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HomeMy WebLinkAbout09-2890 PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2009- ?L ?q d CIVIL TERM MELODY A. EICKHOFF, Defendant NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 PERINI SERVICES/ SOUTH HAMPTON MANOR, L.P. Plaintiff V. MELODY A. EICKHOFF, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2009- 3-0 6 COMPLAINT CIVIL TERM NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the following: 1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 2. Defendant, Melody A. Eickhoff, is an adult individual with a residence address of 131 Amy Drive, Carlisle, Cumberland County, Pennsylvania 17013. 3. Shippensburg Health operates a resident skilled care nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania. 4. On or about June 11, 2008, Melody A. Eickhoff sought to be admitted to the Shippensburg Health facility. 5. On or about June 11, 2008, Melody A. Eickhoff executed an Admission Agreement. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated. 6. Pursuant to the Admission Agreement, Melody A. Eickhoff would be responsible to pay any costs of care which were not covered by a third party payer. 7. On or about June 11, 2008, Melody A. Eickhoff became a resident of the Shippensburg Health facility and remained a resident until August 2, 2008. 8. As of August 2, 2008, Melody A. Eickhoff owed Shippensburg Health the sum of $11,015.18 for the costs of care provided by Shippensburg Health to her. A true and correct copy of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is incorporated. 9. Demand has been made upon Melody A. Eickhoff to pay the amount due. COUNT I-BREACH OF CONTRACT SHIPPENSBURG HEALTH v. MELODY A. EICKHOFF 10. Plaintiff incorporates by reference paragraphs one through nine as though set forth at length. 11. Melody A. Eickhoff has breached her obligation to pay for the costs of care as provided by Shippensburg Health. 12. As a consequence of that breach, Shippensburg Health is owed the sum of $11,015.18 to August 2, 2008. 13. The accrued debt consists of the private pay obligation of Melody A. Eickhoff. 14. The Admission Agreement bound Melody A. Eickhoff to pay for the costs of her care at the facility. 15. The Admission Agreement provides for the recovery of a penalty for late payments in the amount of 1.5% per month. These finance charges total $1,322.19 as of May 1, 2009 and continue to accrue. 16. The Admission Agreement provides for the recovery of reasonable attorney fees and costs incurred by Shippensburg Health to collect a debt due and owing to Shippensburg Health. WHEREFORE, Plaintiff requests judgment in its favor and against Melody A. Eickhoff for the sum of $12,337.37 plus interest, costs and expenses, late fees and any additional amount coming due to the date of award and attorney fees and costs. COUNT II-QUANTUM MERUIT SHIPPENSBURG HEALTH v. MELODY A. EICKHOFF 17. Plaintiff incorporates by reference paragraphs one through sixteen as though set forth at length. 18. During the period of her residency at the facility, Melody A. Eickhoff enjoyed the benefit of care and services provided to her by Shippensburg Health. 19. Melody A. Eickhoff has failed and refused to pay for the costs of her care and services provided by Shippensburg Health. 20. Melody A. Eickhoff has been unjustly enriched by her use and enjoyment of the services and care provided by Shippensburg Health without making payment therefor. WHEREFORE, Plaintiff requests judgment in its favor and against Melody A. Eickhoff for the sum of $12,337.37, plus interest, costs and expenses, late fees and any additional amount coming due to the date of award and attorney fees and costs. Respectfully submitted, ' EN, SBA ;& J David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/shcc/eickhoff/complaint. pld e5/C5/2A?9 12:34 7172495755 Ogg PAGE 06 The statements in the foregoing Complaint are based upon information which has been assembled by my attorney in this litigation. The language of the statements is not may own. I have read the statements; and to the extent that they are based upon information which I have given to my counsel, they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein ace made subject to the penalties of 18 Pa.C.S. § 4904 relating to unworn falsifications to authorities. DATE: Deb Black Business Office Coordinator SHIPPENSBURG HEALTH CARE CENTER ADMISSION AGREEMENT THIS AGREEMENT, made this day of one ?p A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter "Shippensburg") and :ti Ledcf 2?-Chow: (hereafter "Resident"), previously residing at (Street Address and Post Office Box) and (hereafter "Legal Representative"), residing at (Street Address and Post Office Box) . The Legal Representative's relationship with the Resident is that of The staff of Shippensburg will take whatever time is necessary to answer all of your questions. Please continue to ask questions . until you are sure that you understand. PROVISION OF SERVICES NURSING SERVICES: Shippensburg will provide the' Resident with routine nursing services, semi-private accommodations, three meals each day (except as otherwise medically indicated), blankets, bed linens, towels and wash cloths, laundering of blankets, linens, towels, and wash cloths, housekeeping services, and activity programs and social services as established by the facility, as identified on the Rate Schedule. The Rate Schedule is attached to this Agreement and is incorporated herein as if set forth in full. The Rate Schedule sets forth the list of supplies and services Included in Shippensburg's daily rates, those supplies and services which are not covered by the daily rates for 1 EXHIBIT "A" which the Resident will be separately charged, and those supplies and services covered by the Medicare and/or Medicaid programs for enrolled Residents. Federal and state laws and regulations change regularly and frequently require changes related to the care and services Shippensburg provide.$. Additionally, other financial factors may require Shippensburg to make changes related to provision of its care and services. On this basis, the Rate Schedule may be changed, upon notice to the resident. ANCILLARY SERVICES AND SUPELIES: Shippensburg will also provide ancillary services and supplies as set forth in the Rate Schedule, and private accommodations upon the direction of the Residents physician. The ancillary services and supplies are subject to change from time to time at the discretion of Shippensburg. OUTSIDE PROVIDERS AND NON-FACILITY SERVICES: Shippensburg makes available, from time to time, the services of outside providers and non- facility services. These services will be available under Shippensburg's policies and procedures, and at the Resident's sole expense unless the charges for such services are covered by a third party payer.. Should the Resident arrange for the services of outside providers, the providers must be properly licensed or registered under state and federal law, and must comply with all Shippensburg policies and procedures, including, but not limited to, providing Shippensburg with documented proof of their legally required liability insurance coverage. All outside providers must be approved in writing by Shippensburg before providing any services. At Shippensburg's sole discretion, only providers deemed by Shippensburg to fulfill. all of the requirements set forth in federal and state law, as well as Shippensburg's policies and procedures, may provide services to Residents. The Resident recognizes and agrees that all outside providers, including those designated by Shippensburg, are independent contractors. The Resident recognizes and agrees that such providers are not associates or agents of Shippensburg, and that Shippensburg Is not liable for any outside provider's acts or omissions. The Resident shall be solely responsible for payment of all charges of any provider who renders care to the Resident in Shippensburg, unless the charges are covered by a third party payer. Furthermore, the Resident agrees to confirm that any Resident initiated, approved outside provider (i.e. private duty nurse, etc.) has worker's compensation insurance coverage as required by law, as well as liability insurance. To the extent that the outside provider does not have the legally required worker's compensation insurance coverage, the Resident will provide and pay for such coverage. 2 RESIDENT'S RIGHTS Shippensburg welcomes all persons in need of Its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. Furthermore, Shippensburg does not discriminate among persons based on their sources of payment. Consent for Treatment SHiPPENSBURG SERVICES: By signing this Agreement, the Resident consents to Shippensburg providing routine nursing an o er health care services as directed by the attending physician, or when the attending physician is unavailable, Shippensburg's Medical Director. Shippensburg Is not obligated to provide the Resident with any medications, treatments, special diets or equipment without specific orders or directions from the Resident's physician or Shippensburg'.s. Medical Director. From time to time Shippensburg may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. Consent to routine nursing care provided by Shippensburg shall include consent for care by such trainees. PHYSICIAN SERVICES: The Resident acknowledges that he or she is under the medical care of a personal attending physician, and that Shippensburg provides services based on the general and specific instructions of that physician, or when unavailable, Shippensburg's Medical Director. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician, or is unable to select an attending physician, an attending physician may be designated by Shippensburg or in accordance with state law. All attending physicians must meet and conform with all of Shippensburg's policies and procedures, and are subject to the terms set forth In the Outside Providers and Non-facility Services section of this Agreement. RIGHT TO REFUSE TREATMENT: The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make.a decision regarding refusal 3 of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision-maker, subject to state and federal law. Resident's Personal Property Shlppensburg strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in Shlppensburg. However, the Resident shall be permitted to retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the right of other residents or unless determined medically inadvisable as documented by the Resident's physician in the Resident's medical record. Shippensburg shall make reasonable efforts to properly handle and safeguard the Resident's personal property in Shippensburg. The Resident agrees to inform Shippensburg of all valuable property upon admission. If, at any time during the Resident's stay, new items of value are added to the Resident's possessions in Shippensburg, the Resident agrees to so inform Shippensburg's Administrator or designee. The Resident is responsible for obtaining at his or her own expense any insurance coverage necessary to cover potential damage to or loss of any of Resident's personal property. Shippensburg shall not be liable for damage to or loss of any of Resident's personal property. Should the Resident lose his or her property, or believe that his or her property has been otherwise removed from his or her possession, the Resident agrees to follow Shippensburg's procedure for filing reports of lost or stolen property. In the event that Resident is transferred or discharged from Shippensburg, or if the Resident expires, the Resident hereby authorizes Shippensburg to transfer the Resident's personal property to the Resident's Legal Representative, or to any duly authorized representative of Resident's estate. If the Resident's personal property is not claimed or removed within twenty-four (24) hours of the Resident's transfer or discharge, or expiration, the Resident authorizes Shippensburg to place his personal property into storage until claimed. Standard daily storage charges will continue while the Resident's property remains in Shippensburg. Should the Resident's property fail to be claimed within fourteen (14) days of the Resident's transfer, discharge, or expiration, the Resident and Shippensburg hereby agree to a storage and sale arrangement. Under this arrangement, Shippensburg agrees to bear any and all costs of the storage of the Resident's property, not including any Insurance thereon. However, in consideration of Shippensburg's storage of the Resident's property, should the Resident's property fail to be claimed within thirty.(30) days of placement by 4 Shlppensburg into storage, the Resident hereby agrees that Shippensburg may dispose of the Resident's property with and at Shippensburg's discretion, including retaining all proceeds from any sale thereof. Resident's Records CONFIDENTIALITY: Information included in the Resident's medical records is confidential. Unauthorized persons shall not be allowed to review these records without the Resident's written consent, except as required or permitted by law. CONSENT TO RELEASE BY Shioaensburq: The Resident authorizes Shlppensburg to release all or any part of the Resident's medical or financial records to any person or entity which has or may have a legal or contractual obligation to provide the Resident with medical services, or to pay all or a portion of the costs of care provided to the Resident, including but not limited to hospital or medical services companies, insurance companies, workers' compensation carriers, welfare funds, and/or the Resident's employer. The Resident also authorizes release of Information from medical or financial records to any medical professional or institution responsible for the Resident's medical or nursing care when the Resident is transferred or discharged from Shippensburg. The Resident hereby releases Shippensburg from any liability for damages or other loss suffered In or incurred by the Resident and arising out of or directly or indirectly related to the reliance by the facility upon the foregoing authorization. PHOTOGRAPHS: The Resident authorizes Shippensburg to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident In the event of an unauthorized absence from Shippensburg, but shall otherwise be kept confidential. If Shippensburg Intends to use the photograph or videotape for purposes other than those noted above, Shippensburg shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any particular time. RESIDENT'S RESPONSIBILITIES RULES AND REGULATIONS: The Resident agrees that Shippensburg may, to maintain. orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations. It is understood that 5 these rules and regulations may be amended from time to time as Shippensburg may require. Any changes to the rules and regulations shall be given to the Resident in writing. DIET: The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by Shippensburg. The Resident agrees to consult with Nursing or Dietary staff when food or beverages are brought Into Shippensburg. MEDICATIONS: No medications or drugs may be brought upon Shippensburg premises unless the medications or drugs are labeled according to the requiretnents of state and federal law. Packaging of medications must be compatible with Shippensburg's medication distribution system. No drugs or medications may be brought into Shippensburg unless they are delivered directly to the nurses' station. CARE OF SHiPPENSBURG'S PROPERTY: To preserve the value of Shippensburg's property for future residents' use, the Resident agrees to use due care to avoid damaging Shippensburg's property and premises. The Resident shall be responsible for the costs of repair or replacement of Shippensburg's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as Is to be expected from ordinary wear and tear. CARE OF THE RESIDENT'S ROOM: Shippensburg encourages the Resident to have a Shippensburg-like environment, and will attempt to accommodate all reasonable requests to individualize resident rooms. For safety reasons, Shippensburg must approve any addition -or rearrangement of furniture, hanging of pictures, posters, or other similar activities. INDEMNIFICATION: The Resident hereby agrees to indemnify and hold- harmless Shippensburg, its officers, directors, agents, and employees from and against any and all claims, demands or causes of action Mr injury or death to person or damage to property, including all costs and attorneys fees incurred In defending any claim, demand or cause of action which is caused by the' Resident and which is not caused by any willful or negligent action of Shippensburg. This indemnification Includes, but is not limited to, all claims, demands or causes of action stemming from the acts or omissions of the Resident, including but not limited to Resident's refusal of any nursing care, medical or other treatment, or any other item or service deemed necessary by Shippensburg or any other treating health professional. 6 POLICY REGARDING THE IMPLEMENTATION OF THE PATIENT SELF-DETERMINATION CT The following information Is being provided to the Resident as a result. of a federal law which requires certain health care Institutions, including Shippensburg, to disclose to the Resident his or her rights under federal and state law to make decisions regarding his or her health care. Shippensburg recognizes and appreciates the dignity and value of each Resident's life, and the right of each Resident to make decisions regarding his or her care. Where a Resident is incompetent, Shippensburg recognizes the Resident's right to have these decisions mAde on his/her behalf by a substitute decislon-maker in accordance with state law. Shippensburg recognizes the right of each Resident to utilize those health care advance directives recognized under state law, and will honor such advance directives developed In accordance with state law and consistent with the level of care Shippensburg is licensed to provide. A health care advance directive is a written document that states choices for health care and/or names someone to make those. choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of such advance directives. A health care advance directive is not necessary In order IQ be da mitted to or to continue to reside in Shippensburg However, if the Resident has a it can be reviewed and made 4-Dart of his or her medical record It is essential that Shippensburg receives a validly executed original document or documents to ensure that it is authorized to follow the directives therein Questions about Shippensburg's policies regarding health care decision- making and/or advance directives may be presented to Shippensburg's Administrator. -While questions regarding whether and how to execute health care advance directives and about their content should be discussed with the Resident's family, physician and attorney, a health care advance directive form drafted by the Commonwealth of Pennsylvania accompanies this areernent No Resident should use an advance directive form without first consulting the Resident's family, physician, and attorney. CAPACITY OF RESIDENT AND GUARDIANSHIP If the Resident is or becomes unable to understand or communicate, and is determined to be incapacitated by the Resident's physician, in the absence of the Resident's prior designation of an authorized Legal Representative, or upon the unwillingness or inability of the Legal Representative to act, Shippensburg shall have the right to commence a legal proceeding to adjudicate the Resident incapacitated. As a result of such a legal proceeding Shippensburg shall have a court appoint a legal guardian for the Resident. The cost of the fegai proceedings, including attorney's fees and costs, if not covered by the Commonwealth, shall be paid promptly by the Resident or the Resident's estate. FINANCIAL ASPECTS OF THE AGREEMENT Legal Representative While not legally required, if the Resident is unable to make decisions for himself or herself, a Legal Representative should be available to make certain decisions on behalf of the Resident. For the purposes of this Agreement, the Resident's Legal Representative is the person selected by the Resident and defined under state and federal law as the Resident's responsible person, or as the person recognized under state law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed, may be an attorney-in-fact acting under a durable power of attorney for health care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under state law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, verification of such status must be provided to Shippensburg at the time of Admission. Such verification includes providing Shippensburg with a certified copy of any court order, or a validly executed original Power of Attorney or other legal document. For purposes of this Agreement, LEGAL REPRESENTATIVES ARE REQUIRED TO SIGN THIS AGREEMENT FOR ADMISSION, AND AGREE TO DISTRIBUTE TO Shippensburg, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR ITEMS/SERVICES PROVIDED TO THE RESIDENT. Legal Representative is contractually bound by the terms of this Agreement and may become personally liable for failure to perform their fiduciary duties under the Agreement. Legal Representatives are also required to produce financial documentation as proof of the Resident's ability to pay for charges when due. Wherever this Agreement refers to the Resident's financial obligations under this Agreement, the term "Resident" shall be construed to include the obligations of any 'Legai'Representative to act on behalf of Resident. Financial Arrangements INCOME AND ASSETS/CHANGES TO INCOME AND ASSETS: It Is essential that the Resident* advise Shippensburg of the Resident's income and assets, and to communicate changes in the Resident's income or assets to Shippensburg as quickly as possible. The Resident hereby agrees to notify Shippensburg ninety (90) days prior to the time when the Resident has reason to believe that his income and assets will no longer be "sufficient to fulfill his financial obligations under the terms of this Agreement. Generally, when. private funds are depleted, residents apply for Medical Assistance. The Medical Assistance application process can be complicated, and the processing time can be lengthy. Shippensburg is experienced in the Medical Assistance Application process, and can be of great assistance to the Resident in this process.. To be of assistance, Shippensburg must have accurate record of the history and depletion of the Resident's income and significant assets. On this basis, please set forth the Residenf s income and assets below: income Social Security: Account Number: Monthly Income: Payee: Pension: Account Number: Monthly Income: Financial Institution: 9 Payee: Trusts:- Account Number(s): Monthly Income: Financial Institution(s): Beneficlary(s): Type of Trust(s): Other Income (please describe): 10 Payee(s): Assets Residence/Real Estate: Address: Vehicles : Year, Make and Model: State of Registration: Bank Accounts: Account Number(s): Financial Institution(s): Insurance policies: 11 Account Number(s): Financial Institution(s): Beneficiary: , Other Significant Assets (please describe): Liabilities Describe nature and extent: Has a Will been completed?: Yes No If yes, Executor's Name: 12 Executor's Address: Receipt of Income/Representative Payee. Many Residents find security in appointing Shippensburg as the "payee" or "Representative Payee" of the Resident's income. By appointing Shippensburg as the "payee" or the "Representative Payee", the Resident directs that his or her income be directed to Shippensburg for the purposes of paying for the Resident's care and services. Any excess funds accumulated are refunded to the Resident or the Resident's Legal Representative on or before the tenth (10) day of the month. following the receipt of the benefits. This is not required. However, If Administrator or the Administrator's designee, Shippensburg will assist you in making these arrangements. PRIVATE RESIDENTS: A Resident is considered private (or private pay) when no state or federal program is paying- for- the Resident's room and board. A private-pay Resident may have private insurance or another third party, which pays all or some of his or her charges. Daily Rate. The Resident agrees to pay Shippensburg's private pay per diem rate as described In the Rate Schedule. The .Resident agrees to pay Shippensburg in advance for one month's private daily rate. For each additional month's stay, the Resident agrees to pay Shippensburg In advance on or before the tenth (10"') day of the month. Any unused advance payment shall be refunded to the Resident ninety (90) days after the Resident's discharge if the Resident becomes covered by Medicaid or Medicare, or leaves Shippensburg before the end of the month. Rate Adjustments. Shippensburg may occasionally need to Increase the daily rate or optional service charges. If this happens, the Resident shall receive thirty (30) days advance written notice of the rate adjustment. Shippensburg shall provide notice to the Resident, and if known, the Resident's Legal Representative. When a notice of a rate adjustment is received, the Resident can choose to end this Agreement by providing written notice to the Administrator. If the. Resident falls to leave Shippensburg prior to the effective date of the rate adjustment, the Resident shall be considered to have consented to the increase. • Private Insurance. Even when there is private. insurance coverage, re Resident remains Primarily responsible for pa ing all of Shippensbura's charges. Where the Resident's private Insurer is a managed care plan with which Shippensburg has a contract, Shippensburg agrees to invoice the 13 managed care plan directly for the Resident's care and services. However, all charges that are not covered by the managed care plan are the responsibility of the Resident. These non-covered charges Include but are not limited to any coinsurance and/or deductible amounts which the managed care plan requires the Resident to pay, to the extent allowed under federal and state laws. Where the Resident's private insurer is not a managed care plan with which Shippensburg has a contract, Shippensburg will invoice the Resident, who is primarily responsible for payment of the invoice. MEDICAID RESIDENTS: A Medicaid Resident is one who receives benefits from the state Medicaid program for all or a majority of his or her room and board charges. The services currently covered by Medicaid are set forth -in the attached Rate Schedule, which is subject to change. Shippensburg makes no guarantee of any kind that the Resldenfs care will be covered by Medicare, Medicaid, or any third party insurance or other reimbursement source. Shippensburg, its agents and associates are hereby released from any liability for the Resident's potential claim for any failure to obtain such coverage. With respect to applying for and receiving Medical Assistance through the Medicaid Program, Shippensburg will assist the Resident in the application process. The Resident agrees to the following: Qualifying for Medicaid Assistance. If the Resident elects coverage under the Medicaid Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility for Medicaid. These actions must include, but are not limited to, taking any and all steps necessary to ensure that the Resident's assets and income are within the required limits and that these assets and income remain within allowable limits for Medicaid. e Providing Application Information. The Resident agrees to provide all financial and other information required for completion of the Medicaid application accurately and truthfully, as requested by applicable statelcounty agencies. Additionally, the Resident agrees to provide this information in the manner requested by the applicable agencies, and in compliance with any deadlines set by. ,the applicable agencies. Furthermore, the Resident agrees to attend any and all interviews necessary for completion of the Medical Assistance eligibility process, as requested by the applicable state/county agencies. Failure to provide all financial and other information required for completion and support of the Medicaid application accurately and truthfully, as requested by applicable state/county agencies, may result in personal liability for Shippensburg's charges. 14 e Keeping Shippensburg Informed. The Resident agrees to keep Shippensburg informed of the status and progress of the Medicaid application. The Resident agrees to provide Shippensburg with copies of any financial and other Information related to the Medicaid appiication, including a copy of the completed application. e Transferring Assets: If the Resident transfers assets, this transfer may disqualify the Resident for Medicaid and/or cause a discontinuance of the Resident's Medicaid benefits. The Resident acknowledges that this may result in discharge of the Resident due to non-payment, and personal liability for Shippensburg's charges. Legal Representative Controlling Resident's Funds. If the Residents Legal Representative has control of or access to the Resident's Income and/or assets, the Legal Representative agrees to use these funds solely for the Resident's welfare. This includes, but is not limited to, making prompt payment for care and services provided to the Resident as specified and required by the terms of this Agreement. Failure to use these funds solely for the Resident's welfare may result in personal liability for Shippensburg's charges. Providing • Financial information. The Resident certifies that any financial information regarding the Resident's income and assets required by Shippensburg and provided by the Resident is complete and accurate. e Daily Rate Payment. The Resident agrees to pay the costs or Shippensburg's per diem rate as described in the Rate Schedule. Termination of Coverage. The Resident may remain in Shippensburg for as long as he or she is certified eligible for Medicaid coverage, or for as long as any share of cost owed by the Resident is paid as due. A Resident who remains in Shippensburg after Medicaid coverage has been denied and a final determination has been made must pay Shippensburg charges as a private resident. In this event, the Resident will pay based on the private rates, charges, and terms in effect at the time of service. Where the Resident fails to pay the private rates. and charges, the Resident agrees to seek immediate placement at an alternate facility at the earliest possible time. Resident's Share of Cost. The Medicaid program reviews the available monthly income of all persons requesting Medicaid. Based on this review, the Medicaid program requires most Medicaid residents to pay for a reasonable share of the cost of their care. The amount of the Resident's share of the cost of their care can change based upon the services the Resident chooses, and the Medicaid program can adjust the amount of the Resident's share of the cost of their care based upon changes in the 1S Resident's income. Payment of that share is the responsibility of the Resident. Appeal of Finding of Ineligibility. Where the Resident applies for Medical Assistance benefits, the applicable state/county agency may deny the Resident. benefits or some portion of these benefits. Where a denial occurs, the Resident retains all responsibility for obtaining his or her benefits. However, the Resident authorizes Shippensburg to assist the Resident In making any claims and to take all other actions necessary to secure the Resident's benefits, including, but not limited to, assisting the Resident in appealing any state/county agency denial, requesting Interim Assistance benefits, and requesting Reconsideration. The Resident agrees to provide Shippensburg with all information related to obtaining benefits upon receipt, including, but. not limited to, notices of denial. This paragraph shall not create any responsibility on behalf of Shippensburg to obWln benefits or any portion of benefits, nor any liability for failure to obtain same. To facilitate this authorization, but not In lieu thereof, the Resident agrees to properly execute the AUTHORIZATION FOR REPRESENTATION - MEDICAID statement attached to this Agreement. MEDICARE RESIDENTS. A Medicare Resident is one who receives benefits from the federal Medicare program for his or her Shippensburg care. The services currently covered by Medicaid are set forth in the attached Rate Schedule, which Is subject to change. Some additional Items and services may be also covered by Medicare. Shippensburg makes no guarantee of any kind that the Resident's care will be covered by Medicare, Medicaid, or any third party Insurance or other reimbursement source. Shippensburg, its agents and associates are hereby released from any liability for the Resident's potential claim for any failure to obtain such coverage. Continuing Payment of Shippensburg Charges Pending Eligibility. Where the Resident is not currently covered by Medicare, the Resident agrees that white coverage is being pursued the Resident shall pay the private pay rate as a private pay resident as described within this Agreement. If the Resident Is unable to pay the private pay rate, the Resident agrees to pay Shippensburg an amount that is at least equal to the Resident's monthly income from all of the Resident's income sources. This amount, minus any amount not covered by Medicare, shall be refunded to the Resident within thirty (30) days of payment by Medicare should the Resident be found eligible by Medicare. Once the Resident Is determined to be eligible for Medicare, the amount of the Resident's share of cost not covered by Medicare shall be paid to Shippensburg on or before the tenth (I Oh) day of each month. Furthermore, the Resident shall immediately pay to Shippensburg any amount the Resident Is in arrears. If payment of any outstanding amount cannot be 16 made immediately, the Resident shall immediately discuss same with Shippensburg's Administrator or the Administrator's designee, and shall make arrangements to bring his or her account into balance within - the shortest possible time. Daily Rate Payment. The Resident agrees to pay the costs of Shippensburg's per diem rate as described in the Rate Schedule for those supplies and services not paid for by the Medicare program. • Coinsurance and Deductibles. The Resident is responsible for payment of any Medicare coinsurance and/or deductibles that are not paid to Shippensburg by the Medicaid program or. private insurance. Limited Coverage. The Resident understands that Medicare coverage is established by federal guidelines and not by Shippensburg. Medicare coverage Is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the.Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. ? Expiration of Benefits. Prior to admission, the Resident must be able to demonstrate the ability to pay Shippensburg (either privately or through Medicaid) for services rendered after Medicare benefits expire. When Medicare coverage expires, the Resident may remain in Shippensburg if private pay or other payment arrangements have been made.. If the Resident wishes to be discharged from Shippensburg upon. expiration of Medicare benefits, he or she must so advise Shippensburg at the time of the Resident's admission. If the Resident intends to become private pay when Medicare benefits expire, the Resident agrees to pay in advance for one month's private daily rate when the Resident changes to private pay status. No advance payment is required from Medicare Residents who are eligible for Medicaid coverage. Appeals of Denials of Coverage. Where the Resident applies for Medicare benefits, the applicable intermediary, carrier or government agency may deny the Resident these benefits or some portion of these benefits. Where a denial occurs, the Resident retains all responsibility for obtaining his or her benefits. However, the Resident authorizes Shippensburg to assist the Resident in making all claims and to taking all other actions necessary to secure his or her benefits, Including, but not limited to, appealing any initial or subsequent adverse determinations, including requests for Reconsideration. The Resident agrees to provide Shippensburg with all information related to obtaining benefits upon receipt, including; but not limited to, notices of denial. This paragraph does not apply to benefits for which Shippensburg has determined the Resident is not eligible, and does not affect the Resident's right to have a Demand Bill filed. 17 This paragraph shall not create any responsibility on behalf of Shippensburg to obtain any portion of benefits, nor any liability for failure to obtain same. To facilitate this authorization, but not in lieu thereof, the Resident hereby agrees to properly execute the AUTHORIZATION FOR REPRESENTATION - MEDICARE statement attached to this Agreement. MANAGED CARE ORGANIZATIONS: Where the Resident enrolls in or switches the Resident`s enrollment to any managed care organization (hereafter "MCO"), including MCOs that provide Medicare or Medicaid benefits, the Resident agrees as follows: • The Resident shall advise Shippensburg prior to enrolling In or switching the Resident's enrollment to any MCO. • The Resident acknowledges that Shlppensburg is not responsible for and has made no representations regarding the actions or decisions of any. MCO with which Shippensburg .Is. a participating provider, including decisions relating to a denial of coverage. Shippensburg will accept payment from the MCO as payment in full only for those services and supplies covered by the MCO. The Resident is responsible for any co-payments or other costs assigned to the Resident under the managed care plan, or not covered by the MCO under the terms of the managed care plan. If the Resident utilizes services which the MCO refuses to pre-authorize, the Resident shall pay Shlppensburg for those services. Further, the Resident shall pay Shippensburg for services for which the MCO has denied payment because the Resident failed to supply information to the MCO, or for services which are denied subsequently by the MCO. Shippensburg reserves the right to withdraw as a participating provider in any MCO at any time and for any reason. In the'event that Shippensburg withdraws as a participating provider, the Resident may convert his or her coverage to a health plan In which Shlppensburg is a participating provider. Effective the date of Shippensburg's withdrawal from the Resident's MCO, the Resident is obligated to pay for services and supplies provided to the Resident as a private pay resident. If possible, Shippensburg will provide the Resident with advance written notice of its withdrawal from the Resident's MCO thirty (30) days before Shippensburg's withdrawal. ASSIGNMENT OF THIRD PARTY PAYMENTS: The Resident irrevocably authorizes Shippensburg to make claims and to take all other actions to secure receipt of third party payments to reimburse Shippensburg for its charges. To the fullest extent permitted by law, and as security for payment of 18 Shippensburg's charges, the Resident hereby assigns to Shippensburg all of the Resident's rights to any third party payments now or subsequently payable to the extent of all charges due under this Agreement. Resident shall promptly endorse and deliver to Shippensburg any payments received from third parties to the extent necessary to satisfy the charges under this Agreement. To facilitate this assignment, but not in lieu thereof, the Resident hereby agrees to properly execute the ASSIGNMENT OF THIRD PARTY PAYMENTS statement attached to this Agreement. FINANCIAL POWER OF ATTORNEY; The Resident agrees that upon admission the Resident, if able, will supply Shippensburg with a fully executed and legally valid original Financial Power of Attorney appointing an Individual chosen at the Resident's sole discretion to be his financial attomey--in-fact should the Resident become medically incompetent. If not able, the Resident agrees to work with Shippensburg to pursue guardianship. This Power of Attorney need only bec=e effective if the Resident becomes icaily incompetent. If, in the judgment of the Resident, no such individual is available, the Resident agrees to appoint such an individual when one becomes available. Judgment of the Resident's incompetence shall not require a court adjudication, but shall require the written order of Resident's physician plus confirmation by a second examining physician. The Resident's financial attomey-in-fact shag be granted the authority to make financial decisions for the Resident, in the unlimited power to pay Shippensburg's charges and invoices from the Resident's income, and from the proceeds of the attorney-in-fact's sale of the Resident's assets. The selection of this attorney-in-fact serves at the complete discretion of the Resident. However, should the Resident revoke the power of his or her appointed attorney-in-fact, or should the Power of Attorney become inoperable for any reason, the Resident hereby agrees to immediately appoint a successor attorney-in-fact for the financial purposes set forth herein, if such an individual is available. Upon receiving a duly executed copy or facsimile of this Agreement noting the Resident's appointed financial attomey-In-fact, Shlppensburg may act hereunder.. Revocation of the attomey-iri-fact shall be ineffective as to Shippensburg unless and until written or actual notice or knowledge of such revocation is received.. The attomey in-fact's power shall continue In full force and effect and may be relied upon by Shippensburg despite purported revocation until written notice of revocation is received by- Shippensburg. Financial Power of Attorney forms can bg obtained free of charge Shippensburg's Social Service Department. Residents should first consult with his or her family and attorney before executing any Financial Power of Attorney form. 19 Payment Information DUE DATES AND THE OBLIGATION OF TIMELY PAY_ MEN : $hippensburg's charges for services provided shall be billed on a monthly basis to the Resident. These charges are due and payable by the tenth (10th) day of each month. If payment Is no received by the fifteenth (I e) day of each month, the account balance is considered past due, and Shippensburg may add Late charges to the Resident's account. These late charges shall be, assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of Shippensburg or Resident under this Agreement. The Resident recognizes that Shippensburg does not offer credit or accept installment payments. Shippensburg's acceptance of a partial payment does not limit Shippensburg's rights under this Agreement to full payment for the care and services provided. BILLING ADDRESS: All of Shippensburg's invoices are to be mailed to the following address for prompt payment (either. Resident's address or Legal Representative's address, when applicable), FAILURE TO PAY: Shippensburg's due date for its payments falls on the fifteenth (15th) day of each month. - If the Resident fails to make a required payment within twenty-one (21) days of the due date, Shippensburg may require the Resident to vacate Shippensburg after appropriate advance notice. If the Resident Is required to vacate Shippensburg for failure to pay, Shippensburg shall provide advance notice as set forth In Termination section of this Agreement. FEE FQR RETURNED CHECKS: A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. PROPERTY: This Agreement shall operate as an assignment, transfer and conveyance to Shippensburg of as much of the Resident's property as Is equal 20 in value to the amount of any unpaid obligations under this Agreement, and this assignment shall be an obligation of the Resident's estate and may be enforced against the Resident's estate. The Resident's estate shall be liable to and shall pay Shippensburg an amount equivalent to any unpaid obligations of the Resident under this Agreement. This assignment shall apply whether or not the Resident Is residing in Shippensburg at the time of the Resident's death. Bed Holds The Resident may need to be absent from Shippensburg temporarily for hospitalization or therapeutic leave. The Resident may request that Shippensburg hold open the Resident's bed during this time. This Is known as a "bed hold." The Resident, and If known, the Resident's Legal Representative shall be given notice of the bed hold option at the time of hospitalization or therapeutic leave. A schedule of charges for bed holds is located on the Rate Schedule attached to this Agreement. MEDICAID l ESIDENTS: If the Resident's care is paid under the Medicaid Program, Medicaid currently pays for 15 bed hold days. If the Medicaid Resident's hospitalization or therapeutic leave exceeds the bed-hold period paid under the Medicaid program, the Resident may request an additional bed hold period from Shippensburg by agreeing to pay seventy-five dollars ($75.00) a day during the additional bed hold period. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident requires the services provided by Shippensburg and Is eligible for Medicaid benefits. PRIVATE AN1 MEDICARE RESIDENTS: Any private or Medicare Resident may request a bed hold from Shippensburg. The Resident's private Insurance may or may not pay for bed holds. The Medicare program does not pay for bed holds. However, if the Medicare Resident is also eligible for Medicaid, and if proven to the satisfaction of Shippensburg, Medicaid pays for 15 bed hold days. Otherwise, a Private or Medicare Resident requesting a bed hold must pay Shippensburg's bed hold rate set forth In the Rate Schedule for the bed being held during the bed hold period. Perjon_al Funds The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with management of personal funds, and requests so in writing through a Resident Fund Authorization form, Shippensburg will 21 hold, safeguard, manage, and account for these funds. A Resident Fund Authorization form can be obtained from Shippensburg's Administrator or designee. Resident personal funds deposited with Shippensburg shall be handled as follows: Shippensburg shall deposit funds in excess of fifty dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Shippensburg operating accounts. All interest earned on the Resident's funds shall be credited to his or her account. Shippensburg shall have the option of depositing funds of less than W dollars in a non-interest bearing account, an interest bearing account, or a petty cash fund. Shippensburg shall inform the Resident as to how his or her funds are being held. Shippensburg's policy is to maintain all resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. Shippensburg shall have a system that. ensures a complete and separate accounting, based on -generally -accepted accounting principles, of the. personal funds deposited with Shippensburg by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not commingled with Shippensburg's funds or with any other funds besides those of other residents. In addition to the required quarterly accounting, Shippensburg shall provide individual financial records at the written request of the Resident. The personal fund balance a resident receiving Medicaid benefits must remain within a certain dollar range for the Resident to continue to receive benefits. Shippensburg shall notify a Medicaid resident if his or her account balance is within two hundred dollars ($200.00) of the federal Supplemental Security Income (hereafter "SSI„) limit. Shippensburg shall also notify the Resident if the account balance, in addition to the Resident's known non- exempt assets,. reaches the SSI resource limit. Furthermore, Shippensburg shall notify the Resident If the account balance, in addition to the Resident's known non-exempt assets, reaches the resource limits for Medicaid eligibility. A balance in excess of this limit may cause the Resident to lose eligibility for Medicaid or SSI. o If a Resident who has personal funds deposited with Shippensburg expires, Shippensburg shall refund the Resident's personal account. balance within thirty (30) days, and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity as required by state law or regulation. However, any outstanding balance owed to Shippensburg for the Resident's care and services shall first be deducted from the Resident's personal account as permitted by law. 22 • Shippensburg shall ensure the security of all resident personal funds deposited with Shippensburg, and shall not take money from a Medicare and/or Medicaid resident's personal funds for any item or service for which payment is covered by Medicare and/or Medicaid. Funeral Arrangements Shippensburg assumes no financial responsibility for the funeral or funeral related expenses associated with a Resident's passing. Shippensburg recognizes the emotional hardship that such an event may have on, the Resident's family and loved-ones. To assist during this difficult time, Shippensburg will convey the Resident's wishes, as expressed below, concerning arrangements to a designated funeral director. Funeral Arrangements: _ .4r ,c Funeral Director: Burial Fund: Cemetery Lot Location: Person Assuming Responsibility for Burial: TERMINATION OF AGREEMENT RIGHT TO TERMINATE: An explanation of the Resident's rights concerning termination, transfer, and discharge is contained In the Statement of Resident Rights, which is attached to but separate from this Agreement. 23 RESIDENT INITIATED: Notice of resident initiated termination is required for proper discharge planning. Other than In the case of a medical emergency or death, the Resident will provide Shippensburg with written notice two (2) business days before the Resident's termination of this Agreement. REFUNDS: If a Resident has personal funds deposited with Shippensburg upon termination of this Agreement, Shippensburg shall refund the Resident's personal account balance within thirty (30) days, and provide the Resident or the Resident's estate with a full accounting of these funds, However, any outstanding balance owed to Shippensburg for the Resident's care and services shall first be deducted from the Resident's personal account as permitted by law. RESIDENT GRIEVANCEICOMPLAINT RESOLUTION RESIDENT GRIEVANCES: All Residents, family members, and Resident representatives are urged to bring any grievances concerning Shippensburg to the attention of the Shippensburg Administrator or the. Administrator's. designee. In addition to bringing grievances to the attention of Shippensburg Administrator or designee, residents may also contact the outside representative of his or her choice. Outside representatives include the Governor's Action Line at (800) 932-0784, the Department of Health Hot Line at (800) 254-6154, the Long Term Care Ombudsman located within the Local Area Agency on Aging, and the Legal Services Program. The telephone number of the local Long Term Care Ombudsman and the Legal Services Program is located within the Resident's Bill of Rights accompanying this Agreement. ARBITRATION & ENFORCEMENT OF THIS AGREEMENT RESIDENT ARBITRATION: Unless otherwise mutually agreed upon in writing, should grievance procedures fail the Resident and Shippensburg agree that all disputes arising under this Agreement, with the exception of disputes concerning non-payment for services rendered, shall be resolved by binding arbitration before a neutral arbitrator, assigned to the matter In accordance with the National Health Lawyers Association Alternative Dispute Resolution Service 'Rules of Procedure for Arbitration. Such arbitration shall take place at Shippensburg at a mutually agreed upon time. Any time a dispute arises, any party may request the appointment of an arbitrator to resolve the dispute. The requesting party shall notify the other party In writing a minimum of seven (7) business days prior to requesting the appointment of the arbitrator. The costs of the arbitrator and all costs associated with the arbitration, including attorney's 24 fees, costs, and expenses shall be borne by the losing party. The decision of the arbitrator will be final and binding, and may be entered as a judgment in any court having competent jurisdiction. ATTORNEY'S FEES/COLLECTION AGENCY FEES/COSTS: In the event that Shippensburg institutes and is a prevailing party in litigation in court against any party to this Agreement arising from that party's failure to comply with the terms of the Agreement, Shippensburg shall be entitled to receive from the losing party reasonable affomeys'/collection agency fees, along with all court and related- dosts. MISCELLANEOUS PROVISIONS CLINICAL/FINANCIAL INFORMATION: With and at Shippensburg's discretion, the Resident hereby authorizes Shippensburg to obtain all of the, necessary clinical and/or financial documentation from the Resident's prior or transferring hospital or nursing facility. SOLE AGREEMENT: This Agreement, along with any documents attached or Included by reference, is the only agreement between Shippensburg and parties. Changes to this Agreement are valid only if made in wrtUhg and signed by all parties. If changes in state or federal law make any part of this Agreement invalid, the remaining terms remain valid and enforceable. NON=ASSIGNABLE AGREEMENT: The Resident agrees that the right of the Resident to reside at Shippensburg is personal and -not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. GOVERNING LAW. This Agreement shall be governed by and construed by the laws of the Commonwealth of Pennsylvania, and shall be binding upon and shall be for the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns.. SEVERABILITY: The Resident and Shippensburg agree that each separate obligation contained in this Agreement shall be deemed a separate and Independent agreement. If any term, condition, clause or provision of this 25 Agreement shall be determined or declared to be 'void or invalid in law or otherwise, then only that term, condition, clause or provision shall be stricken from this Agreement, and in all other respects this Agreement shall be valid and continue. in full force, effect and operation. CAPTIONS: The captions used in this Agreement are inserted only for the purpose of reference. Such captions shall not be deemed to govern, limit, modify or in any manner affect the scope, meaning or intent of the provisions of this Agreement. The captions shall be given no legal effect. WAIVER: A waiver by either party at any time of any of the terms, conditions, or covenants of this Agreement, or of any default or breach shall not be deemed or taken as a waiver at any time thereafter of the same or any other term, condition or covenant herein contained, nor of the strict and prompt performance thereof. MODIFICATIONS: Shippensburg reserves the. right to unilaterally modify, this Agreement to the extent necessary to conform the Agreement with subsequent changes in law or regulation. Shippensburg will notify the Resident thirty days (30) before such modification, if possible. ACKNOWLEDGMENTS RATE SCHEDULE: The Resident and the Resident's Legal Representative hereby acknowledge the receipt of a copy of the Rate Schedule and sufficient opportunity to ask questions about the Rate Schedule to answer all of their questions about Shippensburg's charges. The Resident and the Legal Representative hereby acknowledge that Shippensburg can and will alter the Rate Schedule from time to time, and that Resident will be subject to those changes. The Resident and the Resident's Legal Representative hereby agree to be subject to those changes as provided in this Agreement. STATEMENT OF RESIDENT'S RIGHTS: The Resident and the Resident's Legal Representative hereby acknowledge being informed orally and of receiving a written copy of the Resident's Rights, as set forth in this Agreement, and as further set forth in ' the accompanying Shippensburg's Statement of Resident's Rights. Furthermore, the Resident and the Resident's Legal Representative hereby acknowledge having sufficient opportunity to. ask questions about the Resident's rights and have received appropriate responses: The Resident and the Resident's Legal Representative hereby acknowledge that the accompanying Statement of Resident's Rights is subject to change 26 from time to time, and shall not be construed as imposing any contractual obligations on Shippensburg or granting any contractual rights to the Resident. COMMONWEALTH'S ADMISSIONS NOTICE PACKET: The Resident and *the Resident's Legal Representative hereby acknowledge being informed orally and of receiving a written copy of the Commonwealth's Admissions Notice Packet, accompanying this Agreement. Furthermore, the Resident and the Resident's Legal Representative hereby acknowledge having sufficient opportunity to ask questions about the Resident's rights and have received appropriate responses. The Resident and the Resident's Legal Representative hereby acknowledge that the Commonwealth's Admissions Notice Packet Is subject to change from time to time, and shall not be construed as imposing any contractual obligations on Shippensburg or granting any contractual rights to the Resident. PRIVACY ACT STATEMENT - HEALTH CARE RECORDS: The Resident and the Resident's Legal Representative hereby acknowledge being Informed orally receiving a written copy of the Privacy Act Statement - Health Care Records, in compliance with -the Privacy. Act of 1974. Furthermore, the Resident and the. Resident's Legal Representative hereby acknowledge having sufficient opportunity to ask questions about the Privacy Act Statement and have received appropriate responses. HEALTH CARE ADVANCE DIRECTIVES: The Resident and the Resident's Legal Representative hereby acknowledge being informed orally and in Writing about health care advance directives, including receiving a copy of the Commonwealth's Medical and Treatment Self-Directive Statement, and of Shippensburg's policy concerning health care advance directives and medical treatment decisions. Furthermore, the Resident and the Resident's Legal Representative hereby acknowledge having sufficient opportunity to ask questions about advance directives, the Commonwealth's Medical and Treatment Self-Directive Statement, and Shippensburg's policy thereon, and have received appropriate responses to all of their questions. AGREEMENT: The Resident and the Resident's Legal Representative hereby acknowledge that they have carefully read, and understand the terms of this Agreement, and that the terms have been explained to them by a representative of Shippensburg. Furthermore, the Resident and the Resident's Legal Representative hereby acknowledge having sufficient opportunity to ask questions about the Agreement and have received appropriate responses. 27 IN WITNESS WHEREOF, INTENDING TO BE LEGALLY BOUND, the parties hereto have executed this Agreement the day of P . and same shall be considered binding upon all parties, and shall remain in full force and effect unless and until cancelled according to the terms of this Agreement. (p- //-?? _10A -4 ?' Ll Resident Date Legal Representative Witness Date Date Admissions Representative Administrator Date Date 35 STATEMENT SHIPPENSBURG HEALTH CARE CTR Phone: 717-530-8300 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Statement Date: 04130109 Melody Elchoff Resident: MELODY EICHOFF 131 Amy Drive Carlisle, PA 17015 20 Service Through Qty Description A oun BALANCE FORWARD 11,018.18 TOTAL AMOUNT DUE »»»»»»> 11,015.18 EXHIBIT "B" Page 1 o OF i'}-'F TARP 2009 MAY -8 ' 18: 5 4 P ??'? / yG G 3 A W- ?- a- y n, a Sheriffs Office of Cumberland County R1Tho Thomas Kline aytitr st cuwbe.. Edward L Schorpp Solicitor V4'• Ronny R Anderson Jody S Smith Chief Deputy OFFICE (?F THE SHERIFF Civil Process Sergeant SHERIFF'S RETURN OF SERVICE 05/14/2009 05:33 M - Dennis Fry, Deputy Sheriff, who being duly sworn according to law, states that on May 14, 2009 t 1733 hours, he served a true copy of the within Complaint and Notice, upon the within named defen ant, to wit: Melody Erckhoff, by making known unto Melodie Erckhoff personally, at 131 Amy Drive, Carlisl , Cumberland County, Pennsylvania, 17013 its contents and at the same time handing to her person Ily the said true and correct copy of the same. SHERIFF COST: $32.94 May 15, 2009 2009-2890 Perini v Erckhoff SO ANSWERS, ? IlP R THOMAS KLINE, SHERIFF Depu eri -,? ty ? f 1e1 't ` ?- `?,3 -TI PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2009- 2890 CIVIL TERM MELODY A. EICKHOFF, Defendant PRAECIPE TO ENTER DEFAULT JUDGMENT PURSUANT TO Pa.R.C.P. 1037 TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, Perini Services/South Hampton Manor, L.P. and against the Defendant, Melody A. Eickhoff, for failure to file an answer to the Complaint of Plaintiff. A true and correct copy of the Notice of Default is appended hereto as Exhibit "A." A true and correct copy of the Certificate of Mailing for the Notice of Default is appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance with Pa.R.C.P. 237.1. Plaintiff requests judgment in the amount of $12,337.37 as set forth in the Complaint, together with interest of $260.64 to June 16, 2009 with a per diem of $5.43 and attorney fees of $813.75 for a total of $13,411.76. Respectfully submitted, ' RIEN, B C & S R David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2009- 2890 CIVIL TERM MELODY A. EICKHOFF, Defendant TO: Melody A. Eickhoff 131 Amy Drive Carlisle, Pennsylvania 17013 Date of Notice: June 4, 2009 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 ' N, BARI AND S R David A. Baric, Esquire 19 West South Street Carlisle, PA 17013 (717) 249-6873 EXHIBIT "A" • f ??. :.. ?... iitOFlRi? ?_tlietneil hps been presented to U. Memetionat med. i ci 4 Sc1?F,+ w ¦\ To: 1 1 • Nfld 3l iu., S?rlisl? , PA t-JUt3 m N _ `\ r0 d d 2 oV ? yZ ? ? Dn 7. roo a •wm to ?? c°o N m PS FCt1?13$17. Apnl 1007 PSN 7530-02-000-9065 EXHIBIT "B" CERTIFICATE OF SERVICE I hereby certify that on June A3 , 2009, I, David A. Baric, Esquire, of O'Brien, Baric & Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Melody A. Eickhoff 131 Amy Drive Carlisle, Pennsylvania 17013 David A. Baric, Esquire i 1u F T it 2 0594? ?f r.:Y 09' fJ ti 12 l t.I l If ti' 1 f r t ! r' LYJ AV N-01 /W 71 LIP Row I• PERINI SERVICES/ SOUTH HAMPTON MANOR, L.P. Plaintiff V. MELODY A. EICKHOFF, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2009- 2890 CIVIL TERM NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236 TO: Melody A. Eickhoff 131 Amy Drive Carlisle, Pennsylvania 17013 Notice is hereby given to you of entry of a judgment against you in the above matter. Date: & Z//Y ZZ , Prothonotary ?i 1.?