curling iron $11.50 Tint $28.00 Wash and set $12.50 Wash, blow dry $13.50 Men's/Women's wash in bed $15.75 Wash, style, blow-dry in bed $26.25 Men's cut - wash $19.25 Mustache trim $1.25 Cut, wash and set $23.50 The Dietary Department. offers three (3) well-balanced nutritious meals daily as well as an alternate menu for personal preference. A PM snack is available upon request at no extra charge. The department employs two Certified Dietary Managers and a Consultant Registered Dietician to provide special diets and dietary consults with residents and families. Our three-week menu cycle offers a variety of homemade items and incorporates fresh fruits and vegetables when in season. Menus are posted in several locations throughout the Home. Our large meal of the day is served mid-day and called Dinner. Our evening meal is called Supper. General Guest Meal Policy Limit four (4) guests per resident (as space permits) for all meals except holidays. Reservations must be made 48 hours in advance for general guest meals. If reservations are not made 48 hours in advance, an alternate guest meal may be served at the discretion of the Dietary Department. Holiday Guest Meal Policy On the holidays of Easter, Mother's Day, Thanksgiving, and Christmas there is a limit of two (2) guests per resident. Due to the volume of guests that may wish to dine of these holidays, the Church of God Home will accommodate the first twenty-five (25) guests to register. Since it is impossible to provide this notice to all family members, please share this information with your extended family. Thank you for your understanding and cooperation. Families are encouraged to participate in special meal events throughout the year, such as our Parents Day and Holiday Buffet. 7 i Extra Dietary Services (Arrangements for these provisions should be made through your Social Worker.) 'You will receive a separate bill from our Business Office for these services. SIZE CAKES: SERVES COST wITAX 9" Round - 2 layers 16 $15.00 Sheet -10"x14' 16 $15.00 '/s Sheet -12"x17" 30 $20.00 Full 60 $30.00 MW itk ICE CREAM: Hand dipped - dishes $1.00 Hand dipped_- 3 al. container $17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate $10.00 GUEST MEALS: Breakfast $4.75 Dinner $7.15 ' Supper $5.80 Sunday and HoGda $7.15 ?. MISCELLANEOUS: ' Potatoes Chips - 3 lbs. $9a5 ' ; Pretzels - 3 lb. $7.55 ' Punch-1 al. $4,00 Lemonade -1 al. $4.00 Iced Tea -1 al. $4.00 Cookies -1 doz. An Kind $3.50 l NOTE: All of the above items include paper-serving products and must be ordered 1 week in advance. Special Orders will be priced by Dietay Department 1 DVD "A Time of Transition" I acknowledge that I have viewed the DVD entitled 'A Time of Transition' and have been provided the I opportunity to ask questions. I further acknowledge that Guide One Insurance, the Home's insurance company, recommends a viewing of this DVD. f ? (t initials) f Guest Room l I There is a cost per night with a maximum stay of five nights. A second person in the room is an additional j charge per night. No young children please. Your friend or relative will be billed for their stay. Reservation can be made through the Residential Housing Administrator (717) 249-5322 extension 3085. i 8 , LEHIGH VALLEY RESPIRATORY CARE - LANCASTER 1176 Enterprise Court - East Petersburg, PA 17520 (717) 5694667,1-800-952-8452, Fax (717) 569-5555 Lehigh Valley Respiratory Care - Lancaster is an independent Home Medical Equipment Company providing respiratory services to tong Term Care Facilities. We are accredited by the Joint Commission of Accreditation of Healthcare Organizations to perform Clinical Respiratory Services. Lehigh Valley Respiratory Care - Lancaster provides Church of God Horne residents with oxygen and respiratory supplies. The Church of God Home will contact Lehigh Valley Respiratory Care - Lancaster for these services when initially needed. Assisted Living Residents: • Lehigh Valley Respiratory Care - Lancaster will then contact the Resident/Responsible Party to schedule the arrangements and discuss their billing procedures. • Oxygen / Respiratory Supplies may be covered under Medicare Part B as long as the qualifying criteria has been met. • Lehigh Valley Respiratory Care - Lancaster will contract with the Resident/Responsible Party on an individual basis and will bill Medicare Part B directly. MEDICAID (MEDICAL ASSISTANCE) Medicaid provides Medical Assistance to low-income persons aged 65 or over, blind, disabled, or members of families with dependent children. The Federal and State Governments jointly finance this program and it is administered by the state. Within broad general Federal Regulations, each state decides eligibility, types and range of services, payment level of services, and administrative and operating procedures. Medicaid's major distinction from Medicare is a form of financial-aide. Medicare is a type of healthcare insurance. When resident resources are reduced to $15,000.00, the facility Business Office should be notified immediately. The following instructions will apply: 1. Resident/Responsible party will be responsible for a burial reserve set up at a bank or funeral home with amount equalizing enough for burial. The amount set aside should include amount of life insurance plus additional funds. A copy of that agreement should be submitted to the Business Office. 2. When all assets are reduced to $2,000.00, call the Business Office for appointment for guidance in the enrollment process. It is the legal responsibility of the POA/Representative Payee to complete the application and enrollment process for Medical Assistance benefits. Every effort will be made by our Business Office staff to assist you. A checklist (pg12-13) is being provided to you with guidelines that will help you get started. Please be aware however; that if the POA/Representative Payee does not follow through in a timely manner, that the Church of God Home, Inc. reserves the right to file the application on the resident's behalf. 3. The Cumberland County Office of Aging will do a level of care assessment of the resident, known as an "Options Assessment" and forward the results to the Pennsylvania Department of Public j Welfare (DPW) for further follow-up by the Cumberland County Assistance Office. Should they assess for a different level of care other than nursing, and/or the resident does not qualify for 9 Medicaid, the facility reserves the right to terminate the admission agreement and will work with resident/responsible party regarding available options. 4. To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Cumberland County Assistance Office 33 Westminster Drive Post Office Box 599 Carlisle, Pennsylvania 17013 P: (717) 697-8545, (717) 240-2700, and 800-269-0173 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 16 West High Street Carlisle, Pennsylvania 17013 (717) 240-6110 5. After preliminary papers are sent to the assistance office, the resident's security deposit will be applied to room and board and any balance due billed to the responsible party. 6. After.being approved, Medicaid requires that the resident's monthly income be submitted to the facility each month. Of that amount, the resident will receive the approved 15.00 monthly allowance for his/her personal needs. The resident, responsible party or the facility may handle this personal money. 7. Allowable expense from resident monthly income is health insurance. After acceptance into the Medicaid program, billing for health insurance should be forwarded to the staff in our business office. The monthly expense for this insurance is deducted from the resident's monthly income and the balance is applied to the room and board. The state pays the facility a per diem (daily) rate times the number of days in the month that a resident, approved for Medicaid, occupies an accommodation. After resident's responsibility is applied to this amount, the balance is billed to the Pennsylvania Department of Public Welfare (DPW) on a monthly basis. Bills for personal needs may be presented in the resident's name to the facility handling funds for reimbursement. Upon enrollment into the Medicaid program, the resident will no longer pay for routine hair care, incontinence supplies, non-emergent medical appointment transportation or personal laundry service. Medicaid will, however, pay for prescription drugs, doctor visits, dental services and eye examinations. 8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits, the facility will hold a bed. i0 CHURCH OF GOD HOME `Gurunirreel ro Corrine" Medicaid (Medical Assistance) Residents 1. The Church of God Home, Inc. requires a copy of monthly 1 quarterly Medical Insurance premiums. As REQUIRED by Pennsylvania State Regulations. 2. Medical Insurance Premiums will be deducted from the Resident's monthly income and the balance of the income less a $45.00 allowance will be applied to room and board. 3. Prescription drugs, physician visits, dental services, and eye examinations are covered by Medicaid, but only with participating dentists and ophthalmologists. Potential charges will be discussed with responsible party on an individual basis, when requesting non-participating providers. 4. Services furnished at no charge to the Resident are as follows: Normal Shampoo every two weeks ¦ One perm every three months • Transportation to and from medical appointments is provided (Distance to appointments will be discussed on an individual basis) • Non-emergent ambulance transportation • Personal Laundry • Incontinent Supplies • Bed hold in the event of hospitalization The following services will be charged: • Any hair care request beyond the above list of provided services • Transportation for a personal use • Telephone hook-up, basic charges, and long distance charges 5. Bed hold days due to hospitalization will be fifteen (15) days per hospital stay. Bed hold days due to therapeutic leave will be thirty (30) days per calendar year. a -17 _0q* (Date) (Resident/Responsible Party) (Res nt N ) (Facility Repre ar e) ]I Medicaid (Medical Assistance) Resident's Checklist CUMBERLAND COUNTY ASSISTANCE OFFICE 33 Westminster Drive Carlisle, Pennsylvania 17013-0599 Telephone: 1-800-269-0173 or (717) 240-2700 In order to determine eligibility for nursing home Medicaid enrollment, the Cumberland County Assistance Office will need the following items to accompany your application when submitted by our billing office. (Photocopies are acceptable) Please call if you have any questions or need help in obtaining the required information. 1. Social Security Card(s) 2. Proof of Date of Birth 3. Health Insurance Cards A. Medicare (Red/White/Blue Card(s)) B. Capital Blue Cross / Highmark Blue Shield Card(s) C. Any other health insurance plan(s) 4.Health Insurance Premiums, provide frequency and amount 5. Lang Term Care Policies, provide monies received and terms ____ 6. Power of Attorney or Guardianship papers 7.Read HIPAA disclosure and complete the HIPAA disclosure request PW1815 &Verification of ALL GROSS VA income needed. (If you are not receiving benefits, you will E need to apply for potential benefits in order to be eligible for Medicaid.) - 9.Verifrcation of ALL GROSS income - provide current award letters, pensions, annuity income, and interest income - 10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and i Annuities -must provide values of 11. Personal Care Account (PCA) Balance 12. Verification of all resources sold, transferred, or given away during the past 3 years (5 years for a Trust Fund) - provide disposition, amounts, and dates I 13. Titles, vehicle registration, and insurance for all vehicles owned, including boats, motorcycles, and trailers 12 14. Current cash value of all life insurance policies. Verification should include company's name, policy number, type of policy, face amount of policy when purchased, ownership of policy, and statement on the current cash value from the insurance company. 15. Deed to burial plot(s) or statement from cemetery 16. Copy of Burial Trust 1 Reserve (including Statement of Irrevocability) 17. Deed to all property and it's current market value - if transferred or sold within the last 36 months, provide a copy of the new deed and the settlement sheet for all sold property _ 18. Title to mobile home and it's current market value - if transferred or sold within the last 36 months, provide a copy of the new deed and the settlement sheet for all sold property 19. Any unpaid medical bills you wish to see if Medical Assistance would cover 20. Rent 1 Mortgage payment proof 21. Utility Bills A. Electric B. Gas C. Oil D. Heat E. Telephone F. Water G. Sewer H. Trash 22. Income Tax Returns - for the past 3 years, provide all schedules and 1099 Forms 13 MEDICARE The Church of God Home participates in the Medicare program administered pursuant to Title XVII I of the Federal Social Security Act. Medicare hospital insurance helps pay for inpatient care in a Medicare-participating skilled nursing facility following a three (3) night hospital stay and your condition requires daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility. A skilled nursing facility is a specially qualified facility, which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are met: 1. You have been in a hospital at least three nights in a row, before your transfer to a participating skilled nursing facility. 2. You are transferred to the skilled nursing facility because you require care for a condition, which was treated in the hospital. 3. You are admitted to the facility within a short time, generally within 30 days after you leave the hospital. 4. A doctor certifies that you need, and you receive, skilled rehabililation services on a daily basis, and 5. The Medicare intermediary or the facility's Utilization Review Committee does not disapprove your stay. All conditions must be met. It is especially important to remember the requirement that you must need skilled nursing care or skilled rehabilitation services on a daily basis. Skilled nursing care means care that can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical, occupational, and speech therapies performed by, or under the supervision of, a professional therapist. The skilled nursing care and skilled rehabilitation services you receive must be based on a doctor's orders. Hospital insurance will not pay for your stay if you need skilled nursing or rehabilitation services only occasionally, such as once or twice a week, or if you do not need to be in a skilled nursing facility to get skilled services. When your stay in a skilled nursing facility Is covered by Medicare, hospital insurance helps pay for up to 900 days each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. 34 If you leave a skilled nursing facility and are readmitted within 30 days, you do not have to have a new 3- night stay in the hospital for your care to be covered. If you have some of your 100 days left and you need skilled nursing or rehabilitation services on a daily basis for further treatment of a condition treated during your previous stay in the facility, Medicare will help pay. In each benefit period, hospital insurance (Medicare Part A) pays for all covered services for the first 20 days you are in a skilled nursing facility. For the 21s' through the 1001h day, as long as you continue to meet the criteria for daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered services except for $133.50 a day. You may be charged up to this amount by the skilled nursing facility or it may be picked up by your secondary co-insurance. Effective May 30, 2008: Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. Major services covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) pays for these services: • A semi-private room, 2 beds in a room • All your meals, including special diets • Regular nursing services • Rehabilitation services, such as physical, occupational, and speech therapy • Drugs furnished by the facility during your stay • Blood transfusions furnished to you during your stay.. Medical supplies such as splints and casts Use of appliances such as a wheelchair Oxygen usage Some services not covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) does not pay for these services: Personal convenience items such as a telephone in your room • Private duty nurses Any extra charges for a private room unless it is determined to be medically necessary • Transportation • Name Labels • Hair Care Personal laundry service NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you receive, you always have the right to appeal the decision. Feel free to contact Medicare at 1-800-633-4227. The Church of God Home reserves the right to withdraw from the Medicare program. 15 MOBILE X-RAY IMAGING, INC. Mobile X-Ray Imaging, Inc. ("MXI-) is the most advanced, most efficient, most complete and the only local mobile diagnostic X-Ray/Uttrasound/EKG service in Central Pennsylvania. Based in Harrisburg, MXI employs technologists in Carlisle as well as both the East and West Shore areas of Harrisburg, making it convenient for us to provide fast efficient service to our customers throughout the region. We provide a broad range of mobile diagnostic services to our nursing home customers at the nursing facility, offering the convenience and comfort of having diagnostic studies performed in the home without the expense and discomfort of ambulance transportation. The following diagnostic services are available on 24 hours per day, 365 days per year basis: Diagnostic X-Ray Studies Electrocardiogram Services Holler Monitor EKG Diagnostic Ultrasound Examinations Our X-Ray and Ultrasound exams are interpreted by Quantum Imaging and Therapeutic Associates (formerly known as A.Z. Ritzman Associates), one of the foremost radiology physician practices in Central Pennsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists, P.C. MXI has introduced the following significant improvements to the mobile diagnostic testing industry in Central Pennsylvania: MXI was the first provider to utilize sophisticated 'high frequency' portable X-Ray units, which produce superior images with less radiation exposure. We were the first mobile service in Central Pennsylvania to provide 24 hours a day, 7 days a -week X-Ray service with round the clock interpretations. We are the only mobile service in Central Pennsylvania, which does our own ultrasound examinations, which gives us complete control over quality and service efficiency. We are the only mobile service in Central Pennsylvania to provide ultrasound service on 24 hours per day, 7 days a week basis, including interpretations. . Our services are covered by Medicare, Medicaid and most major insurances. Mobile X-Ray Imaging, Inc. - 5120 Lancaster Street - Harrisburg, PA 17111 (717) 561-4940 Psychiatrist The Church of God Home, Inc. offers psychiatric services specializing in geriatric services. Philhaven Hospital has contracted with the Church of God Home to provide on-site services for our senior adults. Billing for this psychiatric service will ill be as follows: If the resident is private pay, Philhaven Hospital will bill Medicare first, then your supplemental insurance. If there is still a balance, then the responsible party will be billed. If the resident is on Medical Assistance, Phiihaven Hospital will bill Medicare first, then your supplemental insurance, and Medical Assistance third. There will be no bill to responsible parties. Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-8211 if you need further clarification. We at the Church of God Home welcome this new dimension of expertise to our highly qualified staff. 16 Smoking Policy The Church of God Home does not permit smoking in any of our levels of care. Residents and visitors who smoke are asked to utilize the area provided outside the main entrance for this purpose. Employees and volunteers are not permitted to assist residents in meeting their smoking needs. It will be necessary for residents to get assistance from their family member and friends. All prospective residents will be informed of our Facility's smoking policy. Specialized Services If you have mental retardation, a physical disability, or other disability which occurred before the age of twenty-two (22), you may be eligible to receive support services that would help you to live with your family, in your own apartment, or in another community setting. You may also be eligible for specialized services. For more information, if you'have mental retardation call Central Regional Office of Developmental Programs at (717) 772-6507. It you have another disability (other than mental retardation or mental illness) call United Disabilities Service at (717) 397-1841. If you have mental illness (other than dementia) and you do NOT need nursing facility services, you may be eligible to receive support services that would help you five in your own apartment, in a group home, or another community setting. For more information, call (717) 772-7490. If you are not satisfied with the response you receive, call the Disabilities Rights Network of PA at (215) 238-8070. Transportation Enrollment with the local ambulance service is not required, but is recommended. Not all medical appointments require ambulance stretcher transport and are often handled by our wheelchair lift van. Physician ordered medical appointments are to be scheduled through our nursing department with local physicians, as the Church of God Home does not normally transport to out-olmtown medical appointments. Family members will be contacted to determine their availability to provide transportation, or to serve as a companion to accompany residents during transport, throughout the appointment, and on the return trip. Medical consult sheets accompany residents to their appointments and often there is a need to adjust for a meal or medication routine. Families providing transport are requested to follow the sign out procedures and are asked not to schedule follow-up appointments unless they are intending to provide the transportation. In either event, please be sure to inform the nursing department of the scheduled follow-up appointment. NOTE: Transportation provided by the facility will be at an extra charge. Please see *Chart of Cost" for fee schedule. 17 UNDERSTANDING RESTRAINT USE In order to protect our residents from harm or to promote them to a higher level of independence, it is sometimes necessary for us to use a physical restraint. Physical restraints are any manual method, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to the resident's body. Examples include: bedside rails, leg restraints, arm restraints, hand mitts, soft ties, wheelchair safety bars and geri chairs. These devices are NEVER used as a disciplinary action or for the convenience of the facility to control behavior. Restraints are initiated only after less restrictive measures, such as positioning pillow, pads, wedges, removable lap trays couples with appropriate exercises, or other "enabling" equipment, have been demonstrated to be insufficient. The least restrictive device would be then implemented following a specific doctor's order and/or a phone call to P.O.AJ next of kin. The resident will then be reviewed in the next Restraint Reduction meeting. The following is a comparison of potential BENEFITS and RISKS of restraint use: Potential Benefits • Prevention of falls which might result in injury Protection from other accidents or injuries • Medical treatment allowed to proceed without resident interference • Protection of other residents/staff from physical harm Increased feeling of safety and security Potential Risks Accidental injury from the restraint Chronic constipation • Incontinence Pressure sores • Loss of muscle tone • Loss of balance • Reduced appetite, dehydration • Loss of independent mobility Increased agitation • Symptoms of depression; withdrawal • Contractures Reduced social contact 18 S CHURCH OF GOD HOME -rommi??rd ?n Carinq- Advance Directive Policy i It is God alone who opens the door to earthly life. It is God alone who has the right to close it. All experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of priarities. The Church of God Home recognizes the right of an individual to make and change decisions concerning their medical care in consultation with their physician. This includes the right to accept or refuse artificial means of sustaining life when these decisions are set forth in properly executed Advance Directives/Healthcare Guidelines. In no instance will the Church of God Home condone homicide, euthanasia, suicide or aided suicide. In the absence of advance directive, the care of the resident will be in accordance with currently accepted medical standards. Regardless of the resident's decision about life sustaining treatment, supportive and compassionate care for maximum comfort will be provided. These measures include, but are not limited to, oxygen, medication to relieve pain, food and fluids as tolerated, along with emotional and spiritual support. Should the occasion arise when a resident would refuse nutrition or medical supportive services with the intention of prematurely bring their life to an end, the Home would encourage and recommend counseling and evaluation. The family would be informed and, if a satisfactory resolution cannot be achieved as to the care of the resident, the Home would assist the family in the attempt to relocate the resident to another facility as soon as possible. I acknowledge that I have received a duplicate copy of the above Advance Directive Policy and have had provided the opportunity to ask questions relating to the same. I have also been offered the opportunity to complete an Advance Directive. .2-17 0f (Date) 0.4 (Resident/Responsible Party) (Resident N e) (Facility Repr t ive) 19 420-ba CHURCH OF GOD HOME " C'mumirrrd in C. 16I.V, DELEGATION OF RESPONSIBILITY FORM As a result of medical and/or physical condition or personal choice, residents find it difficult to understand and/or sign for their Resident's Rights and/or their Admission contract. Some residents, although not legally judged incompetent, may be found by a physician to be incapable of understanding these rights and contract information. 'Therefore, a resident may choose to designate an individual to act of their behalf by permitting them to sign the necessary forms indicating receipt of this information. AfV1 is medically/physically capable of ! (Name of resident) understanding Resident's Rights but designates this to: C2-- 17 -- 09' (Date) 20 (Resident/Responsible Party) 42 CHURCH OF GOD HOME -C oninrined to carilly- LEGAL RIGHTS COMPLIANCE RESIDENTS AWARENESS COMMONWEALTH INFORMATION CENTER PENNSYLVANIA DEPARTMENT OF AGING .402A Finance Building 555 Walnut Street Harrisburg, PA. 17120 Harrisburg, PA. 17101 ! Telephone: 1-800-932-0784 Telephone: 717-783-7247 i PENNSYLVANIA DEPARTMENT OF HEALTH j DIVISION OF NURISNG CARE FACILITIES HARRISBURG FIELD OFFICE 132 Kline Plaza, Suite B j Harrisburg, PA. 17104 j Telephone: 717-783-3790 CUMBERLAND COUNTY AGING & COMMUNITY SERVICES OMBUDSMAN PROGRAM HUMAN SERVICES BUILDING 16 West High Street Carlisle, PA. 17013 Telephone: 717-240-6110 -17-?? (Date) PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CUMBERLAND CTY. ASSISTANCE OFFICE 33 Westminster Drive P.O. Box 599 Carlisle, PA. 17013 Telephone: 717-240-2700 1-800-269-0173 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA. 17013 Telephone: 717-243-9400 ( 21 (ResidenUResponsible Party) 4m? CHURCH OF GOD HOME -Crrninrined to Caririy- NON-DISCRIMINATION STATEMENT In accordance with applicable Federal and State civil right laws and regulatory requirements, you, as a resident of this facility, have the right upon admission: • To be provided services at this facility and to be referred for services at other facilities without regard to your race, color, religion creed, handicap, ancestry, national origin, age or sex. • To file a complaint of discrimination if you feel you have been discriminated against on the basis of your race, color, religious creed, handicap, ancestry, national origin, age, or sex. Complaints of discrimination may be filed with any of the following: President/CEO Church of God Home, Inc. 801 N. Hanover Street Carlisle, PA 17013 Phone: (717) 249-5322 Department of Wealth and Human Services Office for Civil Rights 150 S. Independence Mall West Suite 372 Philadelphia, PA 19106-3499 Phone: (215) 861-4441 Pennsylvania Human Relations Commission Harrisburg Region Office Riverfront Office Center 1101-1125 South Front Street, 51h Floor Harrisburg, PA 17104-2515 Phone: (717) 787-9784 07 (Date) Department of Public Welfare Bureau of Equal Opportunity Central Regional Office Rm # 223, Health & Welfare Bldg. P.O. Box 2675 Harrisburg, PA. 17120-2675 Phone: (717) 763-3063 (Resident/Responsible Party) (Resident N r (Facility Repr nt 've) 22 Personal Cash Accounts (PCA) To establish personal cash account (PCA) at the Church of God Horne, Inc., contact our Business Office (Henderson House). The following procedure shall be followed: 1. Sign the following authorization form to open an account 2. Deposit money by checks or cash - A receipt will be issued for cash deposits. 3. Daily withdraw maximum of $30.00 Note: Regular business hours are 9:00 a.m. to 3:45 p.m., Monday through Friday, except holidays. Deposits The resident or family member ! responsible party may deposit cash or checks either at our Business Office (Henderson House) or in our Lobby Front Office during regular business hours and of course, by mail. Personal cash accounts are only meant to provide casual spending money for residents. Disbursements The resident may come to our Lobby Front Office during business hours;to request money. A resident charge slip is completed and the resident or family member / responsible party signs the disbursement slip. Purchases for a resident may be made by family or designated person and a receipt should be submitted to our Business Office for each reimbursement from the resident's account, i.e. TV's, shoes, clothing, etc. ' PCA's are reconciled monthly to the bank statement. Interest paid by the bank is pro-rated to each account i and deposited into each account accordingly. Quarterly statements are issued, along with a cover fetter to be signed by the resident and returned to our Business Office. Each resident of the facility has the right to open a personal cash account (PCA). All accounts, regardless of the resident's status, are handled in the same manner. Upon the death/discharge of a resident, the account balance shall be returned to the executor of their Will or authorized representative of their Estate within thirty (30) days. 23 Personal Cash Accounts (cont.) CHURCH OF GOD HOME 'Ton;nriurd to Authorization to Handle Personal Funds _1-7 _ ot 0 , ?1? (Date) (Residenl/Respon6ble Party) z 6;z4 ?-? (Re dent Name) ' (Facility Reps live) ry:_ IDepieted Funds khen resident's assets reach $15,000.00, family/responsible party should c646ct our Business Office linmediately. family member I responsible party will have to apply for Medical Assistance'lsidents with no family lVember / responsible party, our Business Office will apply for Medical Assistance`U - Residents will receive $45.00 monthly from their income for personal needs ' Other monies may be -deposited into each PCA, as the resident or family member / responsible party desires. (Date) (ResidenUResponsible Party) &1 9-,, 1 - (Resident Name) (Facility Repres lati ). 24 42 CHURM Of GOD HOME 'r'nmmined u? f arinf" Personal Laundry Service This is to advise that the personal laundry will be launde Within outside (circle one) the facility. NOTE: • These arrangeMnis can be changed with notification to Social Services or Charge Nurse. • Residents 1 Responsible Parties providing laundry services need to provide a container with a. lid and box of plastic bag liners for the purpose of storing laundry. • Volunteers are available to assist with labeling clothing ! personal items. Please contact Social Services or Charge Nurse. • Dry cleaning and_ Alteration Services are not provided. 'a??.accepied. • No wool items C9- (Date) ?t (ResidenllResponsbble Party) (Resident Name) (F ty Repr er five) 25 Continuing Care Rx is proud to announce that we have been chosen to be the provider of choice for the i pharmacy services at Church of God Home. The mission of Continuing Care Rx is to provide pharmacy services and programs that meet the ever-changing needs of our facilities and the residents they serve, ensuring continued quality care and positive outcomes in the most cost-efficient manner possible. Pharmacy services for Long-Term Care or Personal Care Residences are mandated by government agencies to offer additional services, which you may not have been accustomed to in a normal retail pharmacy. These additional services are designed to aid in your progress (or that of your loved one). We would like to highlight some of the services we provide to give you a better understanding of the many unique benefits we have to offer the residents we serve: ? Controlled Packaging System - Routine tablet/capsule medications are packaged in a 30-day sealed blister card enabling nursing staff to administer medications in a controlled environment with extreme accuracy and safety. • Medical Records - A medical records staff member maintains and prints monthly charts that are utilized by the caregivers, nursing staff and physicians. + 24-Hour Emergency Service - If a situation occurs that requires the delivery of medications in an emergency, Continuing Care Rx has a pharmacist and driver on call 24 hours a day, 7 days a week to meet these emergency needs. • Consultant Pharmacist -A Consultant Pharmacist is assigned to our facilities to review residents' charts on a monthly basis and to interact with the nurses and physicians to monitor the residents' condition. In addition, they will make recommendations to the physicians when a better and more cost-effective therapy for the existing condition becomes available. • Delivery Service - Medications will be delivered to the facility at predetermined times on a daily basis, ensuring timely delivery of all medications ordered. • Billing - The staff at Continuing Care Rx will handle the billing process for all types of reimbursement. Continuing Care Rx is a member of most insurance groups and we bill directly to these insurance groups. Should you belong to an insurance group with which we are not currently affiliated, we will immediately pursue enrollment in that program in an effort to meet your needs and ease your financial responsibility. We would like to point out that all of the above services are provided at no additional cost, thus ensuring a much more cost-effective and beneficial way of dispensing and monitoring pur residents' medications. We, at Continuing Care Rx, are focused on providing the highest quality of pharmacy services to all of the residents we serve. We look forward to working closely with you (or your loved one) by providing the best service available in the long-term care industry. Note: Please contact Continuing Care RX with any questions or billing concerns at 1-800-675-2279. 26 Pharmacy Services Pirrron .'.'osrt CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 1. Our Ditty to Safeguard Your Protected Health Information We are commined to preserving the privacy and confidentiality of your health information. We are required by certain state and federal regulations to implement policies and procedures to safeguard your health information. Copies of our privacy policies and procedures are maintained in our business office. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revisions that we may make to the notice as may become necessary or as authorized by law. Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care treatment or services you receive is considered protected health information (PHI). Accordingly, we are required to provide you with this Privacy Notice that contains information regarding our privacy practices to explain buw, when and why we may use or disclose your Pill and your rights and our obligations regarding any such uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum amount of PHI necessary- to accomplish the intended purpose of the use or disclosure of such information. We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have about you as well as any information we receive in the future about you. Should we reviselchange this Privacy Notice, we will promptly post the revision [insert location, such as on a websitel. You also may request and obtain a copy of any newirevised Privacy Notice from the contact person identified on the last page of this notice. Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document. 11. How We May Use and Disclose Your Protected Health Information We use and disclose protected health information for a variety of reasons. We have a limited right to use and/or disclose your protected health information for purposes of treatment, payment, or for health care operations. For- other uses and disclosures, you most give us your written authorization to release your protected health information unless the law permits or requires us to make the use or disclosure without your authorization. Should it become necessary to release or give access to your protected health information to an outside party performing services on our behalf (e.g.. maintaining our computers), we will require the party to have a signed agreement with us that the parry will extend the same degree of privacy protection to your information as we do. The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health information. Where appropriate, we have included examples of the different types of uses or disclosures. These include: 1_ Use and Disclosures Related to Treatment We may disclose your protected health information to those who are involved in providing medical and nursing care services and treatments to you. For example we may release protected health information about you to nurses, nursing assistants. medication aides/technicians. medical and nursing students, therapists, other pharmacists, medical records personnel, other consultants, physicians, etc. We may also disclose your protected health information to outside entities performing other services relating to your treatment. such as long term care facilities, hospitals, diagnostic laboratories, home heath/hospice agencies, family members. etc. 2. Use and Disclosures Related to Payment We may use or disclose your protected health information to bill and collect payment for items or services we provided to you. For example, we may contact your insurance company, health plan, or another third party to obtain payment for services we provided to you. P.naec Wanes 27 Prrrar. Narirr 3- Use and Disclosures Related to Health Care Operations We may use or disclose your protected health information for the pa-fonnance of certain functions in monitoring and improving the quality of care and services that you and others receive. For example. we may use your protected health information to evaluate the effectiveness of the care and services you are receiving. We may also disclose your protected health information for auditing, care planning. quality improvement. and learning purposes. 4. Use and Disclosures Related to Treatment Alternatives, Halth-Related Benefits and Services We may use or disclose your protected health information for purposes of contacting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you, such as a newly released medication or treatment that has a direct relationship to a treatment or medical condition. 111_ Uses and Disdosures Requiring Your Written Authorization For uses and disclosures of your protected health information beyond the above excepted purposes, we are requited to have your written authorization, except as otherwise required or permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. Our contact information for purposes of revoking your authorization is listed on the last page of this document. You may use our Authorization for Use or Disclosure of Protected Health Information form and/or our Revocation of onAutharization form to submit your request to u5. Copies of these forms are available upon request. Examples of uses or disclosures that would require your written authorization include. but arc not limited to, the following: 1. A request to provide your protected health information to an attorney for use in a civil litigation claim. ?. A request to provide certain information to an insurance or pharmaceutical company for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you. 3. A request to provide PHI to another individual or facility, where no exception ti-orn the written authorization requirement applies. IV. Uses or Disclosures of Information Based Upon Your Verbal Agreement In the following situations, we may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are unable to object (e.g., because you were not present or. you were incapacitated), disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interest. When a disclosure is made based on these or emergency situations, we will only disclose protected health information relevant to the person's involvement in your care. For example, if you are having an adverse reaction to a medication, and are not able to communicate with us effectively, we may inform a family member involved in your cart of your drug regimen and possible side effects. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so. We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care- We may also disclose your protected health information to a disaster relief organization ror the purposes of notifying your family and/or friends about your general condition, location, and/or status (i.e., whether you are alive or dead). You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection or your objection may be made orally. Our contact information is listed on the last page of this document. (See also Section VI, paragraph l.) V_ Uses and Disdosures of Information That Do Not Require Your Consent or Authorization State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorizaiion include the following: 1. When Required by Law- We may disclose your protected health information when required by federal, state or local law. Privacy Novice i i t 28 Privacy vorice 2. Abuse, Neglect. or Domestic Violence: As required or permitted by law, we may disclose protected health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, we will use our professional judgment in deriding whether or not to make such a report. if feasible, we will inform you promptly that we have made such a disclosure. 3. Communicable Diseases: To the extent authorized by law, we may disclose information to a person who may have been exposed to a communicable disease or who is otherwise at risk of spreading a disease or condition. 4. Disaster Relief: We may disclose protected health information about yuu to government entities or private organizations (such as the Red Cross) to assist in disaster relief efforts. 5. Food and Drug Administration (FDA): We may disclose protected health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device. 6. For Public Aesith Activities: As required or permitted by law, we may disclose protected health information about you to a public health authority, for example, to report disease, injury, or vital events such as death. j 7. For Health Oversight Activities: We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, or to other agencies responsible for monitoring the health care system far such purposes as reporting or investigation of unusual incidents or to ensure that we are in compliance with applicable state and federat laws and i regulations, including civil rights laws. 8. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations or Tissue Banks: We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We may also disclose your protected health information ?o a funeral director for the purposes of carrying out your wishes and/or for the funeral director to perform hislher necessary duties. If you are an organ donor. we may disclose your protected health information to the organization that will handle your organ, eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation. 9. For Research Purposes: We may disclose your protected health information for research purposes without your authorization only when a privacy board has approved the research project. We may use or disclose your protected health information to individuals preparing to conduct an approved research project in order to assist such individuals in identifying persons to be included in the research project. Researchers identifying persons to be included in the research project will not be permitted to remove protected health information from our control. If it becomes necessary to use or disclose information about you that could be used to identify you by name, we will obtain your written authorization before permitting the researcher to use your information. Researchers will be required to sign a Canfrden ialh)v and Non-Disclosure Agreement form before being permitted access to protected health information for research purposes- A sample copy of this agreement may be obtained from our business office. 10. To Avert a Serious Threat to Health or Safety: We may disclose your protected health information to avoid. a serious threat to your health or safety or to the health or safety of others. When such disclosure is necessary, information will only be released-to those law enforcement agencies or individuals who have the ability or authority to prevent or lessen the threat of harm. 11. For Judicial or Administrative Proceedings: We may disclose protected health information about you in the course of a judicial or administrative proceeding, in accordance with our legal obligations. Privacy Notice 29 Pf f%YU r A[JNrr 12. To Law Enforcement: We may disclose protected health information about you to a law enforcement official for certain law enforcement purposes- For example, vie may report certain types of injuries as required bylaw. assist law enforcement to locate someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct. 13. Minors: If you are an unemancipated minor as defined under state law, there may be circumstances in which we disclose protected health information about you to a parent. guardian, or other person acting in loco purends, in accordance with our legal and ethical responsibilities. 14. Parents: If you are a parent of an unemancipated minor, and are acting as the minor's personal representative, we may disclose protected health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child's personal representative in order for your child to receive care or services from us. we may disclose protected health information about your child to you. In same circumstances. we may not disclose protected health information about an unemancipated minor to you. For example, ifyout child is legally authorized to obtain services (without separate consent from you). and does not request that you be treated as his or her personal representative, we may not be required to disclose protected health information about your child to you without your child's written authorization. 15. To Personal Representatives: If you are an adult o emancipated minor, we may disclose protected health information about you to a personal representative authorized to act on your behalf in making decisions about your health care. 16. For Specific Government Functions: We may disclose protected health information about you for certain specialized government functions, as authorized by law. Among these functions are the following: military command; determination of veterans benefits; national security and intelligence activities; protection of the President and other oRcials; and the health, safety, and security Dfcorrectional institutions. 17. For Workers' Compeasation: We may disclose protected health information about you for purposes'-related to workers' compensation. as required and authorized by law. VI_ Your Rights Regarding Your Protected Health Intotfrtation You have the following rights concerning the use or disclosure of your protected health in formation that we create or that we may maintain about you: 1. To Request Restrictions on Uses and Disclosures of Vour Protected Health Information: You have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care or services. For example. you could request that we not disclose to family members or friends information about a medical treatment you received. Should you wish a restriction placed on the use and disclosure of your protected health information, you most submit such request in writing- Such request should be submitted using our Request to Restrict the Use and Disclosure of Protected Health Inforarotiun form. Our contact information for purposes of making such a request is listed on the last page of this document. We are not required to agree to your restriction request. You will be informed if we decline your request. if we accept your request, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you. Ptivac% Notice 30 Yrnon• ?onrr + 2. The Right to inspect and Copy Your Health and Billing Records: You have the right to inspect and copy your protected health information, such as your prescription and billing records. In order to inspect and/or cnpy your protected health information. you must submit a written request to us. If you request a copy of your prescription or billing information or other records. we may charge you a reasonable fee for the paper. labor, mailing, and/or retrie-vat costs involved in filing your requests. We will provide you with information concerning the cost of copying your protected health information prior to performing such service. i Such requests should be submitted on our Request for inspectiontC'opy of P-atected Health Information form. Out contact information for such requests is listed on the Iasi page of this document. We will respond within thirty 136) days of receipt of such requests. Should we deny your request to inspect and/or copy your protected health information. we will provide you with written notice of our reasons of the denial and your rights for requesting a review of the denial, if any. In the event of a review, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons for denial. We will abide by the reviewer's decision concerning your inspection/copy requests. Your denial review request should be submitted on our Denial of InspectioWCopt- of Protected Health Information forth. Copiers of these forms are available from the contact person listed on the last page of this document. 3. The Right to Amend or Correct Your Protected health information: You have the right to request that yout protected health information be amended or corrected if you have reason u+ believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your protected hcatth information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request, unless an extension is necessary, in which case you will be notified, and receive a response to your request within ninety (90) days. If we approve your request, we will make such amendmenis/corrections and notify those with a need to know of such amendments/corrections. We may deny your request if: a. Your request is not submitted in writing. b. Your written request does not contain a reason to support your request, c. The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment: d. It is not a pan of the protected. health information kept by us; e. It is not part of the information which you would be permitted to inspect and copy: and/or f The information is already accurate and complete. If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial, and any written response (of reasonable length) you may have relative to the information and denial process appended to your protected health information. Your amendment/correction request should be submitted on our Request for dmendmentlCorrection of Protected Heahh Information form. Copies of these forms are available from our business office. Our contact information for the purpose of making such a request is listed on the last page of this document. 4. The Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in it certain wav or at a certain location. For example, you may request that we not send any protected health information to you at a health care facility, but instead send communication for you to a residential address or Post Office Box. We will agree to your request as long as it is reasonable for us to do so. You may submit your requests on our Request for Restriction of Confulerttial Communications Corm. Copies of these forms are available from the contact person listed on the last page of this document. Our contact information is listed on the Iasi page of this document. . 5. The Right to Request an Accounting of Disclosures of Protected Health lnror tnation: You have the right to request that we provide you with a listing of certain disclosures of your protected health information that we have mate over a specified period of time. This accounting will not include any information we have made for the purposes of treatment, payment. or health care operations or information released to you, your Privacy Noicc 31 Pr on, . Nome family or friends for notification purposes. disclosures made for national security purposes or to certain law enforcement officials. incidental disclosures, disclosures made as pan of a limited data set (for use in research, public health. etc.), or any disclosures made pursuant to your authorization. Your request must be submitted to us in writing and must indicate the time period for which you wish The information (e.g.. May 1.2003 through August 31.2003). Your request may not include releases far more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information. We will respond to your ! request with sixtp (60) days of the receipt of your wrinen request: Should additional time be needed to reply, you r, will be so notified. However. in no case will such extension exceed thirty (30) days. The first accounting you i request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the.twelve (12) month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. You may submit your requests on our Request for an Accounting of Uisctossrrs of Protected Health Information form available from our business office. Our crtntact information is listed on the last page of this document. 6. The Right to Receive a Paper Copy of This Notice: You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of ibis information from our webshe (as applicable). Our contact information is listed on the last page of this document. Vt. How to File a Complaint About Our Privacy Practices If you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for riling a complaint. You may submit your complaint on our Privacy Practices Com&inr form available from our business office. Our contact information is listed on the last page of this document. Privaev Nodice 32 l4iuoti:\OMC? CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES Record of Acknowledg gent ! ct_mtentauon of MF o rt to Obtain Acknowledgment ' Name of iResidmIl'atientI: _ Date: 0 F4 49 LjrA -Y r; Effective Date of This Privacy Notice April 14, 2003 Contact Information for Questions, Coroplaints or Requests Regarding Your Health Information Should you have any questions concerning our primacy practices, obtaining a copy of our privacy notice- requesting restnctions on the release of votu information. revoking an authorization, amending or correcting }out protected health informatiom obtaining an accounting of our disclosures of your protected health information, requesting inspection or copying of your medical information. requesting that w'e corntounicalc information about your health matters in a certain may, filing complaints o any other concerns you may have relative to our privacy practices; please contact: Brian D- Stwalky Chief Compliance Officer 5775 Allentown Blvd. Suite 202, Harrisburg, PA 17112 Tel: 717-910-1910 Et:L 4, Fax: 717-8111-1952 bxtwallcy,'4ccrxnrg If you wish. you may also file a complaint with the Secretary of the U.S. Dcpanmcrw of Health and Human Services. you may mail your complaint to U.S. Department of Health and Human Services. 200 lndcpendence Avenue, S. W.. Washington. DC 20301: or you may call (202) 619-0257 or 1-877-696-6775 (toll free): or you may log on to the internei address, h11p://1V%v .hhs.gom9ocr. Acknowledgment / Good Faith Effort to Obtain Acknowledgment (check one of the following) j I am the above Resident/Patient and I certify that I received a copy of the Continuing Care Rx's Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanations provided to me and I am confident that Continuing Care Rv is committed to protecting my health information. Date: Signature: Printed Name: K) I cer-64 that I am the authorized representative of above narne Resideant/Paticrit. and that I have received the Privacy Notice on behalf of this indi«dual and that Continuing Care Px provided me with an opponunity to review this document and ask questions to assist me in understanding the patient's privacy rights. I am satisfied with the explanations provided to or and I am confident that the above-named entity is committed to protecting health information. Dowd Of . Signatwe of Representative: ? -? Printed Name: - 17_ tM b k.. E J Relationship to individual: I. . certify that 1 made a good faith effort to obtain the acknowledgment of the above- identified Imsidcnt/padent] or his/her personal representative that he/she had received a copy of the Privacy Notice of Continuing Care R+, but was tunable to obtain such acknowledgment for the following reason(s): j (Rcsidentfttient j or personal representative refused to sign. J (Resident/patiew) or personal representative was unavailable to sign. jOther MIC: Pf1ViC1' Xdicr SignatureTtle: 33 iirw . 42 CHURCH OF GOD - HOME -Cnnrmirrrd w Caning' PODIATRY SERVICES I request that payment of authorized Medicare benefits be made either to myself, or on my behalf, to Dr. William Pu6g for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. es, I have accepted Dr. William Puliq as my podiatry care physician ? No, I decline offered podiatry care physician for my podiatry care -17;0r (Date) iResidenttResponsrble Party) Aw (Resident Name) 1 (Facility Repre at ) 34 42 CHURCH Of GOD HOME -rh minined to C_ urinr" Privacy Act Statement-Healthcare Records ' This form provides you the advice required by the Privacy Act of 1974. This form is not a consent form to release or use healthcare information pertaining to you. 1. Authority for collection of information including Social Security Number (SSN) Sections 1819 (1), 1919 (b)(3)(A), and 1864 of the Social Security Act Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health -status. As of June 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then -- required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the Health Care Financing Administration. . This data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records. 2. Principal purposes for which information is intended to be used The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services. 3. Routine Uses The primary use of this information is to aid in the administration of the survey and certification of Medicare/Medicaid long-term care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. 35 Privacy Act Statement-Healthcare Records (continued) The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System #09-70-1516. Information from this system may be disclosed, under specific circumstances to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional made' at the request of that individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability or the restoration of health; (5) contractors working for HCFA to carry out Medicare/Medicaid functions, collating or analyzing data or to detect fraud or abuse; (6) an agency of a State government for purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title Xi or Title XVIII functions; and (9) another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions. 4. Whether disclosure is mandatory or voluntary and effect on individual of not providing information For nursing home residents residing in a certified Medicare/Medicaid nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medicaid services. NOTE: Providers may request to have the Resident or their Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required. If the Resident or-their Representative agrees to sign the form it merely acknowledges that they have been advised of the foregoing information. Residents or their Representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions. I (we) acknowledge receipt of the Privacy Act Statement - Healthcare Records ,-) -1-7 (Date) 0 ? - (ResidentlResponsible Party) A/M (Resident Nam (Facility Represen b ) 36 42 CHURCH Of GOD HOME -Cammitted it) C arine Private Room Policy - Nursing Policy: It is the policy of the Church of God Home that provisions shall be made for isolating a resident in a single room whenever their medical condition requires isolation. Purpose: To ensure that the resident receives the most suitable protection possible. Procedure: 1. The one private nursing room in this facility may be used as a regular private/single room until the facility's need for an isolation room arises. This room is identified as Room 118 Faith Wing. 2. Any resident using room 118 must agree on admission that they will move out of the room to a semi-private room if the facility needs to use it. 3. When a need for an isolation room arises and a semi-private room is not available at Church of God Home, the resident occupying the private mom will be transferred as soon as possible temporarily to another long-term care facility until a semi-private room becomes available at the Church of God Home. This individual VAN then be returned to the private room when it again becomes available: 4. Individuals interested in occupying a private room should make their interest known on admission to the Director of Admissions or their Social Worker at anytime. 5. The Director of Admissions will maintain a list of those residents interested in the private room. Such resident will be offered the private room, when available, based on their initial admission date to the Church of God Home, regardless of their level of care or the date they placed their name on the waiting list. 6. When not in an isolation need situation, a resident in the private room must be of private pay status. If no longer able to cover the monthly bill, such resident will be asked to relocate into a semi-private room as soon as an appropriate one becomes available at the Church of God Home. ,2 -1-7 -- 0 (Dale) 0(Resident/Responsible Party) ul 4: Y'jj'a'-?YL (Resident Name) 1/ rat.,'W L"- (Facility Repre n five) 37 42 CHURCH OF GOD HOME "Commined to Curiae" Therapy Church of God Home has arranged for Genesis Rehabilitation Services, a professional, full-service therapy company, to provide physical, occupational, and speech therapy services. These services will be provided only when the Resident's physician orders them, and when these services are necessary to attain or maintain the Resident's highest practicable physical, mental and psychosocial well being. While the payment of charges for therapy services is the responsibility of the resident, insurance will usually pay for such services. is If the resident has Medicare Part B coverage, Medicare Part B will pay for 80% of the therapy charges. The balance of the 20% may be paid by the Resident's supplemental insurance. In the event therapy services are not covered, the Resident will be billed privately. Residents should review the coverage for therapy under their plan, and, it necessary, call the insurance company. Residents / Responsible Party may contact our j Business Office with questions related to therapy billing. u_ fined hereby con ents to the provision of therapy services for 1 A-10 (the Resident) as ordered by Resident's physician an deemed necessary to attain or maintain the highest practicable physical, mental and psychosocial well-being. The undersigned understands that no guarantee or assurance has been made as to any result that may be obtained from the Resident's treatment. The undersigned authorizes Church of God Home, Genesis Rehabilitation Services, and the Resident's treating or consulting physicians to release necessary records needed for the provision of therapy services or for payment. 17 Q (Date) (Resident/RespansUe Party) (Re ent Name) I / r17 (Facility Repres ) 38 Vaccinations What Is influenza (Also Called Flu)? The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccination each year. Every year In the Uniled States, on average: • 5% to 20% of the population gels the flu: • more than 200,000 people are hospitalized from flu complications; and • about 36.000 people die from flu. Some people, such as older people, young children, and people with certain health conditions (such as asthma, diabetes, or heart disease), are at high risk for serious flu complications. Symptoms of Flu Symptoms of flu include: • lever (usually high) • runny or stully nose • header-he . muscle aches • extreme tiredness • Stomach symptoms, such as nausea. • dry cough vomiting, and diarrhea, also can occur but • sore throat are more common in children than adults Complications of Flu Compkadons of flu can include bacterial pneumonia, ear inlections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma. or diabetes. How Flu Spreads Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. Somelknes people may become Infected by touching something with tiu viruses on it and then loucidng their mouth or nose. Most healthy adults may be able to knfed others beginning t day before symrploms develop and up to 5 days after becoming sick That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick. Preventing Seasonal Flu: Get Vaccinated The single best way to prevent the flu is to get a flu vaccination each year. There are two types of vaccines: The "flu shot' - an inactivated vaccine (containing killed virus) that is given with a needle. The flu shot is approved for use in people 6 months of age and older. including healthy people and people with chronic medical conditions. Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CoRTROL Ann PnevartTtON SAVER-HEAI-THIER • PEOPLE' 39 Key Facts About Seasonal Influer>IZa (Flu) • The nasal-spray flu vaccine - a vaccine made with five, weakened flu viruses that do not cause the flu (sometimes called LAIV lor'Lfve Aknwaled Influenza Vaccine'}. LAN is approved for use in hee]W people 2-49 years of age who are not pregnant. About two weeks after vaccination, anblx dfas develop that protect against influenza virus infection. Flu vaccines will not protect against t Aike illnesses caused by non-influenza viruses. i i f i I When to Get Vaccinated Yearly flu vaccination should begin in September or as soon as vaccine is avalable and continue throughout the influenza season, Into December, January, and beyond. This is because the timing and duration of influenza seasons vary. While influenza outbreaks can happen as early as October, most of the tkne influenza activity peaks in January or hater. Who Should Get Vaccinated? In general, anyone who wants to nxkm their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year either because they are at high risk of having serious flu-related complications or because they five with or care for high risk persons. During flu seasons when vaccine supplies are limited or delayed, the Advisory Committee On Immunization Practices (ACIP) makes recommendations reoaldirla priority croups for vaccination. Peopte who should get vaccinated each year are: 1. People at high risk for complications from the flu, including: • Children aged 6 months until their 51h birthday, • Pregnant women, • People 50 years of age and bider, People of any age with certain chronic medical conditions, and • People who five in nursing homes and other long-term care facilities. 2. People who five with or care for those at high risk for complications from flu, including: • Household contacts of pennons at high risk for carrocalions hum the flu (see above), • Household contacts and out of hone caregivers at children less than 6 months of age (these children are too young to be vaccinated), and • Health can: workers. 3. Children aged 6 months up to their 191s birthday 4. Anyone who wants to decrease their risk of influenza. Use of the Nasal Spray Flu Vaccine Vaccination with the nasal-spray flu vaccine is an option for healthy' people 249 years of age who are not pregnant, even healthy persons who five with or care for those in a high-risk group. The one exception is healthy persons who care for persons with severely weakened Immune systems who require a protected environment; these healthy persons should get the inactivated vaccine. Page 2 of 3 DEPAR7'MF_NT_OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER-HEALTHIER- PEOPLE` t i f t 40 Who Should Not Be Vaccinated Some people should not be vaccinated without fast consulting a physician. They include: People who have a severe allergy to chicken eggs. • People who have had a severe reaction to an Influenza vaccination In the past. • People who developed Guillain-Bank syndrome (GBS) within 6 weeks of getting an influenza vaccine previously. • Children less than 6 months of age lurttttenza vaccine is not approved for use in this age group). • People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen. It you have questions about whether you should get a flu vaccine. consult your health-care provider. For more about preventing the flu, see the following: • Key Facts About Seasonal Flu Vaccine • Influenza Anaivkal Drugs • Good Health Habits for Prevention • The Flu: A Guide W Parents - -Healthy- indicates persons who do not have an underlying medical condition etas predisposes them to influenza complications. For more Information, visit www.Wc.oovlflu, or call CDC at BOO-CDC-INFO (English and Spar&h) or BBB•232-6348 rM). Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS TOR DISEASE CONTROL AND PREVENTION SAFER -HEALTHIER -PEOPLE- 41 PNEUMOCOCCAL POLYSACCHARIDEVACCINE WHAT YOU NEED TO KNOW u.p+aa3K ?no.vron 9aemeM+.e.drell? ?a?R.a aaei wgw0?•. s.e..n.?wnxsyn+ 'J Why get vaccinated? $ Who should get PPV? POeunux-coal disease is a serious disease that • All adul is 65 years of age or older. causes much sickness and death. In fact, pneumococcal disease kills more people in the • Anyone over 2 years of age who has a long- United States each year than all other vaccine- term health problem such as: preventable diseases combined. Anyone can get - heart disease pneumococcal disease. However, some people are - lung disease at greater risk from the disease. These include - sickle cell disease people 65 and older, the very young, and people - diabetes with special health problems such as alcoholism, - alcoholism heart or lung disease, kidney failure, diabetes, HIV . cirrhosis infection, or certain types of cancer. - leaks of cerebrospinal fluid Pneumococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremial and the covering of the brain (meningitis). About 1 out of every 20 people who get pneumococcat pneumonia dies from it, as do about 2 people out of I D who get bacteremia and 3 people out of 10 who get meningitis. People with the special health problems mentioned above are even more likely to die from the dicase. Drugs such as penicillin were once effective in ueating these infections; but the disease has become more resistant to these drugs, making treatment ofpneumocoecal infections more difficult- This makes prevention of the disease through vaccination even more important. Pneutnococcal polysaccharide lam` `vaccine (PPV) The pneumococcal polysaccharide vaccine (PPV) protects against 23 types of pnenmocoCCRI bacteria. Most healthy adults who get the vaccine develop protection to most or all of these types within 2 to 3 weeks of getting the shot. Very old people, children tinder 2 years of age, and people with some long-term illnesses might not respond as well or at all. Anyone over 2 years of age who has a disease . or condition that lowers the body's resistance to infection, such as: Hodgkin's disease lymphoma, leukemia - kidney failure - multiple myeloma - nephrotic syndiome = HIV infection or AIDS - damaged spleen, or no spleen - organ transplant - Anyone over 2 years of age who is taking any drug or treatment that lowers the body's resistance to infection, such as: - long-terns steroids - certain cancer drugs - radiation therapy Alaskan Natives and certain Native American populations. Pneumococcal Polysaccharide 42 (41 How many doses of PPV are needed? Usually one dose of PPV is all that is needed. However, under-some circumstances a second dose may be given. • A second dose is recommended for those people aged 65 and older who got their first dose when they were under 65, if 5 or more years have passed since that dose. - A second dose is also recommended for people who- have a damaged spleen or no spleen have sickle-cell disease have HIV infection or AIDS have cancer, leukemia, lytnphotna, mtdtiple myelotna - have kidney failure have nepbrotic syndrome have had an organ or boat marrow transplant • are taking medication that lower immunity (such as chemotherapy or long-term steroids) Children 10 years old and younger may get this second dose 3 years after the first dose. Those older than 10 should get it 5 years after the first dose. 5 Other facts about getting the vaccine e • Dtherwise healthy children who often get ear infections, sinus infections, or other upper respiratory diseases do not need to get PPV because of tbese conditions. • PPV may be less effective in some people, especially those with lower resistance to infection. But these people should still be vaccinated, because they arc more likely to get seriously iU ham pneumococcal disease. • Pregnancy: The safety of PPV for pregnant women has not yet been studied. There is no evidence that the vaccine is harmful to either the mother or the fetus, but pregnant women should consult with their doctor before being vaccinated. Women who are at high risk of paeumococcal disease should be vaccinated before becoming pregnant, if possible $ What are the risks from PPV? PPV is a very sale vaccine- / About hair of those who get the vaccine have very mild side cffccts, such as redness or pain where the shot is given. Less than 1% develop a lcvcr, muscle aches, or more severe local reactions, Severe allergic reactions have been reported very rarely. As with any medicine, there is a very small risk that serious problems, even death, could occur after getting a vaccine. Getting the disease is mach more likely to cause serious problems than getting the vaccine. C71 What if there is a serious reaction? What should i look for? • Severe allergic reaction (hives, difficulty breathing, shock). What should 1 do? • Call a doctor, or get the person to a doctor right away. • 7bO your darter what happened, the date and time it happened, and when the vaccination was given. • Ask your doctor, nurse, or health deportment to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at www vatmarg, or by calling 1-800-822-7967. IrAFM dory riot prooide utr&co/ addoiu. $ How can I learn more? • Ask your donor or nurse. They can give you Elie vaccine package insert or suggest other sources of information • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4336 (1-800-CDC-INFO) or - Visit the National Immunization Program webske at www.cdc.SDv/vaccizoes 1 DEPARTaaEIaT OF HEALTH AND HUMAN a1e1R11WEB CENTCRS FOR DISKASE CONTROL. AND PREVENTION Paeumacoaear Vaccine tAbimadon Stateurnl 43 42?? CHURCH Of GOD HOME 't ismmrtrnf fn Cprin; Vaccinations The Church of God Home administers flu vaccine on an annual basis for all residents of our facility. Annually the Tri-Valent Influenza Vaccine will be offered, prior to the beginning of flu season, for all residents who provide written authorization themselves or by his/her responsible party. A resident cannot receive the Tri-Valent Influenza if they are allergic to eggs or egg products. Otherwise, the Tri-Valent Influenza has proven to be generally safe and effective. If you desire to receive the Tri-Valenl Influthe pneumonia vaccine, please complete the autnonzation oelow. the Tri-Valent Influenza vaccine be given annually per facility protocol. ? No, I do not wish to receive the Td-Valent Influenza at any given time. ? I have received literature pertaining to the benefits of the Tri-Valent Influenza vaccine. The Church of God Home also offers a vaccine that provides effective protection against the Pneumococcal form of pneumonia. This vaccine will be available to those residents who desire it and are medically eligible. If you have any questions, you may discuss them with your personal physician r the Church of God"Home physician who monitors your care. - ? I do authorize that the Pneumococcal Pneumonia vaccine be given. ? No, I do not wish to receive the Pneumococcal Pneumonia vaccine at any given time. ? I have received literature pertaining to the benefits of the Pneumococcal Pneumonia Vaccine. If known, please indicate the date when the vaccines listed below were last received: Tri-Valent Influenza vaccine: Pneumonia Vaccine: Tetanus Vaccine: ,2-17-©'7 (Date) 44 (Resident(Responsible Party) 42!b? CHURCH Of GOD HOME -Catnmirtrd 1„ (:oneer Valuables The Church of God Hone desires to administer quality care for all of our residents, focusing on a high quality of life. We do want to avoid any unfortunate situation that could result in any financial or emotional loss to residents and/or families. Our Home has not had many such losses, but when they happen, it is tragic. To minimize the risk of loss, the Church of God Home recommends that residents have no more than five dollars ($5.00) at any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their rooms. By signing this paper you acknowledge being informed of the Home's recommendations. Some people have wisely substituted zircons for diamonds and kept the settings. It is the responsibility of the resident or the responsible party to have items of value independently appraised and insured, if so desired to cover potential damage to or loss of personal property. If damage or loss occurs to the resident's property, the Church of God Home will investigate each incident of loss or damage to determine liability and assess depending on the facts and circumstances of each incident. The Church of God Home shall be responsible for only such losses or damages as are attributed by the Home due to.the negligence of the Home: I7 -- Q q (Dale) 45 (Residenl/Responsible Party) CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this 17 44 day of? c& .200f. by and between the Church of God Home, Inc., called the 'Facility," a Pennsylvarna non-pro IYAr" an on localed4 80 rih Hanover Street, Carlisle, urn Plvania, and ? called "Resident" and called "Responsible Party". The Resident and the Responsible 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 and the Responsible Party agree to the following terms: 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, hot, and cold water. c. Bed, bedding, blankets, laundered bed linens, towels, and washcloths. d. Three meals each day except as otherwise medically indicated. e. Activity programs, Spiritual 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: $ 3(0. dollars per day. 3. SECURITY DEPOSIT - The Resident shall pay the following nonrecurring 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 admission 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. If the admission to Nursing Care is the result of a level of care change from Assisted Living, the Resident will be billed the difference between the two Security Deposit rates. c. 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 or death. Upon discharge or death the following refund policy will be followed: i. Thirty (30) days - Private Pay. u. Ninety (90) days - Medicaid iii. Thirty (30) days - Personal Cash Account There will be no other refunds, in the absence of an over payment, under this Agreement. 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES - Resident is responsible to pay for other services provided by the Facility, which are not covered by the daily ratetcharge. Alist of such services charges is attached to this Agreement on the "Chart of Costs." 46 Admission and Care Agreement- continued 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 property 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 fumished 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 resting 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. Such fees and costs are not included in the Home's daily rate/charge. 5. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident, beginning on vZ - 1.7- 4 9 . 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 Home 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. d. 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. e. Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check. I. 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 changes are computed, billed or become due. The Facility reserves the right to make any such changes at any time. Written notices 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. "MEDICAREIMEDICAID" PROGRAM - The Facility participates in the Medicare program administered pursuant to Title XVIII o f the Federal Social Security Act and the Medicaid (Medical Assistance) Program 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 program at any time in accordance with the taw. 47 Admission and Care Agreement- continued OBLIGATIONS OF RESPONSIBLE PARTY - The Responsible Party is responsible for services and supplies that are billed through the Facility directly to the Resident, Responsible Party, or by any other provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. In the event of an emergency the Responsible Party is asked to leave an emergency contact telephone number (s). (i.e. when vacationing} 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 changes 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 Medicaid (Medical Assistance) Program. The current bed reservation periodls fifteen (15) days for hospitalization, fifteen (15) days for therapeutic leave for residents receiving skilled nursing care, and thirty (30) days for therapeutic leave for residents receiving nursing care. The bed reservation period may be subject to change in accordance with any changes in the Medicaid (Medical Assistance) Program. It the period of hospitalization or therapeutic leave ends within the reservation period under the Medicaid (Medical Assistance) Program, the Resident may return to the Facility. It the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Medicaid (Medical Assistance) Program, the Resident must wait until a suitable bed becomes available for readmission. i 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 Home. t Effective May 30, 2008, Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. ? Yes, I would request a bed hold. i understand that I will be billed at the standard daily rate. ? No, l do not wish to hold a bed in the event of a hospitalization. I understand that by doing so a bed may no be available for readmission. l o be determined at time of hospitalization. 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 Facility or death. Residents receiving Medicaid will receive a 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 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. 48 Admission and Care Agreement- continued The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal cash account 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. The Facility may deduct, at any time, charges due the Facility under this agreement from the Resident's personal funds managed by the Facility. 13. TERMINATION, TRANSFER, DISCHARGE, OR LEAVE OF ABSENCE a. By the Resident: The Resident may terminate this Agreement upon thirty (30) days written notice to this Facility. If the Resident leaves the Facility for any reason other than a medical emergency or death, the Resident must give written notice to the Facility at least thirty (30) days in advance of the departureltransfeddischarge 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 changes 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: L The transfer or discharge is necessary to meet the Resident's welfare which cannot be bet 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; iiiL The safety or health of individuals in the Facility is or otherwise would be endangered, iv. The charges or other amounts due the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf the Pennsylvania Medicaid Program or Federal Medicare benefits under Title XVIII or v. The facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none, a family member of 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, described in subparagraph (i), (h) or (in) 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. 49 Admission and Care Agreement- continued 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 del'nrering 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. 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 / social worker 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. 50 Admission and Care Agreement- continued 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. Re$ident will be provided thirty (30) days written notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. -1`7_D (Date) O 4 (ResidendResponsible Party) A/M (R nt Name) V46U4&1 (facility Represent ) 51 RESIDENT I FAMILY GUIDE TO INQUIRIES AND INFORMATION i H VP Vj H m E C N Inquires E L' o C' y o w ? u v v a CL o a D io .c O c „_ HE r. ev m m m m o O I a x cn M 0 c) U- 0 0 [C z o z Q ca C#) > `n Healthcare Assisted Living x Admissions Independent Living x Admission Billing Question x Medicare x Question Applying for x Medicaid Pharmacy Billing x Laundry Billing x Donation Monetary x I Donation Other X Personal Cash Account x Questions ! Personal Cash Deposits 1 x Withdrawals Guest Meal i Reservations x Party Reserving of Lounge x Family Concerns x HIPPA Changes x i Coordinate Change E in Level of Care x Resident Lost Items x F Telephone j Cable Hook-up x LeTort x I Guest Suite i I 52 RESIDENT / FAMILY GUIDE TO INQUIRIES AND INFORMATION p L ? C H C m N ` h m 1p a'. N Of E C H U o C t? Q' C V t Y V O } E Inquires H W Ul `p V = w ` ` a = v w o ei 0 0 2 M z' a i v) r > o) > n ; Change in Laundry Service X Transport Requests X x Special Hair Care Requests, Payment ` Scheduling X Resident Care X ' Resident Medication X i ' Physician Questions X Therapy Questions X Takin Residents g Out of Facffity X Chan e in POA f g Contact X Address /Phone Change in POA X Health Insurance Cards X Reli ious Que ti g s ons X Funeral Questions X Funeral Procession , Service X Memorial Services X "The Orchard " at s Marsh Run X I i f 53 s Facility Mailing Address: 801 North Hanover Street Carlisle, PA. 17013 Facility Main Telephone #: (717) 249-5322 Wo ~' Facility Administrator: .................. Susan Bower, NHA ................................................................ ext. 3086 , Y Y Y Y Y Y Y Y W Y Y Y L Y Y Y Y Y Y Y Y Y Y Y Y W Y Y Y V Y Y Y Y Y Y Y Y Y W M Y Y V Y Y Y I+ M Y Y Y W W Y Y Y Y Y M Y Activity Dept.: ? .............. Amy Findon, CTRS................................................................. ext. 3021 (Director of Activities) Business Office: ............ Sharon Cramer (Business office (.Henderson House) ......................... xt. 3032 (Sr. Billing A/R Specialist- Personal Cash Accounts) Care Plan: Lynne Shellenberger, RN . - ...... ?...... .. ext. 3033 (Nursing Assessment Coordinat ' Chaplain: ? .............Pastor Bradley Moore................... .z .:.................................. ex 3022 2- - Dietary:? .............. Jeffrey Stamer, CDM........................ ext.' 3008 .......................:........... (Director of Dietary} Joan Ludwig ......................... Hair Care: ...........,.._................................ ext. 3003 ??- (Director of Hair Care) Nursing Dept:: ? .............Mary Hartman, RN, BSN. ext. 3015 ............ ,; ................................ .' (Director of Nursing) .. ? .....•....... Faith Long Hall (Ino3-11 s) .............. .:....::...:......................: ext. 3009 _ _ ? .............Faith Short hall (#s3,1ao-102,117-125_F.................................... ext. 3010 - 'Q. ..... ove 1(#201-215)...: ............... .. ext. 3024 ...Love 11(#217-239)..LY ........... ext. 30`' ? ............. Chris Ward, LPN....... ..•..........••••..•..•............:...... ..ext. 3012 (Assisted Living Administrator), (Hope, Peace and Creekside Apt.) Pharmacy: ? .............Continuing Care RX..................................................... 1-800-675-2279 Social Services: ?.............. Eri aoylor, BSW ................................................................... ext. 3084 (Director of Social Services) Ellen Myers, BSW ................................................................. xt. 3023 (Social Worker) Therapy Dept.: ? .............Genesis Rehabilitation Services............................................. ext. 3017 Volunteer Office: ? ............. Linda Waggoner.................................................................. ext. 3028 rector of (Di Volunteers) Physicia Telephone#: 54 APR-02-2009(THU) 13:36 P.008/008 VERYl PATION The undersigned hereby vcrifics that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. T understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unworn falsification to authorities. 4?' Dated: `? -' - ? I Il ?Lnn OAO r Q.? Representative, Church of God Nome, Inc. nc r q y 2009 APR 1 ? AIM 11= 19 pd- N71. 0 i 1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. CIVIL ACTION - EQUITY No. C q- )-y a ? PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Petitioner Church of God Home, Inc., by and through its attorneys, SCHUTJER BOGAR LLC, and files the following Petition for Preliminary Injunction against Respondent Cindee Fenton a/k/a Cynthia Fenton pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. On or about April 16, 2009, Petitioner filed its Complaint against Respondent. See the Complaint attached hereto as Exhibit "1." 2. The Complaint sets forth an equitable claim against Respondent relating to her breach of the Admission and Care Agreement ("Agreement") that she signed in conjunction with the admission of her husband, William Fenton, to Petitioner's skilled nursing facility. The Complaint also sets forth an equitable claim against Respondent for breach of her statutory duty to support her husband, William Fenton, under Pa. 23 Pa. C.S. § 4603(a). See the Agreement attached to the Complaint as Exhibit "A." 3. Specifically, the Complaint alleges that Respondent breached the Agreement by failing to cooperate fully with the Petitioner in preparing and/or filing for Medical Assistance benefits on behalf of William Fenton, and by failing to provide the necessary verification I documentation to the Cumberland County Assistance Office ("CAO") to determine the eligibility of her husband, William Fenton, for Medical Assistance benefits. See Exhibit 111.11 4. Moreover, in the Agreement, Respondent assigned to Petitioner her husband's rights to Medical Assistance benefits (hereinafter "the Assignment Clause"). She Exhibit "A" to the Complaint. 5. Accordingly, Petitioner now stands in the shoes of the assignor and has assumed William Fenton's rights with respect to his Medical Assistance benefits. See Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) ("[A]ssignee stands in the shoes of the assignor and assumes the rights of the assignor.") 6. However, Respondent's failure to provide the verification documentation that the CAO requires to process and approve her husband's application for Medical Assistance benefits is in breach of the Agreement and interferes with Petitioner's rights to the Medical Assistance benefits that have been contractually assigned to it. See Exhibit "A" to the Complaint. 7. Respondent's continued failure to comply with the terms of the Agreement and provide the verification information required by the CAO to render a decision on her husband's eligibility for Medical Assistance benefits will result in a denial of the pending application for Medical Assistance benefits. 8. Additionally, the Complaint alleges that Respondent breached her statutory duty of support with respect to William Fenton, which includes her failure to assist with securing financial support for her husband through the Medical Assistance benefits system by providing the necessary financial documentation to the CAO to determine the eligibility of William Fenton for benefits. 2 9. The Respondent's statutory duty of support includes the duty to not actively work against Medical Assistance benefits approval. 10. The very nature of the Respondent's breach, i.e., the failure of Respondent to produce the information and documents requested by the CAO to determine the eligibility of William Fenton for Medical Assistance benefits, 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 William Fenton's Medical Assistance benefits, and by extension, its right to be compensated for the skilled nursing services it has provided to Respondent's husband - unless Respondent provides the CAO with the documentation it needs to process and approve William Fenton's application. 11. The requested injunction would restore the parties to the status quo as it existed immediately prior to Respondent's breach of the Agreement and breach of her statutory duty of support. 12. Greater injury would result from the denial of the requested injunction than from the granting of the same, because, absent the injunction, without the verification documentation necessary to secure Medical Assistance benefits, the CAO will deny William Fenton's pending 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 under the Agreement will be forever lost. 13. Petitioner's right to relief is clear. See Exhibit "A" to the Complaint. 14. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, William Fenton has been financially unable to fully compensate Petitioner for the services that it has rendered to him. 3 15. 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 and statutory duties of Respondent. Respectfully submitted, SCHMER Boot LLC Dated: ZOD By. ZJ?14-??n ivia F. Langton Attorney I.D. No 1548 (412) 281-3710 llangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 0 Floor Harrisburg, PA 17101 Attorneys for Petitioner 4 EXHIBIT "1" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. V. CIVIL ACTION - EQUITY No. D9- C i V i t Ter p CINDEE FENTON a/k/a CYNTHIA FENTON COMPLAINT Filed on Behalf of Plaintiff: Church of God Home, Inc. Counsel of Record for Plaintiff: SCHUVER BoGAR LLC Livia F. Langton Attorney I.D. No. 91548 (412) 281-3710 llangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4`b Floor Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, CIVIL ACTION - EQUITY No. V. CINDEE FENTON a/k/a CYNTHIA FENTON, Defendant. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 EN LA CORTE DE ALEGATOS COMfJN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, CIVIL ACTION - EQUITY No. V. CINDEE FENTON a/k/a CYNTHIA FENTON, Defendant. 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 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 SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166. s ? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Defendant. CIVIL ACTION - EQUITY No. COMPLAINT AND NOW, COMES, Church of God Home, Inc. ("Plaintiff'), by and through its attorneys, SCHUDJER BOGAR LLC, and files this Complaint against Cindee Fenton a/k/a Cynthia Fenton ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff Church of God Home, Inc. is a domestic non-profit 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 Cindee Fenton a/k/a Cynthia Fenton, wife of William Fenton, is an adult individual who currently resides at 133 Garland Drive, Carlisle, Pennsylvania 17013. 3. On or about April 18, 2008, William Fenton was admitted to Plaintiffs skilled nursing facility. 4. Plaintiff and Defendant entered into a written Admission and Care Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide William Fenton with skilled nursing services in exchange for Defendant's promise to pay a specific monetary fee from William Fenton's resources, and Defendant assigned to Plaintiff William Fenton's "any payments received from third-parties to the extent necessary to satisfy the charges under this 1 Agreement." See a true and correct copy of the Agreement attached hereto at pages 46 to 51 of Exhibit "A." 5. After William Fenton became a resident of Plaintiff's skilled nursing care facility, he apparently became insolvent. As a result, Plaintiff notified the Defendant that she needed to apply for Medical Assistance benefits for William Fenton. 6. The Defendant failed to prepare and/or file for Medical Assistance benefits, which resulted in this Plaintiff's filing an application for Medical Assistance benefits on William Fenton's behalf. 7. The application referred to above is currently pending; however, it will be denied unless the Defendant provides the Cumberland County Assistance Office ("CAO") with the information necessary to qualify William Fenton for Medical Assistance benefits. 8. If the Defendant fails to produce the information requested by the CAO at or before the due date, the application for Medical Assistance benefits will fail and Plaintiff will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE Plaintiff V. Defendant 9. The allegations contained in Paragraphs 1 through 8 are incorporated herein by reference as if fully set forth at length. 10. Defendant breached the Agreement with Plaintiff by failing to "cooperate fully with the Facility and each third-party payments. Cooperation includes, when requested, providing information, signing and delivering documents." By not cooperating, Defendant has 2 interfered with Plaintiff's right to receive the Medical Assistance benefits that have been contractually assigned to it. 11. The law is clear that an "assignee stands in the shoes of the assignor and assumes the rights of the assignor." Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997). 12. As Defendant has failed to provide the necessary documentation to the Plaintiff and/or the CAO, as required to process and approve William Fenton's application for Medical Assistance benefits, Plaintiff is precluded from the benefits Defendant assigned to it. 13. Upon information and belief, at all times material hereto, William Fenton has been financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to him in accordance with the terms and conditions of the Agreement. 14. Defendant's breach of the Agreement with Plaintiff has irreparably harmed and continues to irreparably harm Plaintiff. 15. 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. WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. COUNT II SPECIFIC PERFORMANCE/STATUTORY DUTY OF SUPPORT Plaintiff v. Defendant 16. The allegations contained in Paragraphs 1 through 15 are incorporated herein by reference as if fully set forth at length. 17. Defendant Cindee Fenton a/k/a Cynthia Fenton is the wife of William Fenton. 18. At all times material hereto, upon information and belief, William Fenton has been indigent. 3 r ' 19. At all times material hereto, Defendant has had a statutory duty to financially support her husband, William Fenton. See 23 Pa. C.S. § 4603(a). 20. At all times material hereto, Defendant has failed to financially support her husband. 21. The statutory duty of Defendant to support her husband must reasonably include the duty to assist with securing financial support through the Medical Assistance benefits system and the duty to not actively work against Medical Assistance benefits approval. 22. At all times material hereto, Defendant has failed to care for, maintain or financially assist her husband by refusing to provide the information and documents requested by the Plaintiff and the CAO to determine the eligibility of her husband for Medical Assistance benefits. WHEREFORE, Plaintiff Church of God Home, Inc. respectfully requests that this Honorable Court order Defendant Cindee Fenton a/k/a Cynthia Fenton to specifically perform her statutory duty and obligation, and to produce the information and documents to the Cumberland County Assistance Office required to secure Medical Assistance benefits for her husband, William Fenton. [This section intentionally left blank.] 4 Respectfully submitted, SCHMER BoGAR LLC Dated: l(0 "w By: ` ivia F. Langt Attorney I.D o. 91548 (412) 281-3710 llangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff .EDIT A CHURCH OF GOD HOME -Cnmmitted to C-tsille'* Nursing Care Admissions Contract Information 1 'r I i 1 t Church of God Home, Inc. 801 N. Hanover Street - Carlisle, PA 17013 P: (717) 249-5322 • F: (717) 249-8622 Revised 0112009 1 t 42!?? CHURCH OF GOD HOME "InI101I11r J to f al inr° Dear Friend: Admission into a health care facility is a teaming experience, both for the new resident and their family. We at the Church of God Home try to make the admission process as positive, pleasant and easy as possible. Because of the number of documents that must be explained and signed upon admission, many facilities look at this as being 'overwhelming'. However, both State and Federal regulations require such forms for permanent records. As we welcome the new resident, a hand is extended in friendship.-. an arm is offered for support... a cheerful pat of encouragement is given... these are a few of the special touches that the Church of God Home has been offering since its doors first opened in 1948. For more then sixty years a Christian spirit has been the guiding philosophy of our Home. That's the reason our care goes far beyond just meeting the physical needs of our residents. We believe in the dignity and self-worth of each individual, and every aspect of our care reflects that belief. Our mission is to minister to the physical, spiritual, and emotional need of each resident in order to help him or her lead a more meaningful life. In sharing these values and standards of the Church of God Home, we hope that our experience will benefit others so that, together, we wig continue to find better ways to serve the needs of elderly people in our society. Carson G. Ritchie, CPA, NHA PresidenUCEO 2 Table of Contents 1. Welcome Lefler ............................................................ ..............................................................2 2. Statement of Vision and Mission .................................................................................................4 3. Ambulance .................................................................... ..............................................................4 4. Chart of Costs ...............................................•.............. ......................................................... 5-7 5. Dietary Services .......................................................... ........................................... 7-8 ............... 6. DVD `A Time of Transition" .......................................... ..................................................•............8 7. Guest Room ................................................................ ...............................................................8 8. Lehigh Valley Respiratory Care - Lancaster ............... ...............................................................9 9. Medicaid (Medical Assistance) .................................... ......................................................... 9-10 10. Medicaid (Medical Assistance) Residents ................... .............................................................11 11. Medicaid (Medical Assistance) Residents Checklist .... ....................................................... 12-13 12. Medicare ...................................................................... .......................................................14-15 13. Mobile X-Ray Imaging, Inc .................................................... ..16 14. Psychiatrist .............................................................................................................................16 15. Smoke Free Environment .........................................................................................................17 16. Specialized Services .................................................................................................................17 17. Transportation ..........................................................................................................................17 18. Understanding Restraint Use ...................................... ..............................................................18 19. Advance Directive Policy ............................................ ........................---- •................................19 20.. Delegation of Responsibility Form ................ - 21. Legal Rights Compliance ............................................ .......................................:.....................21 22. Non-Discrimination Statement .................................... ..........................:........:.........................:22 23. Personal Cash Accounts / Depleted Funds ................ ........................................................ 23-24 24. Personal Laundry Service ........................................... ..............................................................25 25. Pharmacy Services ..................................................... ........................................................ 26-33 26. Podiatry Services ......................................................................................................................34 27. Privacy Act Statement- Healthcare Records ..................................................................... 35-36 28. Private Room Policy / Nursing ..................................................................................................37 29 Therapy ............• ........................... . 30. Vaccinations ............................................................. ........................................................ 39-44 31. Valuables ................................................................... ...............................................................45 32. Admission and Care Agreement ................................ ......................................................... 46-51 a. Security Deposit .................................................. ............................................................46 b. Readmission - Bed Hold Policy .......................... ...............................................................48 33. Resident / Family Guide to Inquiries and Information ......................................................... 52-53 f 34. 'Welcome" (Telephone/Extension) ...........................................................................................54 35. Checklist .................................. .................................. ............ ....................................... ............ 55 STATEMENT OF VISION AND MISSION Vision To provide an aging services' continuum of care that reflects the perfect love of Christ, exceeding the expectations of those we serve. Mission Church of God Home, a Continuing Care Retirement Community, is a Christian Ministry committed to caring for the body, mind and spirit of older persons. Admissions Policy It is the policy of the Church of God Home, a unit of the Eastern Regional Conference of The Churches of God, to admit and treat all persons without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. Only those applicants whose medical nursing care, psychological and behavioral needs can be adequately met by the staff, will be admitted or kept in this facility. In addition, all residents must meet the financial criteria of private pay, Medicaid or SSt payer source. The Board of Trustees is committed to providing housing, services and needed responsible care for older persons with priority to those who are?members of, or affiliated with, the Eastern Regional Conference of The Churches of God. The same requirements for admission are applied to all, and residents are assigned within the facility without regard lo*race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. There is no distinction in eligibility for, or in any manner of, providing any resident service that is provided by or through the facility. All areas of the healthcare center are available to all persons and visitors regardless of their race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. All persons applying for admission, or who are recommending individuals to the Church of Gad Home, are advised to do so without regard to the person's race, color, national origin, age, ancestry, sex; handicap, disability, or religious creed. Ambulance Ambulance enrollment is recommended but is not handled by the facility. If you desire enrollment, please contact- them independently. 4 Chart of Costs Effective January 1, 2009 Nursing Care Room Rates Faith Wing and Love Wing Semi-Private $236.00 per day Private $290.00 per day Assisted Living Room Rates Hope Wing and Peace Wing Semi-Private $103.00 per day (Rm401411) Private $111.00 per day (Rm301) $121.00 per day (Rm303-313) $129.00 per day (Rm400) Creekside Apartments Studio One person $145.00 per day Two persons $245.00 per day One Bedroom One Bedroom, Creek view $165.00 per day $170.00 per day $270.00 per day $315.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for roomllevel of care. In the event of a Level of Care change to a higher level the residenttresponsibleperty will be billed the difference between the security deposits. There are no additional charges while receiving benefits under the Medicare program while in nursing care (except telephone, hair care, personal laundry, transportation, bed hold, bed reserve and name labels). Independent Living Rates LeTort Manor Apartments Apartment Monthly Fee One Person Two Persons A $905 $1,215 B $835 $1,125 - C $835 $1,125 D $820 $1,115 E $820 $1,115 f i NowRphndable $83,000 $73'M $731,000 $63,000 $63,,000 i Apartment Tvae Apartment 'A' Apartment 'B' Apartment 'C" Apartment "D' Apartment 'E' 40% Refundable Rate $109,000 $96.100 $96,100 $81,000 $81,000 Independent Living Rates Creekside Apartments Apartment Monthly Fee One person Two Persons Efficiency $1,305 $1,785 One Bedroom $1,650 $2,290 ---?..- - _ ._.. - - 5 - Chart of Costs (continued) Bed Hold (during hospitalization or LOA) Cable Television (Nursing and Assisted Living) Cable Television (Independent Living) Cable Internet (independent Living) Cable Modem (Independent Living) Clothing Name Labels Guest Room (maximum stay of 5 nights) Incontinence Supplies Liners i Briefs / Pull-ups Miscellaneous supplies Laundry Service (personal clothing) i I Medication (self administered medication) 4 Photocopies (copies of records) Therapy (physical, occupational, speech) Private Telephone, Purchase Telephone Set Monthly Line Fee Hook-up, Activation, One Outlet (one time charge) Dietary Services (guest meals; includes tax) Breakfast Dinner Supper Sundays and Holidays Nutritional Supplies Extra Dietary Service Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Transportation Services Oxygen Concentrator Usage Portable Oxygen Usage Per Diem rate Included $22.00/month $20.00/month $62.00' one time fee Cost 1 person - $28.00/night 2 persons - $33.001night 25% above cost 25% above cost 25% above cost $33.00/month $15.00/day $1.28/pg(1-20) $0.95/pg(21-60) $0.32/pg (61 +) Actual cost unless covered under Medicare or co- payment by secondary insurance At own expense $30.001month $57.75 $5.00 $7.65 $6.30 $7.65 25% above cost Contact your social worker At own expense unless covered by your insurance or covered by medical assistance benefits 0-10 Miles (round trip) .......................$22.00 11-50 Miles (round trip) .....................$44.00 51+ Miles price will be determined based on destinarion and time required. *Rates are double if an escort accompanies the Resident. $3.001day, unless covered under Medicare $12.00/cyCnder, unless covered under Medicare 6 Chart of Costs (continued) Hair Care Color rinse, set $13.00 Cut, Men $11.00 Cut, wash, blow dry $24.50 Cut, Women $11.00 Hot wax $7.00 Men's cut and moustache trim $12.00 Oil treatment, shampoo, set $24.00 Permanents $43.00 Permanents in bed $58.25 Wash, no blow dry $8.25 Men'sMomen's cut-wash in bed $26.75 Color rinse $1.00 Dietary Services Permanents wlconditioner $53.00 Re-comb $8.25 Re-comb and curling iron $11.50 Tint $28.00 Wash and set $12.50 Wash, blow dry $13.50 Men'sNomen's wash in bed $15.75 Wash, style, blow-dry in bed $26.25 Men's cut - wash $19.25 Mustache trim $1.25 Cut, wash and set $23.50 The Dietary Department. offers three (3) well-balanced nutritious meals daily as well as an alternate menu for personal preference. A PM snack is available upon request at no extra charge. The department employs two Certified Dietary Managers and a Consultant Registered Dietician to provide special diets and dietary consults with residents and families. Our three-week menu cycle offers a variety of homemade items and incorporates fresh fruits and vegetables when in season. Menus are posted in several locations throughout the Home. Our large meal of the day is served mid-day and called Dinner. Our evening meal is called Supper. General Guest Meal Policy Limit four (4) guests per resident (as space permits) for all meals except holidays. Reservations must be made 48 hours in advance for general guest meals. If reservations are not made 48 hours in advance, an alternate guest meal may be served at the discretion of the Dietary Department. Holiday Guest Meal Policy On the holidays of Easter, Mother's Day, Thanksgiving, and Christmas there is a limit of two (2) guests per resident. Due to the volume of guests that may wish to dine of these holidays, the Church of Glod Home will accommodate the first twenty-five (25) guests to register. Since it is impossible to provide this notice to all family members, please share this information with your extended family. Thank you for your understanding and cooperation. Families are encouraged to participate in special meal events throughout the year, such as our Parents Day and Holiday Buffet. 7 Extra Dietary Services (Arrangements for these provisions should be made through your Social Worker.) 'You will receive a separate bill from our Business Office for these services. SIZE CAKES: SERVES COST wfTAX 9" Round - 2 layers 16 15.00 % Sheet -10"x14" 16 15.00 '/z Sheet -12"x17" 30 20.00 Full 60 30.00 ICE CREAM: Hand dipped - dishes $1.00 Hand dipped - 3 al. container $17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate 10.00 `. MIN, GUEST MEALS: Breakfast $4.75 Dinner $7.15 Supper $5.80 - Sunday and Holida $7.15 LL.ANEOUS: 7 es Chips - 3 lbs_ $9.75 D res - 3 lb. $7.55 Punch-1 al. $4.00 Lemonade -1 al. $4.00 Iced Tea -1 al. $4.00 Cookies -1 doz. An Kind $3 NOTE: All of the above items include paper-serving products and must be ordered 1 week in advance. Special Orders will be riced b Dieta De rtment DVD "A Time of Transition" I acknowledge that I have viewed the DUD entitled "A Time of Transition" and have been provided the opportunity to ask questions. I further acknowledge that Guide One Insurance, the Home's insurance company, recommends a viewing of this DVD. . Guest Room There is a cost per night with a maximum stay of five nights. A second person in the room is an additional charge per night. No young children please. Your friend or relative will be billed for their stay. Reservation can be made through the Residential Housing Administrator (717) 249-5322 extension 3085. i t r 8 LEHIGH VALLEY RESPIRATORY CARE - LANCASTER 1176 Enterprise Court - East Petersburg, PA 17520 (717) 569-4667,1-800-952-8452, Fax (717) 569-5555 Lehigh Valley Respiratory Care - Lancaster is an independent Home Medical Equipment Company providing respiratory services to Long Term Care Facilities. We are accredited by the Joint Commission of Accreditation of Healthcare Organizations lo perform Clinical Respiratory Services. Lehigh Valley Respiratory Care - Lancaster provides Church of God Home residents with oxygen and respiratory supplies. The Church of God Home will contact Lehigh Valley Respiratory Care - Lancaster for these services when initially needed. Assisted Living Residents: • Lehigh Valley Respiratory Care - Lancaster will then contact the Resident/Responsible Party to schedule the arrangements and discuss their billing procedures. • Oxygen / Respiratory Supplies may be covered under Medicare Part B as long as fhe qualifying criteria has been met. • Lehigh Valley Respiratory Care - Lancaster will contract with the Resident/Responsible Party on an individual basis and will bill Medicare Part B directly. MEDICAID (MEDICAL ASSISTANCE) Medicaid provides Medical Assistance to lows ricome persons aged 65 or over, blind, disabled, or members of families with dependent children. The Federal and State Governments jointly finance this program and it is administered by the state. Within broad general Federal Regulations, each state decides eligibility, types and range of services, payment level of services, and administrative and operating procedures. Medicaid's major distinction from Medicare is a form of financial'aide. Medicare is a type of healthcare insurance. When resident resources are reduced to $15,000.00, the facility Business Office should be notified immediately. The following instructions will apply: 1. Resident/Responsible party will be responsible for a burial reserve set up at a bank or funeral home with amount equalizing enough for burial. The amount set aside should include amount of life insurance plus additional funds. A copy of that agreement should be submitted to the Business Office. 2. When all assets are reduced to $2,000.00, call the Business Office for appointment for guidance in the enrollment process. It is the legal responsibility of the POA/Representative Payee to complete the application and enrollment process for Medical Assistance benefits. Every effort will be made by our Business Office staff to assist you. A checklist (pg12-13) is being provided to you with guidelines that will help you get started. Please be aware however; that if the POA/Representative Pay a does not follow through in a timely manner, that the Church of God Home, Inc. reserves the right to file the application on the resident's behalf. 3. The Cumberland County Office of Aging will do a level of care assessment of the resident, known as an "Options Assessment" and forward the results to the Pennsylvania Department of Public Welfare (DPW) for further follow-up by the Cumberland County Assistance Office. Should they assess for a different level of care other than nursing, and/or the resident does not quality for 9 Medicaid, the facility reserves the right to terminate the admission agreement and will work with residentlresponsible party regarding available options. 4. To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Cumberland County Assistance Office 33 Westminster Drive Post Office Box 599 Carlisle, Pennsylvania 17013 P: (717) 697-8545,(717) 240-2700, and 800-269-0173 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 16 West High Street Carlisle, Pennsylvania 17013 (717) 240-6110 5. After preliminary papers are sent to the assistance office, the resident's security deposit will be applied to room and board and any balance due billed to the responsible party. 6. After-being approved, Medicaid requires that the resident's monthly income be submitted to the -facility each month. Of that amount, the resident will receive the approved 45.00 monthly allowance for his/her personal needs. The resident, responsible party or the facility may handle this personal money. 7. Allowable expense from resident monthly income is health insurance. After acceptance into the Medicaid program, billing for health insurance should be forwarded to the staff in our (business office. The monthly expense for this insurance is deducted from the resident's monthly income and the balance is applied to the room and board. The state pays the facility a per diem (daily) rate limes the number of days in the month that a resident, approved for Medicaid, occupies an accommodation. After resident`s responsibility is applied to this amount, the balance, is billed to the Pennsylvania Department of Public Welfare (DPW) on a monthly basis. Bills for personal needs may be presented in the resident's name to the facility handli g funds for reimbursement. Upon enrollment into the Medicaid program, the resident will no ion er pay for routine hair care, incontinence supplies, non-emergent medical appointment transpo aifon or personal laundry service. Medicaid will, however, pay for prescription drugs, doctor isits, dental services and eye examinations. 8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits, the facility will hold a bed. 10 1 4a!b1l, CHURCH OF GOD HOME -Oun?nirrrri to Curine- Medicaid (Medical Assistance) Residents 1. The Church of God Home, Inc. requires a copy of monthly 1 quarterly Medical Insurance premiums. As REQUIRED by Pennsylvania State Regulations. 2. Medical Insurance Premiums will be deducted from the Resident's monthly income and the balance of the income less a 5.00 allowance will be applied to room and board. 3. Prescription drugs, physician visits, dental services, and eye examinations are covered by Medicaid, but only with participating dentists and ophthalmologists. Potential charges will be discussed with responsible party on an individual basis, when requesting non-participating providers. 4. Services furnished at no charge to the Resident are as follows: Normal Shampoo every two weeks • One perm every three months • Transportation to and from medical appointments is provided (Distance to appointments will be discussed on an individual basis) • Non-emergent ambulance transportation • Personal Laundry • Incontinent Supplies • Bed hold in the event of hospitalization The following services will be charged: ' • Any hair care request beyond the above list of provided services Transportation for a personal use • Telephone hook-up, basic charges, and long distance charges 5. Bed hold days due to hospitalization will be fifteen (15) days per hospital stay. Bed hold days due to therapeutic leave will be thirty (30) days per calendar year. a-t7 -®q (Date) 11 J (ResidentrRespormible Party) Medicaid (Medical Assistance) Resident's Checklist CUMBERLAND COUNTY ASSISTANCE OFFICE 33 Westminster Drive Carlisle, Pennsylvania 17013-0599 Telephone: 1-800-269-0173 or (717) 240-2700 In order to determine eligibility for nursing home Medicaid enrollment, the Cumberland County Assistance Office will need the following items to accompany your application when submitted by our billing office. (Photocopies are acceptable) Please call if you have any questions or need help in obtaining the required information. 1. Social Security Card(s) 2. Proof of Date of Birth - 3. Health Insurance Cards A. Medicare (Red/White/Blue Card(s)) B. Capital Blue Cross 1 Highmark Blue Shield Card(s) C. Any other health insurance plan(s) 4.Health Insurance Premiums, provide frequency and amount 5. Long Term Care Policies, provide monies received and terms 6. Power of Attorney or Guardianship papers 7.Read HIPPA disclosure and complete the HIPAA disclosure request PW1815 8.Verification of ALL GROSS VA income needed. (If you are not receiving benefits, you will need to apply for potential benefits in order to be eligible for Medicaid.) 9.Verification of ALL GROSS income - provide current award letters, pensions, annuity income, and interest income 10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and Annuities - must provide values of - 11. Personal Care Account (PCA) Balance 12. Verification of all resources sold, transferred, or given away during the past 3 year$ (5 years for a Trust Fund) - provide disposition, amounts, and dates 13. Titles, vehicle registration, and insurance for all vehicles owned, including boat, motorcycles, and trailers 12 i E i s t E i I E i ; 14. Current cash value of all life insurance policies. Verification should include company's name, policy number, type of policy, face amount of policy when purchased, ownership of poky, and statement on the current cash value from the insurance company. 15. Deed to burial plot(s) or statement from cemetery 16. Copy of Burial Trust / Reserve (including Statement of Irrevocability) 17. Deed to all property and it's current market value - if transferred or sold within the last 36 months, provide a copy of the new deed and the settlement sheet for all sold property _ 18. Title to mobile home and it's current market value - if transferred or sold within the last 36 '• months, provide a copy of the new deed and the settlement sheet for all sold property 19. Any unpaid medical bills you wish to see if Medical Assistance would cover 20. Rent I Mortgage payment proof 21. Utility Bills A. Electric B. Gas C. Oil D. Heat E. Telephone F. Water G. Sewer H. Trash 22. Income Tax Returns - for the past 3 years, provide all schedules and 1099 Forms 13 F MEDICARE The Church of God Home participates in the Medicare program administered pursuant to Title XVIII of the Federal Social Security Act. Medicare hospital insurance helps pay for inpatient care in a Medicare-participating skilled nursing facility following a three (3) night hospital stay and your condition requires daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility. A skilled nursing facility is a specially qualified facility, which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are met: 1. You have been in a hospital at least three nights in a row, before your transfer to a participating skilled nursing facility. 2. You are transferred to the skilled nursing facility because you require care for a condition, which was treated in the hospital. 3. You are admitted to the facility within a short time, generally within 30 days after you leave the hospital. 4. A doctor certifies that you need, and you receive, skilled rehabilitation services on a daily basis, and 5. The Medicare intermediary or the facility's Utilization Review Committee does not disapprove your stay. All conditions must be met. It is especially important to remember the requirement that you must need skilled nursing care or skilled rehabilitation services on a daily basis. Skilled nursing care means care that can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical, occupational, and speech therapies performed by, or under the supervision of, a professional therapist. The skilled nursing care and skilled rehabilitation services you receive must be based on a doctor's orders. Hospital insurance will not pay for your stay if you need skilled nursing or rehabilitation services only occasionally, such as once or twice a week, or if you do not need to be in a skilled nursing facility to get skilled services. When your stay in a skilled nursing facility is covered by Medicare, hospital insurance helps pay for up to 100 days each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. 14 If you leave a skilled nursing facility and are readmitted within 30 days, you do not have to have a new 3- night stay in the hospital for your care to be covered. If you have some of your 100 days left and you need skilled nursing or rehabilitation services on a daily basis for further treatment of a condition treated during your previous stay in the facility, Medicare will help pay. in each benefit period, hospital insurance (Medicare Part A) pays for all covered services for the first 20 days you are in a skilled nursing facility. For the 2151 through the 1001' day, as long as you continue to meet the criteria for daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered services except for $133.50 a day. You may be charged up to this amount by the skilled nursing facility or it may be picked up by your secondary cc-insurance. Effective May 30, 2008: Medicare requires that each resident 1 responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. Major services covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) pays for these services: • A semi-private room, 2 beds in a room • All your meals, including special diets • Regular nursing services • Rehabilitation services, such as physical, occupational, and speech therapy • Drugs furnished by the facility during your stay • Blood transfusions furnished to you during your stay.. • Medical supplies such as splints and casts • Use of appliances such as a wheelchair • Oxygen usage Some services not covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) does not pay for these services: • Personal convenience items such as a telephone in your room • Private duty nurses • Any extra charges for a private room unless it is determined to be medically necessary • Transportation • Name Labels • Hair Care • Personal laundry service NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you receive, you always have the right to appeal the decision. Feel free to contact Medicare at 1-800-6334227. The Church of God Home reserves the right to withdraw from the Medicare program. 15 MOBILE X-RAY IMAGING, INC. Mobile X-Ray Imaging, Inc. ("MXIJ is the most advanced, most efficient, most complete and the only local mobile diagnostic X-Ray/Ultrasound/EKG service in Central Pennsylvania. Based in Harrisburg, MXI employs technologists in Carlisle as well as both the East and West Shore areas of Harrisburg, making it convenient for us to provide fast efficient service to our customers! throughout the region. We provide a broad range of mobile diagnostic services to our nursing home customers at the nursing facility, offering the convenience and comfort of having diagnostic studies performed in the home without the expense and discomfort of ambulance transportation. The following diagnostic services are available on 24 hours per day, 365 days per year basis: Diagnostic X-Ray Studies Electrocardiogram Services Holter Monitor EKG Diagnostic Ultrasound Examinations Our X-Ray and Ultrasound exams are interpreted by Quantum Imaging and Therapeutic Associates (formerly known as A.Z. Ritzman Associates), one of the foremost radiology physician practices in Central Pennsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists, P.C. MXI has introduced the following significant improvements to the mobile diagnostic testing industry in Central Pennsylvania: • MXI was the first provider to utilize sophisticated "high frequency" portable X-Ray units, which produce superior images with less radiation exposure. • We were the first mobile service in Central Pennsylvania to provide 24 hours a day, 7 days a -week X-Ray service with round the clock interpretations. • We are the only mobile service in Central Pennsylvania, which does our own ultrasound examinations, which gives us complete control over quaiity'and service efficiency. • We are the only mobile service in Central Pennsylvania to provide ultrasound' service on 24 hours. per day, 7 days a week basis, including interpretations. Our services are covered by Medicare, Medicaid and most major insurances. Mobile X -Ray Imaging, Inc. - 5120 Lancaster Street - Harrisburg, PA 17111 (717) 561-4940 Psychiatrist The Church of God Home, Inc. offers psychiatric services specializing in geriatric services. Philhaven Hospital has contracted with the Church of God Home to provide on-site services for our senior adults. Billing for this psychiatric service w_ ill be as follows: If the resident is private pay, Philhaven Hospital will bill Medicare first, then your supplemental insurance. If there is still a balance, then the responsible party will be billed. If the resident is on Medical Assistance, Philhaven Hospital will bill Medicare first, then your supplemental insurance, and Medical Assistance third. There wii! be no bill to respo sible parties. Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-8211 if yo need further clarification. We at the Church of God Home welcome this new dimension of expertise to our highly qualified staff. 16 Smoking Policy The Church of God Home does not permit smoking in any of our levels of care. Residents and visitors who smoke are asked to utilize the area provided outside the main entrance for this purpose. Employees and volunteers are not permitted to assist residents in meeting their smoking needs. It will be necessary for residents to get assistance from their family member and friends. All prospective residents will be informed of our Facility's smoking policy. Specialized Services If you have mental retardation, a physical disability, or other disability which occurred before the age of twenty-two (22), you may be eligible to receive support services that would help you to live with your family, in your own apartment, or in another community setting. You may also be eligible for specialized services. For more information, if you'have mental retardation call Central Regional Office of Developmental Programs at (717) 772-6507. If you have another disability (other than mental retardation or mental illness) call United Disabilities Service at (717) 397-1841. If you have mental illness (other than dementia) and you do NOT need nursing facility services, you may be eligible to receive support services that would help you live in your own apartment, in a group home, or another community setting. For more information, call (717) 772-7490. If you are not satisfied with the response you receive, call the Disabilities Rights Network of PA at (215) 238-8070. Transportation Enrollment with the local ambulance service is not required, but is recommended. Not all medical appointments require ambulance stretcher transport and are often handled by our wheelchair lift van. Physician ordered medical appointments are to be scheduled through our nursing department with local physicians, as the Church of God Home does not normally transport to out-oftown medical appointments. Family members will be contacted to determine their availability to provide transportation, or to serve as a companion to accompany residents during transport, throughout the appointment, and on the return trip. Medical consult sheets accompany residents to their appointments and often there is a need to adjust for a meal or medication routine. Families providing transport are requested to follow the sign out procedures and are asked not to schedule follow-up appointments unless they are intending to provide the transportation. In either event, please be sure to inform the nursing department of the scheduled follow-up appointment. NOTE: Transportation provided by the facility will be at an extra charge. Please see "Chart of Cost" for fee schedule. 17 r ' UNDERSTANDING RESTRAINT USE i In order to protect our residents from harm or to promote them to a higher level of independence, it is j sometimes necessary for us to use a physical restraint. j Physical restraints are any manual method, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to the resident's body. Examples include: bedside rails, leg restraints, arm restraints, hand mills, soft ties, wheelchair safety bars and geri chairs. These devices are NEVER used as a disciplinary action or for the convenience of the facility to control behavior. Restraints are initiated only after less restrictive measures, such as positioning pillow, pads, Wedges, removable lap trays couples with appropriate exercises, or other "enabling" equipment, have been demonstrated to be insufficient. The least restrictive device would be then implemented following a specific doctor's order and/or a phone call to P.O.A.! next of kin. The resident will then be reviewed in the next Restraint Reduction meeting. The following is a comparison of potential BENEFITS and RISKS of restraint use: Potential Benefits E .. } ' - Prevention of fails which might result in injury Protection from other accidents or injuries Medical treatment allowed to proceed without resident interference E - Protection of other residents/staff from physical harm - Increased feeling of safety and security Potential Risks Accidental injury from the restraint Chronic constipation Incontinence Pressure sores - Loss of muscle tone Loss of balance Reduced appetite, dehydration - Loss of independent mobility Increased agitation Symptoms of depression; withdrawal - Contractures Reduced social contact 18 CHURCH OF GOD HOME -r.runiniirrd to Cnrim" Advance Directive Policy It is God alone who opens the door to earthly life. It is God alone who has the right to close it. All experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of priorities. The Church of God Home recognizes the right of an individual to make and change decisions concerning their medical care in consultation with their physician. This includes the right to accept or refuse artificial means of sustaining life when these decisions are set forth in properly executed Advance Directives/Healthcare Guidelines. In no instance will the Church of God Home condone homicide, euthanasia, suicide or aided suicide. In the absence of advance directive, the care of the resident will be in accordance with currently accepted medical standards. Regardless of the resident's decision about life sustaining treatment, supportive and compassionate care for maximum comfort will be provided. These measures include, but are not limited to, oxygen, medication to relieve pain, food and fluids as tolerated, along with emotional and spiritual support. Should the occasion arise when a resident would refuse nutrition or medical supportive services with the intention of prematurely bring their life to an end, the Home would encourage and recommend counseling and evaluation. The family would be informed and, if a satisfactory resolution cannot be achieved as to the care of the resident, the Home would assist the family in the attempt to relocate the resident to another facility as soon as possible. I acknowledge that I have received a duplicate copy of the above Advance Directive Policy and have had provided the opportunity to ask questions relating to the same. I have also been offered the opportunity to complete an Advance Directive. J-0 --off' (Date) TJ _ (Resideni/Responsible Party) (Resident N ) (FacRity Repr t five) 19 CHURCH OF GOD HOME "Commirred to C.uriu DELEGATION OF RESPONSIBILITY FORM As a result of medical and/or physical condition or personal choice, residents find it difficult to understand and/or sign for their Resident's Rights and/or their Admission contract. Some residents, although not legally judged incompetent, may be found by a physician to be incapable of understanding these rights and contract information. 'Therefore, a resident may choose to designate an individual to act of their behalf by permitting them to sign the necessary forms indicating receipt of this information. "is medically/physically capable of (Name of resident) understanding Resident's Rights but designates this to: C2 --1 - 09' (Date) 20 ??? (Resident/Responsible Party) 42 CHURCH OF GOD HOME "C amntirted to Crrrinv LEGAL RIGHTS COMPLIANCE RESIDENTS AWARENESS COMMONWEALTH INFORMATION CENTER 402A Finance Building Harrisburg, PA. 17120 Telephone: 1-800-932-0784 PENNSYLVANIA DEPARTMENT OF HEALTH DIVISION OF NURISNG CARE FACILITIES HARRISBURG FIELD OFFICE 132 Kline Plaza, Suite B Harrisburg, PA. 17104 Telephone: 717-783-3790 CUMBERLAND COUNTY AGING & COMMUNITY SERVICES OMBUDSMAN PROGRAM HUMAN SERVICES BUILDING 16 West High Street Carlisle, PA. 17013 Telephone: 717-240-6110 ,-,) -17-? (Date) PENNSYLVANIA DEPARTMENT OF AGING 555 Walnut Street Harrisburg, PA. 17101 Telephone: 717-783-7247 PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CUMBERLAND CTY. ASSISTANCE OFFICE 33 Westminster Drive P.O. Box 599 Carlisle, PA. 17013 Telephone: 717-240-2700 1-800-269-0173 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA. 17013 Telephone: 717-243-9400 s 21 (ResidentlResponsible Party) 42 CHURCH OF GOD HOME -Cnninrirrrd in Caring- NON -DISCRIMINATION STATEMENT In accordance with applicable Federal and Stale civil right laws and regulatory requirements, you, as a resident of this facility, have the right upon admission: • To be provided services at this facility and to be referred for services at other facilities without regard to your race, color, religion creed, handicap, ancestry, national origin, age or sex. • To file a complaint of discrimination if you feel you have been discriminated against on the basis of your race, color, religious creed, handicap, ancestry, national origin, age, or sex. Complaints of discrimination may be filed with any of the following: PresidentlCEO Church of God Horne, Inc. 801 N. Hanover Street Carlisle, PA 17013 Phone: (717) 249-5322 Department of Health and Human Services Office for Civil Rights 150 S. Independence Mall West Suite 372 Philadelphia, PA 19106-3499 Phone: (215) 861:4441 Pennsylvania Human Relations Commission Harrisburg Region Office Riverfront Office Center 1101-1125 South Front Street, 51h Floor Harrisburg, PA 17104-2515 Phone: (717) 787-9784 -17 _ 0 (Date) Department of Public Welfare Bureau of Equal Opportunity Central Regional Office Rm # 223, Health & Welfare Bldg. P.O. Box 2675 Harrisburg, PA. 17120-2675 Phone: (717) 783-3063 v - (Resident/Responsible Party) (Resident N me) r i (Facility Rep nt "ve) 22 r Personal Cash Accounts (PCA) To establish personal cash account (PCA) at the Church of God Horne, Inc., contact our Business Office (Henderson House). The following procedure shall be followed: 1. Sign the following authorization form to open an account 2. Deposit money by checks or cash - A receipt will be issued for cash deposits. 3. Daily withdraw maximum of $30.00 Note: Regular business hours are 9:00 a.m. to 3:45 p.m., Monday through Friday, except holidays. Deposits The resident or family member 1 responsible party may deposit cash or checks either at our Business Office (Henderson House) or in our Lobby Front Office during regular business hours and of course, by mail. Personal cash accounts are only meant to provide casual spending money for residents. Disbursements The resident may come to our Lobby Front Office during business hours ;to request money. A resident charge slip is completed and the resident or family member I responsible party signs the disbursement skip. Purchases for a resident may be made by family or designated person and a receipt should be submitted to our Business Office for each reimbursement from the resident's account, i.e. TV's, shoes, clothing, etc. PCA's are reconciled monthly to the bank statement. Interest paid by the bank is pro-rated to each account i and deposited into each account accordingly. Quarterly statements are issued, along with a cover letter to be signed by the resident and returned to our Business Office. Each resident of the facility has the right to open a personal cash account (PCA). All accounts, regardless of the resident's status, are handled in the same manner. Upon the death/discharge of a resident, the account balance shall be returned to the executor of their Will or authorized representative of their Estate within thirty (30) days. 23 Personal Cash Accounts (cont.) 42 CHURCH Of GOD HOME `Cantnthird to ('mina" Authorization to Handle Personal Funds CA] (Date) (ResidenWesponsble Party) t (Re 61 Name) (Facility Repr Eve) s depleted Funds khen resident's assets reach $15,000.00, family/responsible party should cgfttect our Business Office mediately. -° amdy member / responsible party will have to apply for Medical Assistance 0sidenls with no family ber / responsible party, our Business Office will apply for Medical Assistance= *- _?tesidents will receive $45.00 monthly from their income for personal needs ..Other monies may be deposited into each PCA, as the resident or family member / responsible party desires. ,j-?7-a?' Q_? (Date) (ResidenUResponsble Party) (Resident Name) r , F., ' r/7 I I (Facitity Repres it ). 24 421- . - CHURCH OF GOD HOME -Cr?mn?irred to r'arinf" Personal Laundry Service '1 This is to advise that the personal laundry will be launde within outside (circle one) the facility. NOTE: • These arrangements can be changed with notification to Social Services or Charge Nurse. • Residents i Responsible Parties providing laundry services need to provide a container with a. fid and box of plastic bag liners for the purpose of storing laundry. • Volunteers are available to assist with labeling clothing ! personal items. Please contact Social Services or Charge Nurse. • Dry cleaning and_ Alteration Services are not provided. • No wool items -4re. accepted. c9- 1-7 - 0 (Date) (Resident/Responsible Party) (Resident Name) (f=acility Repr n time) r i I i i i 1 25 Pharmacy Services Spevialist in Continuing Care Rx is proud to announce that we have been chosen to be the provider of choice for the pharmacy services at Church of God Home. The mission of Continuing Care Rx is to provide pharmacy services and programs that meet the ever-changing needs of our facilities and the residents they serve, ensuring continued quality care and positive outcomes in the most cost-efficient manner possible. i Pharmacy services for Long-Term Care or Personal Care Residences are mandated by government agencies to offer additional services, which you may not have been accustomed to in a normal retail pharmacy. These additional services are designed to aid in your progress (or that of your loved one). i We would like to highlight some of the services we provide to give you a better understanding of the many unique benefits we have to offer the residents we serve: ? Controlled Packaging System - Routine tablet/capsule medications are packaged in a 30-day sealed blister card enabling nursing staff to administer medications in a controlled environment with extreme accuracy and safety. ? Medical Records - A medical records staff member maintains and prints monthly charts that are utilized by the caregivers, nursing staff and physicians. ? 24-Hour Emergency Service - If a situation occurs that requires the delivery of medications in an emergency, Continuing Care Rx has a pharmacist and driver on call 24 hours a day, 7 days a week to meet these emergency needs. • Consultant Pharmacist -A Consultant -Pharmacist is assigned to our facilities to jreview residents' charts on a monthly basis and to interact with the nurses and physicians to monitor the residents' condition. In addition, they will make recommendations to the physicians when a better and more cost-effective therapy for the existing condition becomes available. • Delivery Service - Medications will be delivered to the facility at predetermined times on a daily basis, ensuring timely delivery of all medications ordered. ? Billing - The staff at Continuing Care Rx will handle the billing process for all types of reimbursement. Continuing Care Rx is a member of most insurance groups and we bill directly to these insurance groups. Should you belong to an insurance group with which we are not currently affiliated, we will immediately pursue enrollment in that program in an effort to meet your needs and ease your financial responsibility. We would like to point out that all of the above services are provided at no additional cost, thus ensuring a much more cost-effective and beneficial way of dispensing and monitoring pur residents' medications. We, at Continuing Care Rx, are focused on providing the highest quality of pharmacy se ices to all of the residents we serve. We look forward to working closely with you (or your loved one} by roviding the best service available in the long-term care industry. Note: Please contact Continuing Care RX with any questions or billing concerns at 1-800-6' 5-2279. 26 Pr?ron ."wicr CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY. 1. Our Duty to Safeguard Your Protected Health Information We are committed to preserving the privacy and confidentiality of your health information. We are required by certain state and federal regulations to implement policies and procedures to safeguard your health information. Copies of our privacy policies and procedures are maintained in our business office. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revisions that we may make to the notice as may become necessary or as authorized bylaw. Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care treatment or services you receive is considered protected hroldh information (PHI}. Accordingly. we are required to provide you with this Privacy Notice that contains information regarding our privacy practices to explain how, when and why we may use or disclose your PHI and your rights and our obligations regarding any such uses or disclosures. Except in specified circumstances, we must use or disclose onl} the minimum amount of PHl necessary to accomplish the intended purpose of the use or disclosure of such information. We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have about you as well as any information we receive in the future about you. Should we reviseXchange this Privacy Notice, we will promptly post the revision (insert location, such as on a websitej. You also may request and obtain a copy of any newirevised Privacy Notice from the contact person identified on the last page of this notice. Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document. 11. How We May Use and Disclose Your Protected Health Information We use and disclose protected health information for a variety of reasons. We have a limited right to use and/or disclose your protected health information for purposes of treatment, payment, or for health care operations. For- other uses and disclosures, you must give us your written authorization to release your protected health information unless the law permits or requires us to make the use or disclosure without your authorization. Should it become necessary to release or give access to your protected health information to an outside party performing services on our behalf (e.g., maintaining our computers), we will require the party to have a signed agreement with us that the parry will extend the same degree of privacy protection to your information as we do. The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health in formation. Where appropriate, we have included examples of the different types of uses or disclosures. These include: L Use and Disclosures Related to Treatment We may disclose your protected health in Formation to those who are involved in providing medical and nursing care services and treatments to you. For example we may release protected health information about y to nurses, nursing assistants, medication aides/technicians. medical and nursing students, therapists, other pharmaci ts, medical records personnel, other consultants, physicians, etc. We may also disclose your protected health informati n to outside entities performing other services relating to your treatment. such as long term care facilities, hospitals, di gnostic laboratories, home health/hospice agencies, family members, etc. 2. Use and Disclosures Related to Payment We may use or disclose your protected health information to bill and collect payment for items or services we provided to you. For example, we may contact your insurance company, health plan, or another third party tot obtain payment for services we provided to you. P MCV NO?lae 27 Prrror r .va irr 3- Use and Disclosures Related to Health Care Operations We may use or disclose your protected health information for the performance of certain functions in monitoring and improving the quality of care and services that you and others receive. For example. we may use your protected health information to evaluate the effectiveness of the care and services you are receiving. We may also disclose your protected health in formation for auditing, care planning. quality improvement. and learning purposes. 4. Use and Disclosures Related to Treatment Alternatives, Health-Relsted Benefits and Sdrvices We may use or disclose your protected health information for purposes of contacting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you, such as a newly released medication or treatment that has a direct relationship to a treatment or medical condition- ill. Uses and Disclosures Requiring Your Written Authorization For uses and disclosures of your protected health information beyond the above excepted purposes, we are required to have your written authorization, except as otherwise required or permitted by law- You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing- Out contact information for purposes of revoking your authorization is listed on the lost page ofthis document- You may use our:Awhoi-hationfor WE or Disclosure of Protected Health Information form and/or our Revocation of anAuthorizcuion form to submit your request to us_ Copies of these forms are available upon request. Examples of uses or disclosures that would require your written authorization include. but are not limited to, the following: 1. A request to provide your protected health information to an attorney for use in a civil litigation claim. 2. A request to provide certain information to an insurance or pharmaceutical company for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you. 3. A request to provide PHI to another individual or facility, where no exception from the written authorization requirement applies. IV_ Uses or Disclosures of Informattion Based Upon Your Verbal Agreement In the following situations, we may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are unable to object (e.g., because you were not present or. you were incapacitated), disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best-interest. When a disclosure is made based on these or emergency situations, we will only disclose protected health in formation relevant to the person's involvement in your care-'For example, if you are having an adverse reaction to a medication, and are not able to communicate with us effectively, we may inform a family member) involved in your care of your drug regimen and possible side effects. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so. We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your family and/or friends about your general condition, location. and/or status (i.e., whether you are alive or dead). You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection or your objection may be made orally. Our contact information is listed on the last page of this document. (See also Section VI, paragraph l.) V_ Uses and Disclosures of Information That Do Not Require Your Consent otr Authorization State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make' without your consent or authorizaiion include the following: 1. When Required by Law: We may disclose your protected health information when required by federal, state or local law. Privacy koricc i i f i 28 P.iyory.vc?rce 2. Abuse, Neglect, or Domestic Violence: As required or permitted bylaw, we may disclose protected health information about you to a state or federal agency to repon suspected abuse, neglect, or domestic violence. If such a report is optional, we will use our professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly that we have made such a disclosure. 3. Communicable Diseases: To the extent authorized by law, we may disclose information to a person who may have been exposed to a communicable disease or who is otherwise at risk of spreading a disease or condition. 4. Disaster Relief: We may disclose protected health information about you to government entities or private organizations (such as the Red Cross) to assist in disaster relief effons. S. Food and Drug Administration (FDA): We may disclose protected health information about you to the FDA, or to an entity regulated by the FDA, in order, far example, to report an adverse event or a defect related to a drug or medical device. L For Public Bealth Activities: As required or permitted by law, we may disclose protected health information about you to a public health authority, for example, to report disease, injury, or vital events such as death. j 1. For Health Oversight Activities: We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, or to other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents or to ensure that we are in compliance with applicable state and federal laws and I regulations, including civil rights laws. 11. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations or Tissue Banks: We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a I deceased individual or to determine the cause of death- We may also disclose your protected health information to a funeral director for the purposes of carrying out your wishes and/or for the funeral director to perform his/her necessary duties. { i If you are an organ donor. we may disclose your protected health information to the organizatio#r that will handle t your organ, eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation'. j 9. For Research Purposes: We may disclose your protected health information for research purposes without your authorization only when a privacy board has approved the research project. We may use or disclose your protected health information to individuals preparing to conduct an approved research project in order to assist such individuals in identifying persons to be included in the research project. Researchers identifying persons to be included in the research project will not be permitted to remove protected health information from our control. If it becomes ntemsary to use or disclose information about you that could be used to identify you by name, we will obtain your written authorization before permitting the researcher to use your information. Researchers will be required to sign a Clonfidendalhnr and Non-Disclosure Agreement form before being permitted access to protected health information for research purposes- A sample copy of this agreement may be obtained from our business office. 10. To Avert a Serious Threat to Htxlth or Safety: We may disclose your protected health information to avoid. a serious threat to your health or sakty or to the health or safety of others. When such disclosure is necessary, information will only be releaw.to those law enforcement agencies or individuals who have the ability or authority to prevent or lessen the threat of harm. 11. For Judicial or Administrative Proceedings: We may disclose protected health information about you in the course of a judicial or administrative proceeding, in accordance with our legal obligations. PiiVsryNrAiCr 29 P, rtroe r '1611 r? 12. To Law Enforcement: We may disclose protected health information about you to a law enforcement official fnr certain law enforcement purposes. For example, rye may report certain types of injuries as required bylaw. assist law enforcement to locate someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct. 13. Minors: If you are an unemancipated minor as defined under state law, there may be circumstances in which we disclose protected health information about you to a parent. guardian, or other person acting in torn purenris, in accordance with our legal and ethical responsibilities. 14. Parents: If you are a parent of an unemancipated minor, and are acting as the minor's personal representative, we may disclose protected health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child's personal representative in order for your child to receive care or services from as. we may disclose protected health information about your child to you. In some circumstances. we may not disclose protected health information about an unemancipated minor to you. For example, ifyour child is legally authorized to obtain services (without separate consent from you)_ and does not request that you be treated as his or her personal representative, we may not be required to disclose protected health information about your child to you without your child's written authorization. 15. To Personal Representatives: If you are an adult or emancipated minor, we may disclose protected health information about you to a personal representative authorized to act on your behalf in making decisions about your health care. 16. For Specific Government Functions: We may disclose protected health information about you for certain specialized government functions. as authorized by law. Among these functions are the following: military command; determination of veterans benefits; national security and intelligence activities; protection of the President and other officials: and the health, safety, and security of correctional institutions. 17. For Workers' Compensation: We may disclose protected health information about you for purposes-related to workers' compensation, as required and authorized by law. VI. Your Rights Regarding Your Protected Health Information You have the following rights concerning the use or disclosure of your protected health information that we create or that we may maintain about you: S_ To Request Restrictions on Uses and Disclosures of Your Protected Health Information: You have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your cote or services. For example. you could request that we not disclose to family members or friends information about a medical treatment you received. Should you wish a restriction placed on the use and disclosure of your protected health information, You must submit such request in writing. Such request should be submitted using our Request toi Restrict the Use and Disclosure of Protected Health lnjormmiun form. Our contact information for purposes of making such a request is listed on the last page of this document. We are not required to agree to your restriction request. You will be informed if we dec! ne your request. If we accept your request. we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you. Pri.Dc% Notice 30 + 2. The night to Inspect and Copy Your Health and Billing Records: Pronto •%0wr You have the right to inspect and copy your protected health information, such as your pr ription and billing records. In order to inspect and/or copy your protected health information, you must submit a written request to us. If you request a copy of your prescription or billing information or other records, we may charge you a reasonable i fee for the paper. labor, mailing, and/or retrieval costs involved in filing your requests. We will provide you with information concerning the cost of copying your protected health information prior to performing such service. i Such requests should be submitted on our Request jor InspeetiontCopy of P-otected Health Information form. Out contact information for such requests is listed on the last page of this document. We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your protected health information. we vetll provide you with written notice of our reasons of the denial and your rights for requesting a review of the denial, if any. In the event of a review, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons !,for dental. We will abide by the reviewer's decision concerning your inspection/copy requests. Your denial review request should be submitted on our Denial of Inspection/Copy qr Protected Health Information fern. Copies of these forms are available from the contact person listed on the Iasi page of this document. 3. The Right to Amend or Correct Your Protected health information: You have the right to request that your protected health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your protected health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request, unless an extension is necessary, in which case you will be notified, and receive a response to your request within ninety (90) days. If we appro,ve your request, we will make such amendments/corrections and notify those with a need to know of such amendmerits/cotrections. We may deny your request if: a. Your request is not submitted in writing: b. Your written request does not contain a reason to support your request; c. The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment: d. It is not a pan of the protected. health information kept by us; c. It is nor pan of the information which you would be permitted to inspect and copy: and/or f The information is already accurate and complete. If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial, and any written response (of reasonable length) you may 'have relative to the information and denial process appended to your protected health information. Your amendment/correction request should be submitted on our Request for AinendmentlCorriection of Protected Health /nformatinn form. Copies of these forms arc available from our business office. Our contact information for the purpose of making such a request is listed on the last page of this document. 4. The Right to Request Confidential Com inun "lions: You have the right to request that we communicate with you about your health matters in acertain way or at a certain location. For example, you may request that we not send any protected health information to you at a health care facility, but instead send communication for you to a residential address or Post Office Bo*- We will agree to your request as long as it is reasonable for us to do so. You may submit your requests on our Request jor Restrictinn of Confidential Communications form. Copies of these forms are available from the contact person listed on the last page of this document. Our contact information is listed on the last page of this document. 5. The Right to Request an Accounting of Disclosures of Protected Health Information: You have the right to request that we provide you with a listing of certain disclosures of your protected health information that we have made over a specified period of time. This accounting will not include any information we have made for the purposes of treatment, payment. or health care operations or information leased to you. your Privacy Nolicc 5 31 1,0 NAr' Nortcr family or friends for notification purposes. disclosures made for national security purposes or to certain law enforcement officials. incidental disclosures, disclosures made as part of a limited data set (for' use in research, public health, etc.), or any disclosures made pursuant to your authorization. Your request must be submitted to its in writing and must indicate the time period for which you wish the information (e.g.. May 1.2003 through August 31,1003). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April lit, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information. We will respond to your request with sixty (60) days of the receipt of your written request: Should additional time be needed to reply, you will be so notified. However. in no case will such extension exceed thirty (30) days. The ftrsl accounting you request during a twelve (12) month period will be free. There may be a tea, nable fee for additional requests during the.iwelve (12) month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. You may submit your requests on our Request /or on .lccounring of Disclosurrs of Protected Health Information form available from our business office. Our contact information is listed on the last page of this document. 6. The Right to Receive a Paper Copy of This Notice: You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of this information from our websiie (as applicable). Our contact information is listed on the last page of this document. Vt. How to File a Complaint About Our Privacy Practices li you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretayof the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint. You may submit your complaint on our Privacy Practices Complaint form available from our business office. Our contact in formation is listed on the lase page of this document. NVACC NwiCC 32 k ?T ' t'nuc?c _?oucr CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES Record of Acknowie M! u_meMation of I?Feod F ' Eflort to Obtain Acknowledgment Name of IResidcntt'Patient]: Date: r1a 1 Effective Date of This Privacy Notice April l4, 2003 Contact Information for Questions, Complaints or Requests Regarding Your Health Information Should you have aky questions concerning our privacy practices. obtaining a trop} of our privacy notice. requesting restncnons on the release of vote information, revoking an authorization, amcading or correcting Tout prowled health information. obtaining an accounting of our disclosures of your protected health information, requcs6og inspection or copying of your medical information. requesting that we communicate information about your health matters in a certain way, riling complainm or arr other concerns you may have relative to our privacy practices, please contact: Brian D_ Stwalk_r• Chief Compliance Officer 5775 Allentown Blvd. Suite 202, Harrisburg, PA 17112 Tel: 717-810-1450 Ext. 4, Fax: 717-810-1952 hAtwalley "tcemorg If you wish you mac also file a complaint with the Secretary of the U.S. Dcpanmen of Health and Human Services. You may mail your complaint to U.S. Depanment of Health and Human Services. 200 Independence Avenue, S.W., Washington. DC 211201: or you may call (21)2) 6194)257 or 1-877-696-6775 (loll free): or you may log on to the Internet address. hetp:/hv%,-- .hhs.gov/oer. Acknowledgment / Good Faith Effort !a Obtain Acknowledgment (check one of the following) I j I am the above Resideat/Patient and I certify that I mccivcd a copy of the Continuing Care Rx's Privacy Notice and that 1 have had an opporiunhy to review this document and ask questions to assist me in understanding my rights relative to the pracction of my health information. I am satisfied with the explanations provided to me and I am confident that Continuing Care Rv is committed to protecting my health information. Date: _ Signature: Printed Name: K] l certif}• that 1 am the authorized representative of above name Resident/Patieni. and that I have received the Privacy NcHice on behalf of this individual and that Continuing Care Rx provided tux lvith an opponunity to review this document and ask questions to assist me in understanding the patient's privacy rights. I am satisfied with the explanations provided to ire and I am confident that the above-named entity is committed to protecting health information. Datc:Q?_ 1 r _ Of Signature of Representative: ? Printed Name: 17,1 N D - j Relationship to Individual: I ) I- . certif. that I made a good faith effort to obtain the acknowledgment of the above- identified Iresidcnt/patientj or his/her personal representative that hdshe had received a copy of the Pnvacy Notice of Continuing Care Rx, but was unable to obtain such acknowledgment for the folloAing reason(s): I ] IResident/Patient] or personal representative refused to sign. I J [Resident/patiew) or personal rcprtsetrtative Was unavailable to sign. I lOther Dale: Signaturelfitle: Mvacy \wice 33 42 CHURCH OF GOD - HOME -rnnrrniwd in (-',trios' PODIATRY SERVICES I request that payment of authorized Medicare benefits be made either to myself, or on my behalf, to Dr. William Pu6Q for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. es. I have accepted Dr. William Pulp as my podiatry care physician ? No, I decline offered podiatry care physician for my podiatry care 1--17 (Date) 4-(Resident?2esponsbte Party) (Resident Name) U` (Facility Repr ati ) 34 i CHURCH OF GOD HOME -Chtnlnined to Curing" Privacy Act Statement-Healthcare Records This form provides you the advice required by the Privacy Act of 1974. This form is not a consent form to release or use healthcare information pertaining to you. 1. Authority for collection of information including Social Security Number (SSN) Sections 1819 (f), 1919 (b)(3)(A), and 1864 of the Social Security Act Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and (health -status. As of Juste 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the Health Care Financing Administration. This data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records. 2. Principal purposes for which information is intended to be used The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services- 3. Routine Uses The primary use of this information is to aid in the administration of the survey a d certification of Medicare/Medicaid long-term care facilities and to improve the effectiveness and qualit of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. 35 Privacy Act Statement-Healthcare Records (continued) The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System #09-70-1516. Informatron from this system may be disclosed, under specific circumstances to: (1) a congressional office from the record of an indivvidual in response to ar ' inquiry from the congressional made-at the request of that individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an individual or organization for a research, evaluafo, or epidemiological project related to the prevention of disease of disability or the restoration/ of health; (5) contractors working for HCFA to cant' out Medicare/Medicaid functions, collating or analyzing data or to detect fraud or abuse; (6) an agency of a State government for purposes of determining,'! evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (S) Peer Review Organizations to perform Title XI or Title XVIII functions; and (9) another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions. 4. Whether disclosure is mandatory or voluntary and effect on individual of not providing information For nursing home residents residing in a certified Medicare/Medicaid nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of Icare given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medicaid services. NOTE: Providers may request to have the Resident or their Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required. If the Resident or their Representative agrees to sign the form it merely acknowledges that they have been advisedl,of the foregoing information. Residents or their Representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions. I (we) acknowledge receipt of the Privacy Act Statement - Healthcare Records -j-7 - aQ (Date) 0., (Resident/ResponstWe Party) ?Z& 6=?? (Resident Nam (Facility Represen b e) 36 42 CHURCH Of GOD HOME "('ammined no C'arine Private Room Policy - Nursing Policy: It is the policy of the Church of God Home that provisions shalt be made for isolating a resident in a single room whenever their medical condition requires isolation. Purpose: To ensure that the resident receives the most suitable protection possible. Procedure: 1. The one private nursing room in this facility may be used as a regular private/single room until the facility's need for an isolation room arises. This room is ident d as Room 118 Faith Wing. 2. Any resident using room 118 must agree on admission that they will naive out of the room to a semiprivate room if the facility needs to use it. 3. When a need for an isolation room arises and a semi-private room is not available at Church of God Horne, the resident occupying the private room will be transferred as soon as possible temporarily to another long-term care facility until a semi-private room becomes available at the Church of God Home. This individual will theft be returned to the private room when it again becomes available: 4. Individuals interested in occupying a private room should make their interest known on admission to the Director of Admissions or their Social Worker at anytime. 5. The Director of Admissions will maintain a list of those residents interested in the private room. Such resident will be offered the private room, when available, based on their initial admission date to the Church of God Home, regardless of their level of care or the date they placed their name on the waiting list. 6. When not in an isolation need situation, a resident in the private room must be of private pay status. If no longer able to cover the monthly bill, such resident will be asked to relocate into a semi-private room as soon as an appropriate one beconhes available at the Church of God Home. - / -- a (Date) (Resident/ResponetWe Party) al Jma? (Resident Name) V. /7 / I nW L." (Facility Repre five) 37 CHURCH OF GOD HOME 'Committed ?o Curiae" Therapy Church of God Home has arranged for Genesis Rehabilitation Services, a professional, full-service therapy company, to provide physical, occupational, and speech therapy services. These services will be provided only when the Resident's physician orders them, and when these services are necessary to iattain or maintain the Resident's highest practicable physical, mental and psychosocial well being. While the payment of charges for therapy services is the responsibility of the resident, insurance will usually pay for such services. If the resident has Medicare Part B coverage, Medicare Part B will pay for 80% of the therapy charges. The balance of the 20% may be paid by the Resident's supplemental insurance. In the event therapy services are l not covered, the Resident will be billed privately. Residents should review the coverage for therapy under their plan, and, it necessary, call the insurance company. Residents 1 Responsible Party may contact our Business Office with questions related to therapy billing. ?jy?i rl aAAA igned hereby m ents to the provision of therapy services for (the Resident) as ordered by Resident's physician an deemed necessary to attain or maintain the highest practicable physical, mental and psychosodal well-being. The undersigned understands that no guarantee or assurance has been made as to any result that may be obtained from the Resident's treatment. The undersigned authorizes Church of God Home, Genesis Rehabilitation Services, and the Resident's treating or consulting physicians to release necessary records needed for the provision of therapy services or for payment. r? /7 -- D (Date) 38 (Resident/Responsible Party) (Re s (d ent Name) (Facility Re b ) i 4 Vaccinations What Is Influenza (Also Called Flu)? The flu is a contagious respiratory illness caused by influenza viruses. It ran cause mild to severe illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccination each year. Every year in the United States, on average: • 5% to 20% of the population gets the flu: • more than 200,000 people are hospitalized Irom flu complications; and • about 36,000 people die from W. Some people. such as older people, young children, and people with certain health conditions (such as asthma, diabetes, or heart disease), are at high risk for serious nu complications. Symptoms of Flu Symptoms of flu include: • fever (usually high) . runny or stuffy nose • headache . muscle aches • extreme tiredness . Stomach symptoms, such as nausea, • dry cough vomiting, and diarrhea, also can occur but • sore throat are more common in children than adults Complications of Flu Complications of flu can Include bacleriai pneumorda, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart tailors, asthma, or diabetes. How Flu Spreads Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. Sometirnes people may become infected by touching something with flu viruses on it and then touching the>r mouth or nDSe. Most healthy adults may be able to infect others beginning t day before symptoms develop and up to 5 days after becoming sick. That means that you may be able to pass an the On to someone else before you know you are sick, as well as while you are sick. Preventing Seasonal Flu: Get Vaccinated The single best way to prevent the flu is to get a flu vaccination each year. There are two types of vaccines: • The "flu shot" -an inactivated vaccine (conta-rning killed virus) that is given with a needle. The flu shot is approved for use in people 6 months of age and older. including healthy people and people with chronic medical conditions. Page I of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AHD PREVENT/OH SAFER-HEALTHIER - PEOPLE' 39 Key Facts About Seasonal Influenza (Flu) • The nasa"pray flu vaccine - a vaccine made with five, weakened Nu viruses that do not cause the flu (sometimes called [AN for 'Live Attenuated Influenza Vaccine'. LAN is approved for use in healthy' people 2-49 years of age who are not pregnant. About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will nut protect against flu-kite illnesses caused by non-influenza viruses. When to Get Vaccinated Yearly flu vaccination should begin in September or as soon as vaccine is available and continue throughout the influenza season, into December, January, and beyond. This is because the timing and duration of influenza seasons vary. Mule influenza outbreaks can happen as early as October, most of the tone influenza activity peaks in January or later. Who Should Get Vaccinated? In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year either because they are at high risk of having serious fhu-related complications or because they five with or rare for high risk persons. During nu seasons when vaccine supplies are limited or delayed, the Advisory Committee on Immunization Practices (ACiP) makes recommendations regarding orfothy arouDS lot vaccination. People who should get vaccinated each year are: 1. People at high risk for complications from the flu, including: • Children aged 6 months until their 51h birthday. • Pregnant women, • People 50 years of age and 'alder, • People of any age with certain chronic medical conditions, and • People who fire in.nursing homes and other long-term care facilities. 2 People who five with or care for those at high risk for complications froifn flu, including: ¦ Household contacts of persons at high risk lot complication ham the flu (see above), • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated), and • Health care workers. 3. Children aged 6 months up in their iP birthday 4. Anyone who wants to decrease their risk of influenza. Use of the Nasal Spray Flu Vaccine Vaccination with the nasal-spray flu vaccine is an option for healthy' people 249 years of age who are not pregnant, even healthy persons who five with or care for those in a hlgh4M group. The one exception is healthy persons who care for persons with severely weakened immune systems who require a protected environment; these healthy persons should get the inact'?vated vaccine. DEPAR7MENT.OF HEALTH AND HUMAN SERvICEs CENTERS rOR DISEA5E CONTROL AND PREVENTION SAFER•HEAL*r"rER• PEOPLE 40 Who Should Not Be Vaccinated Some people should not be vaccinated without first consulting a physician. They include: • People who have a severe allergy to chicken eggs. • People who have had a severe reaction to an Infl»enza vaccination in the past. • People who developed Guillain-Bang syndrome fGBSI within 6 weeks of getting an Influenza vaccine previously. • Children less than 6 months of age funituenza vaccine is not approved for use in this age group). • People who have a moderate or severe illness with a fever should wait to gat vaccinated until their symptoms lessen. If you have questions about whether you should gel a flu vaccine. consult your health-care provider. For more about preventing the flu, see the following: - Key Facts About Seasonal Flu Vaccine . Influenza Antiviral Drugs • Good Health Habits for Prevention . The Flu: A Guide for Parents 'Healthy' indicates persons who do not have an underlying medical condition that predisposes them to influenza complications. For more Information, visit www.cdc.aov/Au, or call CDC at 800-CDC-INFO (English and Spanish) or 888-232-6348 rm). DEPARTMENT OF HEALTH AND HUMAN SaRvIC£5 CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER-HEALTHIER-PEOPLE' F i i 41 "Wr PNEUMOCOCCAL VAC C I N POLYSACCHARIDE WHAT YOU NEED TO KNOW '1 Why get vaccinated? 3 Who should get PPV? Pneumococcal disease is a serious disease that • All adults 65 years of age or older. causes much sickness and death. In fact, pneumococcal disease kills more people in the - Anyone over 2 years of age who has a long. United States each year than all other vaccine- term health problem such as: preventable diseases combined. Anyone can get - heart disease pneumococcal disease. However, some people are - lung disease at greater risk from the disease. These include - sickle cell disease people 65 and older, the very young, and people - diabetes with special health problems such as alcoholism, - alcoholism bears or lung disease, kidney failure, diabetes, HIV . cirrhosis infection, or certain types of cancer. - leaks of cerebrospinal fluid Pnetunococtal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain (meningitis). About 1 out of every 20 people who get pneumococcal pneumonia dies from it, as do about 2 people Dot of 1 D who get bacteremia and 3 people out of 10 who get meningitis. People with the special health problems mentioned above are even more likely to die from the di e. Drugs such as penicillin were once effective in treating these infections; but the disease has become more resistant to these drugs, making treatment ofpneumococcal infections more difficult- This makes prevention of the disease through vaccination even more importam- 2 Pneumococcal polysaccharide vaccine (PPVy The pneumococcal polysaccharide vaccine (PPV) protects against 23 types of pneumococcal bacteria. Most healthy adults who get the vaccine develop protection to wort or all of these types within 2 to 3 weeks of getting the shot. Very old people, children tinder 2 years of age, and people with some long-term illnesses migbt not respond as well or at all. Anyone over 2 years of age who has a disease . or condition that lowers the body's resistance to infection, such as: - Hodgkin's disease - lymphoma, leukemia - kidney failure - multiple mydoma - nephrotic syndrome = H1V infection or AIDS • damaged spleen, or no spleen - organ transplant • Anyone over 2 years of age who is taking any drug or treatment that lowers the body's resistance to infection, such as: - Jong-terns steroids - certain cancer drugs - radiation therapy • Alaskan Natives and certain Native American populations. (Pneurnococml Polysaccharide 42 4 How many doses of PPV are needed? Usually one dose of PPV is all that is needed. However, under some circumstances a second dose may be given. A second dose is recommended for those people aged 65 and older who got their first dose wbm they were under 65, if 5 or more years have passed since that dose. - A second dose is also recommended for people who: have a damaged spleen or no spleen have sickle-cell disease have HIV infection or AIDS have aacer, leukemia, lymphoma, multiple myeloma j - have kidney failure t have nephrotie syndrome - have had an organ or bone marrow imnsplamt are taking mediation that lowers immunity E (such as chemotherapy or long-term steroids) Children 10 years old and younger may get this second dose 3 years after the first dose. Those older than 10 should get it 5 years after the first dose. ( Other facts about getting !the vaccine • Otherwise healthy children who often get ear infections, sinus infections, or other upper respiratory diseases do not need to get PPV because of these conditions. • PPV may be less effective in some people, especially those with lower resistance to infection. But these people should still be vaccinated, because they are amore likely to get seriously ilt from pncumococ®s disease. - Pregnancy: The safety of PPV for pregnant women has not yet been smiliciL There is no evidence that the vaccine is harmful to either the mother or the fetus, but pregnant women should consult with their doctor before being vaccinated. Women who are at high risk of paeumoweeal d'estmse should be vaccinated before becoming pregnant, if possible. Less than I% develop a lcvcr, muscle aches, or more severe local reactions. Severe allergic reactions have been reported very rately. As with any medicine, there is a very small risk that serious problems, even death, could occur after getting a vaccine Getting the disease is much more likely to cause serious problems than getting the vaccine. What if there is a serious reaction? What should I look for? • Severe allergic: reaction (hives, difficulty breathing, shock). What should 1 do? • Call a doctor, or get the person to a doctor right away. -Teti your doctor what happened, the date and time it happened, and when the vaccination was given. • Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at www.vacmarg, or by calling 1-800.827-7067. IVAERS dory trot provide arrdical adoice. $ How can I learn more? • Ask your doctor or nurse. They can give you the vaccine puekage insert or suggest other sources of information. • Cali your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit the National Immunization Program welishe at www.cdc.gov/vocrines 6 What are the risks from PPV? PPV is a very sale vaame. ?4 DaipApTMa7rT OF HEALTH AND HUMAN s About half of those who get the vaccine have very mild side effects, such as redness or pain where the shot is given. CENTCRS FOR DISEASE CONTROL AMD PREVCN-60" Pncumccoced Wccine inrwruodan Slat cot 43 42?? CHURCH OF GOD HOME I nmmr?rrnt rn raring Vaccinations The Church of God Home administers flu vaccine on an annual basis for all residents of our facility. Annually the Td-Valent Influenza Vaccine will be offered, prior to the beginning of flu season, for all residents who provide written authorization themselves or by his/her responsible party. A resident cannot receive the Tri-Valent Influenza if they are allergic to eggs or egg products. Otherwise, the Tri-Valent Influenza has proven to be generally safe and effective. If you desire to receive the Tri-Valent Influenza v ne and/or the pneumonia vaccine, please complete the authorization below. I do authorize that the TrWalent Influenza vaccine be given annually per facility protocol. ? No, I do not wish to receive the TrWalent Influenza at any given time. ? I have received literature pertaining to the benefits of the Tri-Valent Influenza vaccine. The Church of God Home also offers a vaccine that provides effective protection against the Pneumococcaj form of pneumonia. This vaccine will be available to those residents who desire it and are medically eligible. If you have any questions, you may discuss them with your personal physician r the Church of God- Home physician who monitors your care. _ ? I do authorize that the Pneumococcal Pneumonia vaccine be given. ? No, I do not wish to receive the Pneumococcal Pneumonia vaccine at any given time. ? I have received literature pertaining to the benefits of the Pneumococcal Pneumonia' Vaccine. If known, please indicate the date when the vaccines listed below were last received: Tri-Valent Influenza vaccine: Pneumonia Vaccine: Tetanus Vaccine: .2-/7-0 (Dale) 44 (ReWent/Responsible Party) 42? CHURCH. OF GOD HOME "f'.nnrrliltrrl nr f:unrrc Valuables The Church of God Home desires to administer quality care for all of our residents, focusing] on a high quality of life. We do want to avoid any unfortunate situation that could result in any financial or emotional loss to residents and/or families. Our Home has not had many such losses, but when they happen, it is tragic. To minimize the risk of loss, the Church of God Home recommends that residents have no more than five dollars ($5.00) at any one time in their possession or rooms, and keep no valuables, real or i' trmsic, in their rooms. By signing this paper you acknowledge being informed of the Home's recommendations. Some people have wisely substituted zircons for diamonds and kept the settings. It is the responsi ility of the resident or the responsible party to have items of value independently appraised and insured, if so desired to cover potential damage to or loss of personal property. If damage or loss occurs to the resident's property, the Church of God Home will investigate each incident of loss or damage to determine liability and assess depending on the facts and circumstances of each incident. The Church of God Home shall be responsible for only such losses or damages as are attributed by the Home due lo.the-negligence of the Home: I17 - 0? (Date) 45 O (Resident/Responsible Party) CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this / 7 44 day of , 20jff, by and between the Church of God Home, Inc., called the 'Facility," a Pennsylva is non-pro t c ation located4 80 rth Hanover Street, Carlisle, umbe and Coun , Pe ylvania, and called "Resident" and called 'Responsible Party`. The Resident and the Responsible 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 and the Responsible Patty agree to the following terms: 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 d* living. b. Accommodations consistent with the level of care provided to the Resident including heat, air conditioning, electricity, hot, and cold water. c. Bed, bedding, blankets, laundered bed linens, towels, and washcloths. d. Three meals each day except as otherwise medically indicated. e. Activity programs, Spiritual 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: $ 3(0 Ad dollars per day. 3. SECURITY DEPOSIT - The Resident shall pay the following nonrecurring 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 admission day. The amount of the security deposit is $7 3/G `. 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. If the admission to Nursing Care is the result of a level of care change from Assisted Living, the Resident will be billed the difference between the two Security Deposit rates. c. The security deposit for private pay residents, after deductions for the payment f any 'outstanding bills owed to the Facility, will be refunded within thirty (30) days aft the Resident's discharge or death. Upon discharge or death the following refund policy will be ollowed: i. Thirty (30) days - Private Pay n. Ninety (90) days - Medicaid iii. Thirty (30) days - Personal Cash Account There will be no other refunds, in the absence of an over payment, under this Agreement. 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES - Resident is responsible to pay for other services provided by the Facility, which are not covered by the daily ratefcharge. A list of such services charges is attached to this Agreement on the °Chart of Costs! 46 Adm fission and Care Agreement- continued The services of a licensed physician and dentist, a registered pharmacist and licensed pha acy 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-hislher'own physician or any other service provider so long as the physician or other service provider is property licensed or registered under the law, and thaCall 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 AgreenmenL The respc risibility 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 resting 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. Such fees and costs are not included in the Home's daily ratelcharge. b. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident; beginning on a - 17- Q 9 . All pre-admission charges will be billed after admission, and recurring charges wilt 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 Home for whatever reason, including illnessl 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. d. 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. e. Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check. f. 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 changes are computed, billed or become due. The Facility reserves the right to make any such changes at any time. Written notices 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. "MEDICAREIMEDICAID" PROGRAM - The Facility participates in the Medicare p ogram administered pursuant to Title XVIII o f the Federal Social Security Act and the Med id (Medical Assistance) Program administered pursuant to the Pennsylvania state plan and Titl XIX of the Federal Social Security Act. However, the Facility reserves the right to withdraw Ir the Medicare/Medicaid program at any time in accordance with the law. 47 Admission and Care Agreement- continued 9. OBLIGATIONS OF RESPONSIBLE PARTY - The Responsible Party is responsible for services and supplies that are billed through the Facility directly to the Resident, Responsible Party, or by any other provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. In the event of an emergency the Responsible Party is asked to leave a emergency contact telephone number (s): (i.e. when vacationing) I 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 de th, and if the Resident is not eligible for, or receiving medical assistance, the Resident's bed will be reserved and changes for the reserved bed will continue to accrue unless the Resident or Respor?ssible Party otherwise directs in writing. If the Resident or Responsible Party elects not to reser to 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 Medicaid (Medical Assistance) Program. The current bed reservation pedW*is fifteen (15) days for hospitalization,,fifteen (15) days ` for therapeutic leave for residents receiving skilled nursing care, and thirty (30) day for therapeutic leave for residents receiving nursing care. The bed reservation period may be subject to-change in accordance with any changes in the Medicaid (Medical Assistance) Program. If the period of hospitalization or therapeutic leave ends within the reservation period under the Medicaid (Medical Assistance) Program, the Resident may return to the Facility. If the period of hospi l'rzation or therapeutic leave exceeds the maximum time for reservation of a bed under the M icaid (Medical Assistance) Program, the Resident must wait until a suitable bed becomes availabl for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of ';are if, at the time of readmission, the Resident requires the services provided by the Home. Effective May 30, 2008, Medicare requires that each residert / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. ? Yes, I would request a bed hold. I understand that I will be billed at the standard daily rate. ? No, I do not wish to hold a bed in the event of a hospitalization. 1 understand that by doing so?e bed may no be available for readmission. EJ-Vo'be determined at time of hospitalization. 11. REFUNDS - The security deposit for private pay residents, after deductions for the ayment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after th Resident's discharge Facility or death. Residents receiving Medicaid will receive a refund, if y due, within ninety (90) days. There will be no other refunds, in the absence of an overpaymen, under this Agreement. 12. PERSONAL FINANCES - The Resident has the right to manage his/her personal hinds. 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` personal funds. If the Resident 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. 48 Admission and Care Agreement- continued The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal cash account 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 per nal 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. The Facility may deduct, at any time, charges due the Facility under this agreement from the Resident's personal funds managed by the Facility. 13. TERMINATION. TRANSFER DISCHARGE, OR LEAVE OF ABSENCE a. By the Resident: The Resident may terminate this Agreement upon thirty (30) days written notice to this Facility. If the Resident leaves the Facility for any reason other th n a medical emergency or 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 Agreements If advance written notice is not given to the Facility, there will be due to the Facility its daily and other changes 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- L The transfer or discharge is necessary to meet the Residents welfare which cannot be bet by the Facility; ii. The Residents 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 wcqu bee angered; iv. The charges or other amounts due the Facility under this Agreement have of been paid to the Facility or treated as paid to the Facility on the Resident's behalf the P nsylvania Medicaid Program or Federal Medicare benefits under Title XVIU or v. The facility ceases to operate. The Facility generally will notity the Resident and Responsible Party or if none, a family member of 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, described in subparagraph (i), (ii} or (in) 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. 49 Admission and Care Agrement- codnW t E f - 14. T141RD PARTY PpYMEN15 -TtoResidentmaybe ormay become eligible tolreceive financial assistance, reirnbursemenpr Ito bene%from thid-parties, such as throutsistance private insurance, employee beneft$ans. Mdicd asistance under the Pennsylvania Medical Program, Medicare benefits, supplemntirymedical or other health insurance, supple ntal security income insurance, or old age survivirs',oriasabi?ty insurance under or pursuant to the f=ederal Social Security Act or Program: If lie Itesderit becomes e4ble 'to receivg payments from any third-parties for the stay and care of the fesidert, the ResidenUResponsible Party shall, at oil times, cooperate fully with the Facility and eab tlrrdparty payments. Cooperation includes, when requested, providing informatim, signing aid delivering documents, and having the Facility designated by the Social Security Administratioi as the Resident's representative payee for receipt of Federal Social Security benefits orany othergoamental assistance, reimbursement or benefits to the extent of all charges due the Fa ably. TheResidant irrewcably authorizes the Facility to make claims and to take such other actions as maybe necessary force Facility's receipt of third-party payments. To the fullest extent penT*ed bylaw, the Resident hereby assigns now or hereafter p yable to the extent of all charges due to the endorse and turn over to the Facility any payments racer ed from third-parties to the extent necessary to satisfy he charges under this Agreement. 15. PERSONAL PROPERTY- The Readentf Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, persona! possessions, and other items of property. f he facility may limit the amount or type of propertythat he 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'spersorial kiventory located with their medical record on the day of admission or any day thereafter. The same Is true it removing an item of value from the resident's room. You are requested to see he charge nurse 1 social worker regarding resident's personal property. If nametag1bets are needed for clothing items, please leave them at the nursing - station. 16. RESPQNSIBILITIES OF RESIDENT. The Resident shall comply fully with all governmental taws and regulations, the provisions d this Agreement and he 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 shag be governed by the laws of themmonvvealth 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 a other. If any provision of this Agreement is found by competent legal authority to be i valid, the other provisions shall remain in full force and effect as if the invalid provision ad not been part of this Agreement. 50 I': 1 Admission and Care Agreement- continued 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. Re$ident will be provided thirty (30) days written notice of changes in charges and, if practicalble, reasonable notice of any modifications required by law. (Date) (ResidenWesponsible Party) //)/Jw (Rest ent Name) (Facility Represegl) i 's i t i 51 i¦ RESIDENT ! FAMILY GUIDE TO INQUIRIES AND INFORMATION n uires O 15- 0 L- go U) M QS U y L71 0 ? E N C C N d q E Uo -? ?? ?? a z U3 M0 do 0x zn ?z cacti >n Healthcare Assisted Liming x Admissions Independent Living x Admission Billing Question x Medicare x Question Applying for x Medicaid Pharmacy Biting x Laundry Billing x Donation Monetary x Donation Other x Personal Cash Account x Ouestions Personal Cash Deposits I x withdrawats Guest Meal Reservations x Party Reserving of Lounge X Family Concerns X HIPPA Changes X Coordinate Change in Level of Care X Resident Lost Items X Telephone Cable X Hoak-u LeTort X Guest Suite 52 t 0 RESIDENT! FAMILY GUIDE TO INQUIRIES AND INFORMATION d 4? t Y7 to ty C i 0 E y ?. Inquires E v ` ° to s 0 o n Cc t v o f c t s 2 v o m m w "' a o ?' = i <t xtp M0 U eLO 02 MIr m za ?_ tAtt) >a Change in Laundry Service X Transport Requests X x Special Hair Care Requests, Payment Scheduling X Resident Care X Resident Medication X Physician Questions X Therapy Questions X Taking Residents Out of Facility X Change in POA Contact X _ Address /Phone Change in POA X Health Insurance Cards X Religious Questions X Funeral Questions X Funeral Procession Service X Memorial Services X "The Orchards' at Marsh Run T 7 1 1 x i t i f 53 Facility Mailing Address: Facility Main Telephone #: 801 North Hanover Street Carlisle, PA. 17013 (717) 249-5322 Facility Administrator:................... Susan Bower, NHA ...................................................... ...... ext. 3086 Y"" ww"V ?YY Y Y. IaY Y Y YYYYYLYMYYY Y YW wwm YL Ym YIiMM V VY Y MMMMMY &? V W%& " V Y"" Activity Dept. ? .............. AmyFindon, CTRS................................................................. ext. 3021 (Director of Activities) Business Office: ...........Sharon Cramer (Business Office 1-Henderson House)._ ...................... xt. 3032 (Sr. Billing AIR Specialist- Personal Cash Accounts) . Care Plan: .............Lynne Shellenberger, RN . .. GI.Z.... !.. }........ ext. 3033 (Nursing Assessment Coordina[ Chaplain- ? .............Pastor Bradley Moore ...................... ?..:....................... ........... ex . W22 t Dietary? .............. Jeffrey Starner, CDM......................... ........................ ............ ext.' 308 (Director of Dietary) Hair Care: ?.... --..._Joan Ludwig ............................ ....... .......ext. 3003 (Director of Hair Care) Nursing Devi:: ? .............Mary Hartman, RN, BSN...: _......... ; ...................... ....... ext. 3015 (Director of Nursing) .............. Falb Long Hall #io3-11s ............ ..:? :ext. 3009 ..............Faith Shbrt Nall (#99,100-102 117-126 .......................... ? ;........ext. 3010 ? . ..... ove I (#201-215) ....................... ....... ext. 3024 ...Love 11(#217-239 ).. ......... -ext. 30Q' ? ............. Chris Ward, LPN...................................................................... ext. 3012 (Assisted Living Administrator), (Hope, Peace and Creekside Apt ) Pharmacy: Social Services: Therapy Dept.: ? .............. C intinuing Care W..................................................... 1-800-675-2279 ? ..............En y1or, BSW.................................................................... ext. 3084 (DUnct;Myers, of Social Services) Ellen BSW .................................................................ext. 3023 (Soda[ Worker) i ? ..............Genesis Rehabilitation Services ...................................F......... ext. 3017 Volu steer Office: ? .............. Linda Waggoner............................. (Director of Volunteers) Physicia Telephone: 54 ......... ext. 3028 0 RPR-02-2009(THU) 13;36 P.008/008 VEMCATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. T understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unswom falsification to authorities. Dated: J C?? n .n OA(t Representative, Church of God 14orne, Inc. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. AND NOW, this CIVIL ACTION - EQUITY No. ORDER day of 2009, a hearing in the above-captioned matter on Petitioner's Petition for the Issuance of a Preliminary Injunction is scheduled for , 2009, at o'clock _ m. in Court Room No. , Cumberland County Courthouse. BY THE COURT: J. V ? M IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. And now, the day of CIVIL ACTION - EQUITY No. ORDER 2009, the Court finds that Petitioner has established its right to a special preliminary injunction: (1) The injunction is necessary to prevent immediate and irreparable harm to Petitioner that cannot be adequately compensated by damages; (2) Greater injury would result from refusing Petitioner's request fopr an injunction, and the issuance of an injunction will not substantially harm Respondent; (3) A preliminary injunction will properly restore the parties to their', status quo as it existed immediately prior to Respondent's breach of her contractual duties pursuant to the Agreement she entered into; (4) Respondent's breach of her contractual duties is clear; (5) A preliminary injunction will properly restore the parties to their: status quo as it existed immediately prior to Respondent's breach of her statutory! duty of support pursuant to 23 Pa. C. S. § 4603(a); (6) Respondent's breach of her statutory duty is clear; (7) The injunction Petitioner seeks is reasonably suited and limited in scope and breadth to abate the existing activity; and (8) The injunction is in the public's interest. It is ORDERED AND DECREED that Respondent is directed to cooperate with Petitioner's efforts to secure Medical Assistance benefits on William Fenton's behalf in 2 accordance with her obligations under the Agreement and her statutory duty of support. Said cooperation specifically includes, but is not limited to, immediately providing any and all financial records and information requested and needed by the Cumberland County Assistance Office to assess William Fenton's eligibility for Medical Assistance benefits within fifteen (15) days of the date of service of this Order and taking any and all other actions necessary to obtain Medical Assistance benefits with five (5) business days of written notification by the Petitioner. BY THE COURT: J. 3 CERTIFICATE OF SERVICE I hereby certify that on this date a true and correct copy of the foregoing Petition for Preliminary Injunction was served U.S. Postal Service, First Class mail, upon the following: Cynthia Fenton 133 Garland Drive Carlisle, PA 17013 Dated: ?6?r R By: Linda L. Scisciani, Paralegal 5 FILED-:?:=I=l; P OF THE PR, PHOCNOTARY 2009 APR 17 11,11111 : 20 CHURCH OF GOD HOMES, INC., PETITIONER V. CINDEE FENTON, A/K/A CYNTHIA FENTON, RESPONDENT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 09-2428 CIVIL IN RE: PETITION FOR PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 23?d day of April, 2009, upon consideration of the Petition for a Preliminary Injunction, IT IS HEREBY ORDERED AND DIRECTED that: 1. A Rule is issued upon the Respondent to show cause why the relief requested should not be granted; 2. The Respondent will file an answer on or before May 1, 2009; 3. The Prothonotary is directed to forward said Answer to this Court. 4. A hearing on the above matter will be held on Tuesday, May 5, 2009, at 11:00 a.m. in Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. By the Court, ? Kirk Sohona9a, Esquire 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Xivia Langton, Esquire U. S. Steel Tower Attorneys for Petitioner 'A, ?k 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 `v` M. L. Ebert, Jr., % J. JN? t. 0 :01 V ? 88V Roz ?Cynthia Fenton Respondent 133 Garland Drive Carlisle, PA 17013 Q-->F%*Ls rn?ULZL qlaylo? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 09-2428 AFFIDAVIT OF SERVICE Church of God Home, Inc. vs. Cindee Fenton a/k/a Cynthia Fenton Commonwealth of Pennsylvania County of Dauphin se. I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 8:39 PM on 04/21/2009,1 served Cindee Fenton a/k/a Cynthia Fenton at 133 Garland Drive, Carlisle, PA 17013 in the manner described below: W Defendant(s) personally served. 11 Adult family member with whom said Defendant(s) reside(s). Relationship is Adult in charge of Defendant(s) residence who refused to give name and/or relationship. Manager/Clerk of place of lodging in which Defendant(s) reside(s). Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. Other: a true and correct copy of Complaint; Notice to Defend; Petition for Preliminary Injunction; Order issued in the above captioned matter. Description: Sex: Female - Age: 50 - Skin: White - Hair: Gray - Height: 5'08" - Weight: 160 D / /7 At Sworn to and subscribed before me on this 22X%Ci day of AdQil 20&9. N Y PUBLIC X r Joffi Shinkowsky Sh nkowsky Inves ions 316 Fawn Ridge N r Harrisburg, PA (800) 276-0202 Atty File#: CGH-024 - Our File# 7115 Law Firm: Schutjer Bogar, LLC - Pittsburgh Address: 600 Grant Street, Suite 3290, Pittsburgh, PA, 15219 Telephone: (412) 281-0965 k1tiONWEALM OF PENNSYLVAMA NOTARIAL, SEAL Erin M. Johnson, Notary Public Lower Paxton Township, Dauphin County M emission expires November 18, 2012 FII EI O} HC;M- OF THE PR711 # '{ "'1 TRY 2009 APR 27 P? 12. 0 4, f { SJS,14t., l IN THE COURT OF COMMON PLEAS OF CUM13FAU AND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., petitioner, V. CDWEE FENTON aWs. CYNTHIA FENTON, Respondent. CIM ACTION - EQUITY No. 09-2429 1' qjKI • s. e . i AND NOW, COME, Church of God Home, Inc., ("petitioner"), by and through its attorneys, Scmvrxit BoGAR LLC, and Cindee Fenton awa Cynthia Fenton ("Respondent"), who hereby stipulate and agree to the following: 1. On April 17, 2009, Petitioner filed a Complaint against Respondent. 2. The Complaint sets forth, among other things, a claim against Respondent relating to her faihue to specifically perform the terms of the Admission and Care Agreement that she entered, into with Petitioner. 3. Because of Respondent's alleged inaction, Petitioner filed an application for Medical Assistance benefits on behalf of William Fenton - who is Respondent's husband. 4. In furtherance of the application for Medical Assistance benefits and in compliance with the Agreement, Respondent was obligated to provide certain information and verifications to the Cumberland County Assistance Office. 5. The application for Medical Assistance benefits was denied and an appeal of the denial is now pending; however, it too will be denied if the information nocessary to qualify William Fenton for Medical Assistance benefits is not timely provided to the Cumberland 10 39Vd (INV138MW 86£010Z ZI:6e 60OZ/10/50 County Assistance Office. 6. The parties agree to the entry of an Order directing Respondent to provide any ad ail records and information required by the Cumberland County Assistance Office to d a*A D the eligibility of William Fenton for Medical Assistance benefits within twenty (20) dAys of the date of the Order, and to take any and all other actions necessary to obtain Medical Assistance benefits for her husband, William Fenton, with five (S) business days of written notification by the Petitioner. A copy of that Order is attached hereto as Exhibit "A." 7. Petitioner agrees to withdraw, without prejudice, its Petition for Preliminary Injunction if Respondent acts in compliance with the proposed Order. Respectfully submitted, ScHurJF.it Boctit LLC Doted: _ In" r . 2DO9 Hy. ) . Livia F. Cal" Attorney 1.6. No. 91348 Telephone: 412.281.3710 Marijane Treacy Attorney I.D. No. 84070 Telephone: 412.281.3535 600 Orant Street, Ste 3290 Pittsburgh, PA 13219 Attorneys for Petitioner By:, CbWee Fenton &Wa Cynthia Fenton Respondent Z0 39dd QNV-13800W 80£010Z ZT:60 600Z/I0/90 J EXHIBIT "A" CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Stipulation for Entry of Injunction was served via first class mail, upon the following: Cindee Fenton 133 Garland Drive Carlisle, PA 17103 Respondent Dated: / D By: - Linda Scisciani, Paralegal 2009MA -4 AM l0: 5 CUM=:?. _ i A- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. CIVIL ACTION - EQUITY No. 09-2428 PRAECIPE TO CONTINUE HEARING DATE AND NOW, COMES, Church of God Home, Inc., by and through its attorneys, SCHUTJER BoGAR LLC, and files the following Praecipe to Continue Hearing Date, as follows: 1. On or about April 17, 2009, Petitioner filed its Complaint, Petition for Preliminary Injunction and Brief in Support of the Petition for Preliminary Injunction against Cindee Fenton a/k/a Cynthia Fenton ("Respondent"). 2. On or about April 23, 2009, this Court scheduled a hearing for May 5, 2009 on the Petition for Preliminary Injunction. 3. On or about May 1, 2009, Petitioner and Respondent entered into a Stipulation for Entry of Order. 4. In accordance with the Stipulation for Entry of Order, Respondent has been providing the information, in her custody and control, requested by the CAO. 5. On or about May 1, 2009, Petitioner filed the Stipulation for Entry of Order and a proposed Order with this Honorable Court, which Order when entered will require Respondent, to "provide any and all records and information required by the Cumberland County Assistance Office ("CAO") to determine the eligibility of William Fenton for Medical Assistance benefits 431k ?v IL f- 4 within 20 days of the date of the Order, and to take any and all other action necessary to obtain Medical Assistance benefits for her husband, William Fenton, within five (5) business days of written notification by the Petitioner.,, 6. Due to the fact that Respondent has been cooperating in providing the verification information needed by the CAO, Petitioner hereby requests that this Honorable Court continue the May 5, 2009 hearing on the Petition for Preliminary Injunction, until the 20 days for Respondent's action under the Order have passed and Respondent's compliance therewith can be confirmed. WHEREFORE, Petitioner requests that this Honorable Court grant this Praecipe to Continue Hearing Date and order Respondent to comply with all previous orders. Dated: 1 2AUf Respectfully submitted, By: 2!!' Livia F. L gton Attorney I.D. No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mitreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Anthony Lucido Attorney I.D. No. 76583 (717) 909-0353 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Attorneys for Petitioner CERTII?'ICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Continue Hearing Date was served via UPS, Overnight Delivery, postage prepaid, upon the following: Cindee Fenton 133 Garland Drive Carlisle, PA 17103 Dated: Q By: ?' ?eW?aV? Linda Scisciani, Paralegal OF THE Vc ',711`1- N. -1 lARY 2009{SAY--4 rh(':53 PEN IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., CIVIL ACTION - EQUITY Petitioner, V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. No. 09-2428 AMENDED PRAECIPE TO CONTINUE BEARING DATE AND NOW, COMES, Church of God Home, Inc., by and through its attorneys, SCHUVER BOGAR LLC, and files the following Amended Praecipe to Continue Hearing Date, as follows: 1. On or about April 17, 2009, Petitioner filed its Complaint, Petition for Preliminary Injunction and Brief in Support of the Petition for Preliminary Injunction against Cindee Fenton a/k/a Cynthia Fenton ("Respondent"). 2. On or about April 23, 2009, this Court scheduled a hearing for May 5, 2009 on the Petition for Preliminary Injunction. 3. On or about May 1, 2009, Petitioner and Respondent entered into a Stipulation for Entry of Order. 4. In accordance with the Stipulation for Entry of Order, Respondent has been providing the information, in her custody and control, requested by the CAO. 5. On or about May 1, 2009, Petitioner filed the Stipulation for Entry of Order and a proposed Order with this Honorable Court, which Order when entered will require Respondent, to "provide any and all records and information required by the Cumberland County Assistance Office ("CAO") to determine the eligibility of William Fenton for Medical Assistance benefits within 20 days of the date of the Order, and to take any and all other action necessary to obtain Medical Assistance benefits for her husband, William Fenton, within five (5) business days of written notification by the Petitioner." 6. Due to the fact that Respondent has been cooperating in providing the verification information needed by the CAO, Petitioner hereby requests that this Honorable Court continue the May 5, 2009 hearing on the Petition for Preliminary Injunction, until the 20 days for Respondent's action under the Order have passed and Respondent's compliance therewith can be confirmed. 7. Upon information and belief, the Honorable M. L. Ebert, Jr. has been assigned to this case; however, Judge Ebert has not ruled on any other matters in this action. 8. Upon information and belief, there is no counsel of record for the Respondent; therefore, concurrence regarding this Praecipe was only discussed with the Respondent. WHEREFORE, Petitioner requests that this Honorable Court grant this Praecipe to Continue Hearing Date and order Respondent to comply with all previous orders. Dated: l2 2D0 Respectfully submitted, By: Livia F. Langt n Attorney I.D. No. 548 (412) 281-3710 llangton@schutj erbo gar. com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutj erbogar. com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Anthony Lucido Attorney I.D. No. 76583 (717) 909-0353 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Attorneys for Petitioner CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Amended Praecipe to Continue Hearing Date was served via UPS, Overnight Delivery, postage prepaid, upon the following: Cindee Fenton 133 Garland Drive Carlisle, PA 17103 Dated: 0 By: yn-rt? .1 1 Linda Scisciani, Paralegal 2009 MAY 13 P l I : s:, 0 !..!lr. MAY 0 8 2009 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Petitioner, CIVIL ACTION - EQUITY No. 09-2428 V. CINDEE FENTON a/k/a CYNTHIA FENTON, Respondent. ORDER tti AND NOW, this S , day of Kau , 2009, in consideration of the parties' Stipulation for Entry of Order: It is hereby ORDERED AND DECREED that within twenty (20) days of this Order, Cindee Fenton a/k/a Cynthia Fenton shall provide any and all records as required by the Cumberland County Assistance office to determine William Fenton's eligibility for Medical Assistance benefits, and to take any and all other actions necessary to obtain Medical Assistance benefits for her husband, William Fenton, with five (5) business days of written notification by the Petitioner. ACCORDINGLY, the Preliminary Injunction Hearing scheduled for May 5, 2009 will be continued until the passage of twenty days (20), at which time Petitioner shall confirm compliance with this Stipulation, in which case the Petition for Preliminary Injunction will be withdrawn without prejudice. If Respondent's compliance cannot be confirmed, a Preliminary Injunction Hearing will be rescheduled. BY THE COURT: - * **IJL q I J. CU :i Wd Si Ow HE