HomeMy WebLinkAbout09-3825PERM SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2009- 3 g? CIVIL TERM
NANCY L. GRIMES,
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
PERM SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
NANCY L. GRIMES,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO.2009- 3Y.26'
CIVIL TERM
COMPLAINT
NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a
Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets
forth the following:
1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Nancy L. Grimes, is an adult individual with a residence address of 6
Cypress Trail, Fairfield, Adams County, Pennsylvania 17320.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
4. On or about April 18, 2008, Cameron J. Grimes sought to be admitted to the
Shippensburg Health facility.
5. On or about April 18, 2008, Nancy L. Grimes, wife of Cameron J. Grimes
executed an Admission Agreement on behalf of Cameron J. Grimes, at the facility. A true and
correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated.
6. Pursuant to the Admission Agreement, Cameron J. Grimes would be responsible
to pay any costs of care which were not covered by a third party payer.
7. On or about April 18, 2008, Cameron J. Grimes became a resident of the
Shippensburg Health facility and remained a resident to January 30, 2009.
8. Pursuant to the Admission Agreement, Nancy L. Grimes agreed, as the
responsible party for Cameron J. Grimes, to pay the costs of care provided from the income of
Cameron J. Grimes.
9. As of January 30, 2009, Cameron J. Grimes owed Shippensburg Health the sum
of $8,280.23 for the costs of care provided by Shippensburg Health to him. A true and correct
copy of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is
incorporated.
10. Upon information and belief, Cameron J. Grimes passed away on March 12, 2009.
11. Demand has been made upon Nancy L. Grimes to pay the amount due for the
costs of care provided to Cameron J. Grimes.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. NANCY L. GRIMES
AND CAMERON J. GRIMES
12. Plaintiff incorporates by reference paragraphs one through eleven as though set
forth at length.
13. Nancy L. Grimes has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
14. As a consequence of that breach, Shippensburg Health is owed the sum of
$8,280.23 to January 30, 2009.
15. The accrued debt consists of the private pay obligation of Cameron J. Grimes.
Nancy L. Grimes has failed to pay the private pay obligation from the benefits she has received in
the name of Cameron J. Grimes.
16. The Admission Agreement bound Cameron J. Grimes to pay for the costs of his
care at the facility and bound Nancy L. Grimes to pay the costs of care from the assets and
income of Cameron J. Grimes.
17. 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 $124.22 as of May 26,
2009 and continue to accrue.
18. 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 Cameron J. Grimes
and Nancy L. Grimes for the sum of $8,280.23 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-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. NANCY L. GRIMES
19. Plaintiff incorporates by reference paragraphs one through eighteen as though set
forth at length.
20. During the period of Cameron J. Grimes' residence at the facility, Nancy L.
Grimes has been receiving social security and pension benefits of Cameron J. Grimes.
21. The proper use of those funds would have been to pay the costs of care accruing
for the care of Cameron J. Grimes at Shippensburg Health.
22. At the time of receipt of those funds, Nancy L. Grimes knew that these funds
should be paid over to Shippensburg Health for the costs of Cameron J. Grimes care.
23. Nancy L. Grimes gave no consideration for the funds of Cameron J. Grimes she
has received.
24. Demand has been made upon Nancy L. Grimes to tender the funds of Cameron J.
Grimes to Shippensburg Health and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Nancy L. Grimes
requiring her to:
a) return the subject matter in specie;
b) pay over the value if Nancy L. Grimes has consumed the money in beneficial use;
c) pay its value if Nancy L. Grimes has disposed of the funds received; and
d) award costs, expenses and interest.
Respectfully submitted,
RIEN, BARIC & S
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/grimes/complaint.pld
06/02/2009 12:23 7172495755 OBS PAGE 07
VE ION
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have head the statements; and to the extent that they are based upon information which I have
given to my counsel, they are true and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §
4944 relating to unworn falsifications to authorities.
DATE: -1.0-4-09 44L4j A M-k
Deb Black
Business Office Coordinator
SHIPPENSBURG HEALTH CARE CENTER
ADMISSION AGREEMENT
THIS AGREEMENT, made this day of
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
"Shlppensburg') and 6 _k/r_; &&j . (hereafter
"Resident"), previously residing at (Street Address and Post Office Sox)
and
IUWry CAS d,,,ta (hereafter
"Legal Representative"), residing at (Street Address and Post Office Box)
0 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 cjaily
rates, those supplies and services which are not covered by the daily rates for
EXHIBIT "All
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 provlde.5.
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 SUPPLIES: Shippensburg will also provide
ancillary services and supplies as set forth in-the Rate Schedule, and private
accommodations upon the direction of the Resident's physician. The ancillary
services and supplies are subject to change from time to time at the discretion
of Shippensburg.
uu ai tut= -Kuviur:KS ANU 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 soki-bxpense 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 Mate 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
discdminate.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 and osier 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 trafning 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-fadNty SerWces
section of this Agreement.
RIGHT TO REFUS8 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
iaw.
Residenf s Personal Pro»erty
Shippensburg strongly discourages the keeping of valuable jewelry,
papers, large sums of money, or other items considered of value in
Shippensburg. However, the Resident shall be permitted to retain and use
personal clothing and possessions as space permits, unless to do so would
infringe upon the right of other residents or unless determined medically
inadvisable as documented by the Resident's physician In the Resident's
medical record. Shippensburg shall make reasonable efforts to properly handle
and safeguard the Resident's personal property In Shippensburg. The Resident
agrees to Inform Shippensburg of all valuable property upon admission. If, at
any time during the Resident's stay,. new items of value are added to the
Resident's possessions in Shippensburg, the Resident agrees to so inform
Shippensburg's Administrator or designee.
The Resident is responsible for obtaining at his or her own expense any
insurance coverage necessary to cover potential damage to or loss of any of
Resident's personal property. Shippensburg shall not be liable for damage to or
loss of any of Resident's personal property. Should the Resident lose his or her
property, or believe that -his or her property has been otherwise removed from
his or her possession, the Resident agrees to follow Shippensburg's procedure
for filing reports of lost or stolen property.
In the event that Resident Is transferred or discharged from
Shippensburg, or If the Resident expires, the Resident hereby authorizes
Shippensburg to transfer the Resident's personal property to the Resident's
Legal Representative, or to any duly authorized representative of 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 fall to be claimed within thirty (30) days of placement by
4
Shippensburg Into storage, the Resident hereby agrees that Shippensburg may
dispose of the Resident's property with and at Shippensburg's discretion,
including retaining all proceeds from any sale thereof.
R+esfdent's Records
CONpIDgNTIAL : 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 Shione sbura: The Resident authorizes
Shippensburg 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
tecords 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 shalt 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 RUPON31BILITIES
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
6
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.
DIE : The Resident understands that his or her diet is medicaid 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
requirefnents 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.
INDEMNISCATION: The Resident hereby agrees to indemnify and hold
harmless Shippensburg, its officers, directors, agents, and employees from and
against any and all claims, demands or causes of action for injury or death to
person or damage to properly, 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 wiNfui 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 RsEQARD! 6 THE IMPLEMENIM1914
OF THE PATIENT SELF-DETERMINATION ACT
The following Information Is being provided to the Resident as a result of
a federal law which requires certain health care institutions, Including
Shippensburg, to disclose to the Resident his or her rights under federal and
state law to make decisions regarding his or her health care.
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, Shlppensburg recognizes the
Resident's right to have these decisions made on his/her behalf by a substiMe
decision-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 mare 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 careadvance directive is not geressary In order to bS admitted
to or to continue to reside In Shiapensbura. However. If the Residdg t has a
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 healh care advance dbg form.
No Resident should use an advance directive form without first consulting
the Resident's family, physician, and attorney.
7
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
shalt 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 legal
proceedings, including attomey'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
Leal 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 Residenrs 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
flnanclal obligations under this Agreement, the term "Resident" shall be
8
construed to Include the obligations of any 'Legal 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 fuel 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, Shippensburo must have.
accurate record of the history and depletion of the Resident's Income and
significant assets. On this basis, please set forth the Resident's income and
assets below:
Income
Social Security:
Account Number:
Monthly Income:
Payee:
Sion:
Account Number:
Monthly Income:
Financial Institution:
If A
9
Payee:
Tru is
Account Number(s):
Monthly Income:
Financial Institution(s):
Beneftclary(s):
Type of Trust(s):
Other Income (please describe)
10
Payee(s):
Assets
Residence/Real gltate:
Address: CT.? ss L
2A;?rjr,IZ P.4 JqJaQ
Vehicles :
Year, Make and Model:
State of Registration:
Bank Accounts:
Account Number(s):
Financial Institution(s):_ n2, X50
insurance Policies:
19
Account Number(s):.
Financial Institution(s):
Beneficiary: ,
Other Significant Assets (please describe}:
?mil„ 2-A A i 14Y /Vv-)
Llabitities
Describe nature and extent:
Has a Wilt been completed?: Yea No
if yes, Executor's Name: rj b&45
12
Executor's Address: L Ctr_?r ??? ?'rl
Recelpt 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
fha RDOWenf tQ 1.,+n.,....a...? A- '-?'-- -- - .
Administrator or the Administrator's designee, Sh v ?
In making these arrangements. ShIppensburg will assist you
PRIVATE RESIDENTS: A Resident is considered private (or private pay) when
no state or federal. program is paying. for the Residenfq room and board. A
pdvate-pay Resident may have private insurance or another third party, which r
pays all or some of his or her charges.
• Dally Rate. The Resident agrees to pay Shippensburg's private. pay per
diem rate as described in the Rate Schedule. The Resident agrees to pay
Shippensburg in advance for one month's private daily rate. For each
additional month's stay, the Resident agrees to pay Shippensburg in
advance on or before the tenth (10th) day of the month. Any unus2d
advance payment shall be refunded to the Resident ninety (SO) 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 fails 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, the
Resident remains Drimarlly responsi le for Davin
g all of Slijppensbura's
c a s. 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 Residents private insurer Is not a
managed care plan with which Shippensburg has a contract, Shippensburg
will 'involce the Resident, who Is primarily responsible for payment of the
invoice.
MgDiCAID RESIDENTS: A Medicaid Resident 'is one who receives benefits
from the state Medicaid program for all or a majority of his or her room and
board charges. The services currently covered by Medicaid are set forth In the
attached Rate Schedule, which Is subject to change. Shippensburg makes no
guarantee of any kind that the Resident's care will be covered by
Medicare, Medicald, 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:
o 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.
Providing Application Information. The Resident agrees to provide aid
financial and other Information required for completion of the Medicaid
application accurately and truthfully, as requested by applicable state/county
agencies. Additionally, the Resident agrees to provide this information In
the manner requested by the applicable agencies, and in compliance with
any deadlines set by the applicable agencies. Furthennore, the Resident
agrees to attend any and all Interviews necessary for completion of the
Medical Assistance eligibl ty 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
• Keeping Shippensburg Informed. The Resident agrees to keep
Shippensburg informed of the status and progress of the Medicaid
application. The Resident agrees to provide Shippensburg with copies of
any financial and other information related to the Medicaid application,
including a copy of the completed application.
• 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 Resident's
Legal Representative has control of or access to the Resident's income
and/or assets, the Legal Representative agrees to use these funds solely for
the Resident's welfare. This includes, but Is not limited to, making prompt
payment for care and services provided to the Resident as 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•Financlal 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.
• 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
15
Resident's Income. Payment of that share is the responsibility of the
Resident.
e Appeal of Finding of Ineligibility. Where the Resident applies for Medical
Assistance benefits, the applicable statelcounty agency may deny the
Resident benefits or some portion of these benefits. Where a dental 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 dental, 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 obtain benefits or any
portion of benefits, nor any liability for failure to obtain same. To facllitMe
this authorization, but not in lieu thereof, the Resident agrees to properly
execute the AUTHORIZATION FOR REPRESENTATION - MEDICAID
statement attached to this Agreement.
MEDi.QARE 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.
Contlnuing Payment of Shippensburg Charges Pending Eligibility.
Where the Resident is not currently covered by Medicare, the Resident
agrees that while coverage is being pursued the Resident shall pay the
private pay rate as a private pay resident as described within this
Agreement. If the Resident is unable to pay the private pay rate, the
Resident agrees to pay Shippensburg an amount that Is- at least equal to the
Resident's monthly income from all of the Resident's Income sources. This
amount, minus any amount not covered by Medicare, shall be refunded to
the Resident within thirty (30) days of payment by Medicare should the
Resident be found eligible by Medicare.
Once the Resident is determined to be eligible for Medicare, the amount
of the Resident's share of cost not coverect by Medicare shall be paid to
Shippensburg on or before the tenth (10e`) day of each month. Furthermore,
the Resident shall Immedlately 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
Shlppensburg'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 Bltl 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.
MAIa,GED CARE ORGANV, IIOON_S: 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 Shippensburg is not responsible for and
has made no representations regarding the actions or decisions of any. MCO
with which Shippensburg is a participating provider, Including decisions
relating to a denial of coverage.
Shippensburg will accept payment from the MCO as payment In full only for
those services and supplies covered by the MCO. The Resident Is
responsible for any co-payments or other costs assigned to the Resident
under the managed care plan, or not covered by the MCO under the terms
of the managed care plan. If the Resident utilizes services which the MCO
refuses to pre-authorize, the Resident shall pay Shippensburg for those
services. Further, the Resident shall pay Shippensburg for services for
which the MCO has denied payment because the Resident failed to supply
Information to the MCO, or for services which are denied subsequently by
the MCO.
Shippensburg reserves the right to withdraw as a participating provider In
any MCO at any time and for any reason. In the event that Shippensburg
withdraws as a participating provider, the Resident may convert his or her
coverage to a health plan in which Shippensburg Is a participating provider.
Effective the date of Shippensburg's withdrawal from the Resident's MCO,
the Resident Is obligated to pay for services and supplies provided to the
Resident as a private pay resident. If possible, Shippensburg will provide
the Resident with advance written notice of its withdrawal from the
Resident's MCO thirty (30) days before Shippensburg's withdrawal.
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
Shlppensburg's charges, the Resident hereby assigns to Shlppensburg 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 Shlppensburg any payments recelved front third parties
to the extent necessary to satisfy the charges under this Agreement. To
facilitate this assignment, but not in Ileu. 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 Shlppensburg with a fully executed
and legally valid original Financial Power of Attorney appointing an Individual
chosen at the Resident's sole discretion to be his financial attorney-in-fact
should the Resident become medically incompetent. If not able, the Resident
agrees to work with Shlppensburg to pursue guardianship. This. Power of
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 attorney4n-fact shall be
granted the authority to make financial decisions for the Resident, Including the
unlimited power to pay Shippensburg's charges and invoices from the
Resident's Income, and from the proceeds of the attorney-in-fact's sale of the
Resident's assets.
The selection of this 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 attorney-iri-fact shall be Ineffective . as to
Shpppensburg 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 Shlppensburg despite purported
revocation until written notice of revocation Is received by Shlppensburg.
Residents should first consult with his or her family and attorney
before executing any Financial Power of Attorney form.
19
Payment Information
uuc WA I Mb 8MM 1 Hk UBUQATIo OE TIMELY PAYIIAENT: Shlppensburg's
charges for services provided shall be billed on a monthly basis to the Resident.
These charges are due and payable. by the- tenth (1bt) day of eat:h month. If
payment is no received by the fifteenth (I . ) 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 after 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 Shlppensburg'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 falls 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 Terminatfon section
of this Agreement.
FEE FOR RETURNED CHECKS: A service fee of $25.00 (twenty=five dollars)
or the actual fee charged by the bank, whichever is greater, will be charged for
any returned check.
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 Shlppensburg 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 olds
The Resident may need to be absent from Shlppensburg temporarily for
hospitalization or - therapeutic leave. The Resident may request that
Shlppensburg 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 RESIDENTS: 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 Shlppensburg 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 Shlppensburg and Is eligible for
Medicaid benefits.
PRIVATE AND ME2ICAB9 RESIDENTS: Any private or Medicare Resident may
request a bed hold from Shlppensburg. The Resident's private insurance may or
may not pay for bed holds. The Medicare program does not pay for bed holds.
However, N the Medicare Resident is also eligible for Medicaid, and if proven to
the satisfaction of Shlppensburg, 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.
Personal 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, Shlppensburg 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 fifty dollars in a non-interest bearing account, an interest bearing
account, or a petty cash fund. Shippensburg shall inform the Resident as to
how his or her funds are being held. Shippensburg's policy Is to maintain all
resident funds in a separate account, except for a nominal amount
maintained in a petty cash fund for the Resident's convenience.
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.
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 jurlsdiction 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 Trom 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 responsibiiity for the funeral or
funeral related expenses associated with a Rpsident'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:? Pei
Funeral Director:
Burial Fund:
Cemetery Lot Location:
Person Assuming
Responsibility for Burial:
TERMINATION OF AGREEMENT
RIGHT TO JERMINATE: 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.
R N S: 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 Lpng 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 nonpayment 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 vises, 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
Shlppensburg Institutes and is_a prevailing party In litigation. In court against any
party to this Agreement arising from that party's faildre to comply with the terms
of the Agreement, -Shlppensburg shall be : entitled to. receive from the losing
party reasonable attomeys'/collection agency fees, along with ail court and
related costs.
MISCELLANEOUS PROVISIONS
CLINICAUFINANCIAL INFO TION: With and at Shippensburg's discretion,
the Resident. hereby -authorizes Shlppensburg 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 Shlppensburg and
parties. Changes to this Agreement are valid only if made in writing and signed
by all parties. If changes in state or federal law make any part of this
Agreement Invalid, the remaining terms remain valid and enforceable.
NON ASSIGNABLE AGREEMENT: The Resident agrees that the right of the
Resident to reside at Shlppensburg Is personal and not assignable. The
Resident may not transfer his or her rights under this Agreement to any other
person.
GOYERNING 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.
SPEY, ERAl3ILITY: The Resident and Shlppensburg 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 terns, 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 Shlppensburg's Statement of
Resident's RightQ. 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 sufficlent
opportunity to ask questions about the Privacy Act Statement and have
received appropriate responses.
HEALTH CARE ADVANCE DIRECTNES: 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 sufficlent 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. ?Ld day of
64; 1 f . and same shall be
considered binding upon all parties, and shall remain in full force and effect
unless and until cancelled according to the terms of this Agreement.
Resident
u
ZUfi&jyj '7r,
L al presentative
Date
O
Date
Witness
A Isslons Represe tive
Administrator
Date
?//lsr/.off
Date I
Date
N'P?6
4 4A U, A
VC
HEALTH CARE CENTER
121 Walnut Bottom Road (717) 530-8300
Shippensbur& Pennsylvania FAX (717) 530-8304
17257-9005
5/26/2W9 Resident Account: Cameron J. Grimes Page 1 of 5
Date Item Descriot(on Amount B nc
4/18/2008 Medical - Private 200.00 200.00
4/28/2008 Room Charges 2,652.00 2,852.00
4/30/2008 Payment Received -2,852.00 . 0.00
5/1/2008 Room Charges 3,468.00 3,468.00
5/112008 Medical- Private 109.65 3,577.65
5/9/2008 Barber/Beauty 12.00 3,589.65
5/9/2008 Payment Received -12.00 3,577.65
5/17/2008 Payment Received -3,577.65 0100
5/18/2008 Room Charges-Bed Hold 11050.00 11050.00
5/31/2008 Payment Received -1,050.00 0.00
513112008 Interest on 4108 Charges 0.00 0.00
613012008 Interest on 5/08 Charges 0.00 0.00
7/112008 Co-Insurance 1,152.00 1,152.00
7/0/2008 Payment Received -1,152.00 0.00
7/10/2008 Co-Insurance 2,816.00 2,816.00
7/31/2008 Payment Received -2,816.00 0.00
713112008 Interest on 6108 Charges 0.00 0.00
8/1/2008 Barber/Beauty 12.00 12.00
8/1/2008 Co-Insurance 768.00 780.00
8/1/2008 Medical - Private 200.00 980.00
8/1/2008 Medical - Private 160.00 1,140.00
8/1/2008 Payment Received -12.00 1,128.00
8/6/2008 Payment Received -768.00 360.00
8/7/2008 Room Charges 5,250.00 5,610.00
8/31/2008 Payment Received -5,610.00 0.00
813112008 Interest on 7108 Charges 0.00 0.00
EXHIBIT "B"
5/26/2009 Resident Account: Cameron J. Grimes Page 2 of 5
9/1/2008 Medical - Private 200.00 200.00
9/1/2008 Medical - Private 16p.00 360.00
9/1/2008 Room Charges 6,300.00 6,660.00
9/30/2008 Payment Received -6,300.00 360.00
9/30/2008 Payment Received -360.00 0.00
-
913012008 Interest on 8108 Charges 0.00 0.00
_ _
10/1/2008 Medical - Private 160.00 160.00
_
10/1/2008 Medical - Private - 200.00 360.00
10/1/2008 Room Charges 6,510.00 6,870.00
10/13/2008 Barber/Beauty_ 12.00 6,882.00
10/13/2008 Payment Received -12.00 6,870.00
10/31/2008 Payment Received -6,510.00 360.00
10/31/2008 Payment Received -360.0
0 0.00
1013112008 _
interest on 9108 Charges _
0.00 0.00
11/1/2008 _
Medical - Private M _ 160.00 160.08
_
11/1/2008 Medcial - Private 200.00 360.00
_
11/1/2008 Room Charges 6,300.00 6,660.00
_
11/5/2008 Co-Pay- Medical Private _ 15.43 6,675.43
_
11/6/2008 Co-Pay- Medical Private 15.43 6,690.86
-
11/7/2008 Co-Pay- Medical Private 15.43 6,706.29
11/10/2008 Co-Pay- Medical Private 15.43 6,721.72
_
11/11/2008 Co-Pay- Medical Private 15.43 6,737.15
-
_
11/13/2008 Co-Pay- Medical Private 15.43 --? 6,752.58
1
11/17/2008 Co-Pay- Medical Private 15.43 6,768.01
11/19/2008 Co-Pay- Medical Private 15.43 6,783.44
11/20/2008 Co-Pay- Therapy - 13.31 6,796.75
11/20/2008 Co-Pay- Therapy 10.42 6,807.17
11/20/2008 Co-Pay- Therapy _ 5.42 6,812.59
11/20/2008 Co-Pay- Therapy _ 5.48 6,818.07
11/21/2008 Co-Pay- Therapy _ 5.48 6,823.55
_
11/21/2008 Co-Pay- Therapy 5.42 _ M 6,828.97
11/21/2008 Co-Pay- Therapy _ _ 5.21 6,834.18
11/21/
2008 Co-Pay- Medlcal Private 15.43 6,849.61
_
11/24/2008 Co-Pay- Medical Private 15.43 6,865.04
_
11/24/2008 Co-Pay- Therapy - 10.42 6,875.46
-
11/24/2008 Co-Pay- Therapy 5.42 6,880.88
V
11/24/2008 Co-Pay- Therapy 5.48 6,886.36
-
11/25/2008 Co-Pay- Therapy 5.48 6,891.84
_
11/25/2008 _
Co-Pay- Therapy 5.42 6,897.26
11/25/2008 Co-Pay-Therapy _ 10.42 6,907.68
11/26/2008 Co-Pay- Therapy 5.21 6,912.89
-
11/26/2008 Co-Pay- Medical Private 15.43 6,928.32
_
11/26/2008 Co-Pay- Therapy 5.42 6,933.74
11/26/2008 Co-Pay- Therapy 10.96 6,944.70
*Interest calculated at 1.5% per month or 18% per annum.
s,/26/2009 Resident Account: Cameron J. Grimes Page 3 of 5
11/28/2008 Co-Pay- Therapy _ 10.96 6,955.66
11/28/2008 Co-Pay- Therapy 5.42 6,961.08
11/28/2008 Co-Pay- Medical Private 15.43 6,976.51
11/28/2008 _ Co-Pay- Therapy 5.21 _
6,981.72
11/30/2008 _ Payment Received _ y -6,300.00 681.72
11/30/2008 Payment Received
- -360.00 321.72
1113012008 Interest on 10108 Charges 0.00 - 321.72
12/1/2008 Room Charges 6,510.00 6,831.72
12/1/2008 _ Co-Pay- Therapy _ 5.82 6,837.54
12/1/2_00_8 _ Co-Pay- Therapy 6.07 6,843.61
12/1/2008 Medical - Private
- Y - 200.00 7,043.61
12/1/2008 Lab
- 140.00 - - 7,183.61
12/1/2008 - _
Medclal - Private _ 160.00 7,343.61
12/1/2008 Co-Pay- Therapy 5.76 _
M 7,349.37
12/1/2008 Co-Pay- Medical Private 17.96 _
7,367.33
12/2/2008 Co-Pay- Medical Private 17.96 7,385.29
12/2/2008 Co-Pay- Therapy 5.76 _
r 7,391.05
12/2/2008
_ Co-Pay- Therapy 5.82 7,396.87
12/2/2008 Co-Pay-Therapy - - 12.14 7,409.01
12/3/2008 Co-Pay- Medical Private 17.96 _
7,426.97
12/3/2008 Co-Pay- Therapy 5.76 7,432.73
12/3/2008 Co-Pay- Therapy 12.14 7,444.87
12/4/2008 Co-Pay- Therapy 18.21 7,463.08
12/4/2008 Co-Pay- Therapy 5.76 7,468.84
12/5/200_8 Co-Pay- Therapy 6.07 7,474.91
12/5/2008 Co-Pay- Therapy _
5.82 7,480.73
12/5/2008 Co-Pay- Medical Private 17.96 7,498.69
12/5/2008 Co-Pay- Therapy 11.52 7,510.21
12/8/2008 _ Co-Pay- Medical Private 17.96 7,528.17
12/8/2008 Co-Pay- Therapy 5.76 7,533.93
12/8/2008 Co-Pay-Therapy _
12.14 7,546.07
12/9/2008 Co-Pay- Medical Private 17.96 7,564.03
12/9/2008 Co-Pay- Therapy 5.76 7,569.79
12/9/2008 _ Co-Pay-Therapy _ 5.82 7,575.61
12/9/2008 Co-Pay- Therapy ?- 6.07 -
7,581.68
12/10/2008 Co-Pay- Medical Private -
17.96 7,599.64
12/10/2008 Co-Pay-Therapy 5.76 _
7,605.40
12/10/2008 Co-Pay- Therapy - M
5.82 7,611.22
12/10/2008 Co-Pay- Therapy 6.07 7,617.29
12/11/2008 Co-pay- Medical Private 17.96 7,635.25
12/11/2008 Co-Pay- Therapy 5.82 7,641.07
12/11/2008
_
_, Co-Pay- Therapy 12.14 7,
653.21
.
.
12/12/2008 _..
Co-Pay- Medical Private 17.96 7,671.17
12/12/2008 [ Co-Pay-Therapy _
7777iW 7,676.93
*interest calculated at 1.5% per month or 18% per annum.
5/26/2009 Resident Account; Cameron J. Grimes Page 4 of 5
12/12/2008 Co-Pay- Therapy
? 5.82
- 7,682.75
12/12/2008 Co-Pay- Therapy - 12.14 _
_ 7,694.89
12/15/2008 T
-- Co-Pay- Medical Private _
17.96 7,712.85
12/15/2008 Barber/Beauty 12.00 _ 7,724.85
12/15/2008 - Co-Pay- Therapy 5.76 7,730.61
12/15/2008 Co-Pay- Therapy 5.82 7,736.43
12/15/2008 Co-Pay- Therapy 6.07 7,742.50
12/16/2008 Co-Pay- Medical Private 17.96 7,760.46
12/16/2008 Co-Pay- Therapy
_ - 5.76 7,766.22
12/16/2008 - - Co-Pay- Therapy 5.82 7,772.04
12/16/2008 _ Co-Pay- Therapy 12.14
^
- 7,784.18
12/17/2008 Co-Pay- Therapy
- 13.61
_
-` 7,797.79
12/17/2008 Co-Pay- Therapy 5.76 7,803.55
12/17/2008 Co-Pay- Therapy _ 5.82 7,809.37
12/17/2008 Co-Pay- Therapy 6.07 7,815.44
12/18/2008 Co-Pay- Medical Private 17.96 7,833.40
12/18/2008 Co-Pay- Therapy 5.76 7,839.16
12/18/2008 - Co-Pay- Therapy 5.82 - 7,844.98
12/18/2008
_ Co-Pay- Therapy 12.14 7,857.12
?-
12/19/2008 Co-Pay- Medical Private 17.96 7,875.08
12/19/2008 Co-Pay-Therapy __
5.76 7,880.84
12/19/2008 - Co-Pay- Therapy 5.82 7,886.66
12/19/2008 Co-Pay-Therapy 6.07 7,892.73
12/22/2008 Co-Pay- Medical Private
?- 17.96
M 7,910.69
12/22/2008 X Co-Pay-Therapy -- -
5.76 _ 7,916.45
-
12/22/2008 Co-Pay- Therapy
_ 5.82 7,922.27
12/22/2008 _ Co-Pay- Therapy 6.07 7,928.34
12/23/2008 Co-Pay- Medical Private 17.96 7,946.30
12/23/2008 Co-Pay- Therapy 5.76 7,952.06
12/23/2008 Co-Pay- Therapy 5.82 7,957.88
12/23/2008 Co-Pay- Therapy 6.07 7,963.95
12/24/2008 T Co-Pay- Medical Private 17.96 7,981.91
_
12/24/20
08 - Co-Pay- Therapy _ 5.76 7,987.67
_
12/24/2008 Co-Pay- Therapy 5.82 7,993.49
12/24/2008 _ Co-Pay- Therapy 12.14 8,005.63
12/26/2008 Co-Pay- Medical Private _ 17.96 8,023.59
12/26/2008 Co-Pay- Therapy _ Y 5.76 _ 8,029.35
v
12/26/2008 Co-Pay- Therapy 5.82 8,035.17
12/26/2008 Co-Pay- Therapy _ 12.14 8,047.31
12/28/2008 Co-Pay- Medical Private _ 17.96 8,065.27
12/29/2008 Co-Pay- Medical Private 17.96 8,083.23
12/29/2008 Co-Pay- Therapy 5.76 81088.99
12/29/2008 Co-Pay- Therapy 5.82 8,094.81
12/29/200$ _ Co-Pay- Therapy 12.14 8,106.95
*Interest calculated at 1.5% per month or 18% per annum.
5/26/2009 Resident Account: Cameron J. Grimes Page 5 of 5
12/29/2008 Payment Received -6_,510.00 1,596.95
12/30/2008 Co-Pay- Medical Private _ 17.96 1,614.91
_
12/30/2008 Co-Pay- Therapy 5.82 1,620.73
12/30/2008 Co-Pay- Therapy 18.21 1,638.94
12/31/2008 -
Co-Pay- Medical Private __ _ 17.96 _ 1,656.90
12/31/2008 Co-Pay- Therapy 5.76 1,662.66
12/31/2008 Co-Pay- Therapy 5.82 1,668.48
12/31/2008 Co-Pay- Therapy _ 6.07 1,674.55
-y
12131/2008 Interest on 11108 Charges 4.83 1,679.38
1/1/2009 Medical - Private 200.00
_ 1,879.38
1/1/2009 Medical - Private 160.00 2,039.38
1/5/2009 Co-Pay- Medical Private 17.96 2,057.34
1/6/2009 ?- Co-Pay- Medical Private 17.96 2,075.30
1/7/2009 Co-Pay- Medical Private _ 17.96 2,093.26
1/8/2009 Co-Pay- Medical Private 17.96 _
2,111.22
_
119/2009 Co-Pay- Medical Private 17.96 2,129.18
1/12/2009 Co-Pay- Medical Private 17.96 2,147.14
_
1/13/2009 Co-Pay- Medical Private
- - 17.96 2,165.10
-
_
1/14/2009 Co-Pay- Medica
I
Private -17.96 2,183.06
1/1/2009 ~-- _
_
Room Charges 6,090.00 -
8,273.06
1/30/2009 Barber/Beauty 12.00 - -
8,285.06
113012009 08 Charges
Interest on 121 20.30 8,305.36
212812009 _
Interest on 1/09 Charges 99.09 _ 8,404.45
Resident Total $8,404.45
*Total Resident
Account Balance
$8,280.23
*Total Interest on
Account $124.22
*Interest calculated at 1.5% per month or 18% per annum.
r-!5?
CF. 77
2^ s ll l 0 fir; J
CU /
i- yi'4Y 1F ? i.{
r?
Sheriff s Office of Cumberland County
R Thomas Kline
Sheriff ~ ~ f (~"~- r l ~~ ('~
~~~111p ~1. CC,11lil~~rr.~t ~ ~~'t:`~'a"~.tr ;T~Rs~
Ronny R Anderson w r~4
Chief Deputy L~~'D5 A~t~~ ~ ~ ~i`I ~~ ~ f
Jody S Smith
Civil Process Sergeant ~ C%U vi~:._ ~, ~. .~.Y
Edward L Schorpp ~ ~ ~'~ 4 r!
Solicitor
Perini Services/ South Hampton Manor, LP Case Number
vs.
Nancy L. Grimes 2009-3825
SHERIFF'S RETURN OF SERVICE
06/10/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and
inquiry for the within named defendant, to wit: Nancy L. Grimes, but was unable to locate her in his
bailiwick. He therefore deputized the Sheriff of Adams County, PA to serve the' within Complaint and
Notice according to law.
06/19/2009 05:50 PM -Adams County Return: And now June 18, 2009 at 1750 hours I, James W. Muller, Sheriff of
Adams County, Pennsylvania, do herby certify and return that I served a true copy of the within Complaint:
upon the within named defendant, to wit: Nancy L. Grimes by making known unto herself personally,
defendnant at 6 Cypress Trail Fairfield, PA 17320 its contents and at the same time handing to her
personally the said true and correct copy of the same.
SHERIFF COST: $37.00
August 14, 2009
SO ANSWERS,
,_
R THOMAS KLINE, SHERIFF
! • • i ~ • i • i ~ ~ ~ • i ! ~ ~
MASON DIXON BUSINESS FORMS, INC. 33000026
DATE RECEIVED DATE PROCESSED
SHERIFF' S DEPARTN~ENT
ADAMS COUNTY, PENNSYLVANIA
COURTHOUSE, GETTYSBURG, PA 17325
INSTRUCTIONS: See "INSTRUCTIONS FOR SERVICE OF PROCESS BY
SHERIFF SERVICE THE SHERIFF" on the reverse of the last (No. 5) copy of this form. Please
PROCESS RECEIPT, end AFFIDAVIT OF RETURN tYPe or print legibly, insuring readability of all copies.
Do not detach any copies. ACSD ENV.ar
i. rLArrvnrris/ 2. COURT NUMBER
PERINI SERVICES/SOUTH HAMPTON MANOR, L.P. 2009-3825 Civil Term
J. UCrCI`IVnrvl/J/ 4.'rYPE OF WRIT OR COMPLAINT:
NANCY L. GRIMES Complaint in Civil Action
SERVE o. wpm` yr rrvvivvur+~, i.vnnrArvr, I:VHrVMAI IUN, trG., TD SERVICE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED OR SOLD.
Nancy L. Grimes
6. ADDRESS (Street or RFD, Apartment No., City, Boro, Twp., State and ZIP CODE)
AT 6 Cypress Trail, Fairfield, PA
7. INDICATE UNUSUAL SERVICE: ^ PERSONAL ^ PERSON IN CHARGE ^ DEPUTIZE ^ CERT. MAIL ^ REGISTERED MAIL ^ POSTED ^ OTHER
Now, , I, SHERIFF OF ADAMS COUNTY, PA., do herelby deputize the Sheriff of
County to execute this Writ and make return therof accordiing to law. This deputation being
made at the request and risk of the plaintiff.
SHERIFF OF ADAMS COUNTY
6. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE.
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN-Any deputy sheriff levying upon or alttaching any property under within writ may leave
same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to
any plaintiff herein for any loss, destruction or removal of any such property before sheriN's sale thereof.
9. SIGNATURE of ATTORNEY or other ORIGINATOR requesting service on behyyalf of: 10. TELEPHONE NUMBER 11. DATE
David A. Baric Es LTPLAINTIFF
~ g' ^ DEFENDANT (717) 249-(1873
SPACE BELOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS LINE
12. I acknowledge receipt of the writ SIGNATURE of Authorized ACSD Deputy or Clerk and Title 1;1. Date Received 14. Expiration /7~Sg date
or complaint as indicated above.
_ JULY 10, 2009
15. I hereby CERTIFY and RETURN that I l~have personally served, ~] have served person in charge, ^ have legal evidence of service as shown in "Remarks" (on reverse)
^ have posted the above described property with the writ or complaint described on the individual, company, corporation, etc., at the address shown above or on the
individual, company, corporation, etc., at the address inserted below by handing/or Posting a TRUE and ATTESTED COPT/ therof.
16. U I hereby certify and return a NOT FOUND because I am unable to locate the individual, company, corporation, etc., Warned above. (See remarks below)
17. Name and title of individual served ts. a person of suitable age and discretion Read Order
Nancy L. Grimes then residing in the delendant's usual
__ place of abode. ^ ^
19. Address of where served (complete only if different than shown above) (Street or RFD, Apartment No., City, Boro, Twp., ~20. Date of Service 21. Time
State and ZIP CODE)
6/19/09 ~ 5:50PM
22. ATTEMPTS Date Mllea Dep.lnt. Date Mlles Dep.lnt. Dste Mlles Dep.lnt. Date Mlles Dep.lnt. Date Mlles Dep.lnt.
23. Advance Costs
~.,M
~ ~
g1f~Jff
'iw 24. 25. 26. 27. Total Costs
26XOT>~r}[1~FXai REFUND
•
•
Y $29.70 Pd. 8/13,/09 }~[ $70.30 Ck. #20701
AFFIRMED and subscribed to before me this
day
MY COMMISSION EXPIRES
I ACKNOWLEDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE
OF AUTHORIZED ISSUING AUTHORITY AND TITLE.
SO ANSWER.
Jason Trimmer
aY (l~oep~ (PI ~ Print or Type) _ ~. Date
Signature of Sfterift Date
JAMES W. MITLLEF; 6/19/2009
SHERIFF CIF ADAMS CCIUNTY
39. Date Received
33000926
{ } (1) The within
SHERIFF'S RETURN OF SERVICE
, the within named
defendant by mailing to
mail, return receipt requested, postage
prepaid, an the
a true and attested copy thereof at __
The return receipt signed by _ _
defendant an the
made a part of this return.
{ 2) Outside the Commonwealth, pursuant to Pa.
and attested copy thereof at
is hereto attached and
R.C.P. 405 (c) {1} (2), by mailing a true
in the fallowing manner:
( } (a} i:a the defendant by ( } registered ( ) certified mail, return receipt requested,
postage prepaid, addressee only on the ___ ~~_ __ ~_. _ _~_..
said receipt being returned NOT signed by defendant, but wsth a notation by the Postal Authorities
that Defendant refused to accept the same. The returned receipt and envelope is attached hereto
and made a part of this return.
And thereafter:
( ) (b} To the defendant by ordinary mai! addressed to defendant at same address, with the return
address of the Sheriff appearing therean, on the
! further certify that after fifteen (15) days from the mailing date, !have not received
said envelope back from the Postal Authorities. A certificate of mailing is hereto attached as a
proof of mailing.
{ } { 3 } 13y publication in the Adams County Legal Journal, a weekly publication of general circulation in
the County of Adams, Commonwealth of Pennsylvania, and the Gettysburg Times, a daily
newspaper published in the County of Adams, Commonwealth of Pennsylvania and having general
circulation in said County far _._._. __...__._~___ _..--_ ~.___ ~_._._. __.~._. _____...~
successive weeks of
__ .~ The Affidavi#s
#ram said Adams County Legal Journal and Get#ysburg Times, are hereto attached and made
part at this return.
{ } { 4 } ey mailing to
_ ~_~
by- _ mail, return receipt requested, postage prepaid,
a true and attested copy thereof at
an the __ _.__. _..
The
Authorities marked
is hereto attached,
returned by the Postal
( } (5 } other
In The Court of Common Pleas of Cumberland County, Pennsylvania
Perini Services/ South Hampton Manor, LP
vs.
Nancy L. Grimes
6 Cypress Trail
Fairfield, PA 17320
Civil No. 2009-3825
Now, June 10, 2009, I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of
Adams County to execute this Writ, this deputation being made at the request and risk of the Plaintiff.
ri~"~ine,,tt,,/ ~~.,rr.~
Sheriff of Cumberland County, PA
Affidavit of Service
Now, , 20 , at o'clock M, served the
within
upon
at
by handing to
a copy of the original
and made known to
Sworn and subscribed before
me this day of ,20
So answers,
the contents thereof.
Sheriff of
COSTS
SERVICE $
MILEAGE_
AFFIDAVIT
County, PA