HomeMy WebLinkAbout09-4170
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2009- 111-76 CIVIL TERM
EMILY R. GROVES,
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/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2009- yP70 CIVIL TERM
EMILY R. GROVES,
Defendant
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:
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, Emily R. Groves, is an adult individual with a residence address of 35
Country View Estates, Newville, Cumberland County, Pennsylvania 17241.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
4. On or about October 3, 2006, Emily R. Groves sought to be admitted to the
Shippensburg Health facility.
5. On or about October 3, 2006, Emily R. Groves executed an Admission Agreement
at the facility. A true and correct copy of a portion of the Admission Agreement is attached
hereto as Exhibit "A" and is incorporated. Upon information and belief the full Admission
Agreement was executed by the parties, however, Plaintiff has been unable to locate all pages of
the Admission Agreement.
6. Pursuant to the Admission Agreement, Emily R. Groves would be responsible to
pay any costs of care which were not covered by a third party payer.
7. On or about October 3, 2006, Emily R. Groves became a resident of the
Shippensburg Health facility and remained a resident to December 16, 2006.
8. As of the date of discharge, Emily R. Groves owed Shippensburg Health the sum
of $6,450.75 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 Emily R. Groves to pay the amount due for the costs
of care provided to her.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. EMILY R. GROVES
10. Plaintiff incorporates by reference paragraphs one through nine as though set forth
at length.
11. Emily R. Groves 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
$6,450.75 plus interest.
13. The accrued debt consists of the private pay obligation of Emily R. Groves.
14. The Admission Agreement bound Emily R. Groves 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 $2,709.28 as of May 31,
2009 and continue to accrue at the rate of $3.18 per diem.
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 Emily R. Groves for
the sum of $6,450.75 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
SHIPPENSBURG HEALTH v. EMILY R. GROVES
UNJUST ENRICHMENT
17. Plaintiff incorporates paragraphs one through seventeen as though set forth at
length herein.
18. Despite demand therefore, Emily R. Groves has failed and refused to pay the costs
of her care accruing during her residency at the facility.
19. Emily R. Groves has been unjustly enriched through her receipt of the care and
services provided without making payment therefore.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the
sum of $6,450.75, interest, costs and expenses and attorney fees.
Respectfully submitted,
N, BA C R
v '
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.d it/shcc/groves/complaint.pld
06/10/2009 16:49 7172495755 OBS PAGE 06
VEM
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which 1 have
given to my counsel, they are true and connect to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 p&C.S. §
4904 relating to unsworn falsifications to authorities.
DATE: _ Lod/??09
Deb Black
Business Office Coordinator
HEALTH CARE CENTER
121 Valnut Bottoia Road (717) X30-8300
SiliPpmbuxF. Penwivama ' FAX (717) 530-83104
17257-9005 ' 'M 1-800-654-5984
ADMISSION A WOMOM
This A rmwent is•between Shippensburg Ereaith Care Center (the `cFac'dity? .or "we"• a4
Emil (the "ReddeaC or "qou") and1 if you or the court have
deftGadd an individual to aet on your behalf or there is another individual to act on your
belu of operation Qf law, ("yourepreseutative"): A
dux' fist of the rights and esponsibMes applicable to your repres"tive is listed in Exhibit 1
and. is incorporated into this Agreement.
Pam for Your Care
1 7-1. are appt*g to this facility as a private••pay resident, you must provide all financial
fia4 aadon requested by us. • If we ltef find that the information you or your representative
provided' was incomplete or i accurate; we will consider that as a breach of this Agreement
which gives us the right to pursue all legal remedies against you or your representative.
'Who Can Be Reauired td Pay for Your Care
Only'yotr and your insurer can be required tb pay fur your care. No.other•FFerson, (Le. a family
member, frlend, neighbor, legal' representative or guardian) can be rediuured to pay from their
own fimds• for your care, although he or she may knowiWy and vo
ltiatarily agree to gtiraraatee
Payer for the cost of-Your care. We require the person responsible for making payments on
your behalf to pay for your care under the terms of this contract in a timely manner.
If ybu 'are a beneficiary of Medicare; Medicaid or any other third party payment plan, your
repres a agrees to m*e all necessary payments from your f=&. Your represetttatiye
could face a civil penalty for intentionally fulin' g to pay required amounts from your Bards and
could face a criminal penalty for abasing your funds,
Prr' ate Pay Residents
The items and services included in our daily rate is basic room, board and general nursing care as
requited by your medical condition. Payment for items and services that are. included in the
daily rate. and is payable one month. in advance and due on the first of each month. Items and
services included in your daily rate are listed in Exhibit 2A
You will be charged separa.•tely for additional items , and services not included in our daffy rates
such as special nursing care, 'special equipment, pharmacy charges, -laboratory charges, medical
iraasportatioa and additional services such as telephone expense, dry cleanink. beauty and barber
services-and newspapers. * Items find services for which you Will be charged are fisted in lit
2B. Payment for these additional item's and services are due after you have requested theme, and;
you have received and have'been bided for them. Witiun 30 days of receiving an item or service,
EXHIBIT "A"
If you or your representative do not pay the money you owe us and we hire a collection agency
or attomey, you agree to be liable for their fees and court costs.
private Duty Riarses Geriatric Aides
if you want a private duty nurse or a private &q geristrib aide,. You are responsible for selecting
a person licensed and/or •certi led according to Pennsylvania laws and regulations. You are also
responsible for paying b i14 or her and for letting us know that you have hired one. The person
you hire is not ati employee or agent of the facility, but he or she must meet our standards and
follow our policies and •procedures.. P..Mployees of the Faa'? maynot serve as private duty
nurses or privatd duty geriatric aide.
A dingy Your Bed if'You Leave the FacIIity
I£you are hospitalized or on leave from the Facility, we will hold yotar bed for. -you as follows:
A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medickre
Program (and you are not covered under Medicaid), unless you notify us otherwise, we
will hold your bed for as long as you pay for it at the daily rate you are curnntly being
charged.
B. If Medicaid pays for part or all of your ma ing bomb care and you need to be
hospitalized, we will hold your bed for up to the maximum number of days required by
this state, -a rently 15 days. If you leave for any other reasons we will hold your bed for
up to the maximum number of days required by this state, curready 18 days. You have a
right to be readmitted to the &c lity to the first available appropiiate bed. While we are
holding your bed, you are still required to pay the Facility any. amount for wbich you are
liable as determined by the Medicaid Program.
C. If you have applied for Medicaid, your bed will bd reserved in accordance with Paragraph
B. However, if you are found to be ineligible for Medicaid, then you are required to pay
for the bed as a private pay resident as described in Paragraph A-
D. Other third party payers may or may not have a bed hold policy. We will discuss this if it
applies to you.
As a musing home resident, you have many rights according to State and Federal law. These are
desmbed in detail in Exhibit 6, which is attached and is part of this Contract. .
You may make complaints about your care in the Facility and you may also suggest changes in
the policies and services of the Facility. You will not be harassed or discriminated against for
making a complaint or suggesting a change in a policy or service. You may present your
complaints to facility, management company or to one of the following State agencies:
Cynthia L. Hardman
Administrator
Shippensburg Health Care Center
121 Walnut Bottom Road
Shippensburg, PA 17257
717-530-8300
Ombudsman
Office of Aging
16 West High Street
Carlisle, PA 17013
717-240-6110
717-532-7286 Ext. 6110
Peter E. Perini, Sr.
President
Magnolia Management, Inc.
1710 Underpass Way
Hagerstown, MD 21740
301-745-8700
Department of Health
100 North Cameron Street
2°d Floor
Harrisburg, PA 17101
717-783-3790
Your Right to Make Decisions
You have the right to make your own medical decisions and to manage your personal affairs. If
you become disabled, it may be necessary for someone else to make decisions for you. For this
reason, we recommend tha you have a living will and/or advance directive for medical decisions
and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a
description of your legal rights to decide about your future medical treatment.
Transfer: Relocation and Discharge
You have the right to remain here, and you may not be transferred, relocated or discharged
against your will, except for the following reasons: (1) A medical reason (i.e. the facility can not
provide the kind of care that you need, your condition has improved so that you no longer need
the care that we provide, or a medical emergency arises; (2) Your welfare or the welfare of other
residents or staff; (3) Nonpayment for stay, or (4) the Facility ceases to operate.
If we decide that you should be transferred or discharged, we will notify you, and an immediate
family member or legal representative, by letter 30 days in advance. If you are transferred
because of an emergency situation, we will provide the required notice as soon as practicable.
The letter will contain the reasons for the transfer or discharge and its effective date. The letter
will also tell you how you can appeal our decision to transfer or discharge you.
If you are discharged involuntarily, we will attempt to make other appropriate arrangements for
your care. However, if other arrangements are not available, your representative agrees to accept
you in his or her custody if it is medically appropriate.
Your Right to End This Contract
If you decide to end this Contract and leave the Facility, you must pay your bill before you leave.
You must give us five (5) days written notice to terminate this contract. If you leave before the
end of that time, you must still pay for each day of the required notice.
I11. the event you die while a resident of the facility, your representative is responsible for making
the funeral arrangements. We will notify your representative immediately. If we are unable to
reach your representativeti we will contact the funeral home of your choice to. facnitate
iddidonal Documents
It is not possible to cover everything that is important to your, gay in our Facility in the body of
this Contract. Thereforey we have included additional important documents as Fxlubits. These
Exhbits are part of this Contract. Please'verify that you received the E*Jbits and that the
cotes of the Exhibits were explained to you by placing -your' initials ow the lane next to the
description of each Exhibit.
Exhibit 1. Rights and Obligations of Representatives.
Exhibit 2. For Private Pay Residents:
(a) Items and services covered by daily rate.
(b) Items and services not covered by daily rate.
Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits.
Exhubit 4. (a) Items and Services Covered by Medicaid.
(c) Items dnd Services Not Covered by Medicaid.
Exhibit 5. Physicians Who Practice at the Facility.
Exhibit 6. Legal Rights of Pennsylvania. to Decide Future Medical Treatment.
Exhibit 7. Policies and Procedures Coneerning Your Personal Funds and Your
Personal Property.
Exhibit 8. Services Provided by Outside Health Care Providers.
Changes in Y-aw
Any provision of this Contract that is found to be invalid or unenforceable as a result of a change
in State or Federal law will not invalidate the remaining provisions of this Contract If there are
services we have agreed to provide that are later found to be =possible to render as.a result of a
change in State or Federal law, it is agreed that to the extent possible, the Resident and the
Facility will continue to fulfill our respective obligations under this Contract cohdstent with the
law.
SHIPPENSBURG HEALTH CARE CENTER
PHOTOGRAPHIC RF FMF, FORM LJ + I I? `1 • C
(RESIDENT/FAMILY 1VIEMF3ER)
I. hereby provide. to Shippensburg Health Care Center Cshippensburg') my, consent (;Consent")
that all photogra*, videotapes or film. footage taken of, me and/or:mys.personal. belomgiags
and/or. recordiggs made of my, voice may be used by Shippensburg• orwits: affiliatesr for the
purposer of illustration, advertisiM,publication; promotion, orany?other.xmonr-,I.iindets d
that-this. Consent survives-my death. I further understand that this Consentiisrnot•xequired for the
photograph that-is taken for identification purposbs and placed in my.,modicalrecord+cha't.:..K
• Lo /3 O?
XANE:
(Signature) Date
mot'
,
(S a e) Date
ae,
Wit)
As a representative for the resident, I authorize the above Consent 101031o
NAI B: i?
(Signature) Date
'T (Print)
RELATIONSHM -
HEALTH CARE
CENTER
121 Walnut Bottom Road
Shippensburg, Pennsylvania
17257-9005
6/3/2009 Resident Account: EMILY R. GROVES
*Interest calculated at 1.5% per month or 18% per annum.
(717) 530-8300
FAX (717) 530-8304
Page 1 of 2
EXHIBIT "B"
6/3/2009 Resident Account: EMILY R. GROVES Page 2 of 2
913012007 Interest 96.76 7,321.59
1013012007 Interest 96.76 7,418.35
1113012007 Interest 96.76 7,515.11
1213012007 Interest 96.76 7,611.87
113012008 Interest 96.76 7,708.63
212812008 Interest 96.76 7,805.39
313012008 Interest 96.76 7,902.15
413012008 Interest 96.76 7,998.91
513012008 Interest 96.76 8,095.67
613012008 Interest 96.76 8,192.43
713012008 Interest 96.76 8,289.19
813012008 Interest 96.76 8,385.95
913012008 Interest 96.76 8,482.71
1013012008 Interest 96.76 8,579.47
1113012008 Interest 96.76 8,676.23
1213012008 Interest 96.76 8,772.99
113012009 Interest 96.76 8,869.75
212812009 Interest 96.76 8,966.51
313012009 Interest 96.76 9,063.27
413012009 Interest , 96.76 9,160.03
513012009 Interest 96.76 9,256.79
Resident Total $9,256.79
*Total Resident
Account Balance
$6,450.75
*Total Interest on
Account $2,806.04
*Interest calculated at 1.5% per month or 18% per annum.
nLU` a ?r
THE 7
lipy
G `'r y
Gf- /??
Sheriffs Office of Cumberland County
R Thomas Kline .$ tr 01 una?rr?? Edward L Schorpp
Sheriff Solicitor
r ? tir Ronny R Anderson Jody S Smith
Chief Deputy o"iCE OF THE L."ERirr Civil Process Sergeant
Perini Services/ South Hampton Manor, LP
Case Number
vs.
Emily R. Groves 2009-4170
SHERIFF'S RETURN OF SERVICE
06/27/2009 04:18 PM - 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: Emily R. Groves, but was unable to
locate her in his bailiwick. He therefore returns the within Complaint and Notice as not found as to the
defendant Emily R. Groves. Dorothy Smyser is the resident at 35 Country View Estates Newville, PA
17241 and believes the defendant is deceased. The Post Office has advised that mail is forwarded to 513
N. Pitt Street Carlisle, PA 17013. However, the tenant, Jessica Hartzel has never heard of Emily R.
Groves. An exact address is not available.
SHERIFF COST: $55.04
June 29, 2009
SO ANSWERS,
c rn
rn
x-
PERM SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
EMILY R. GROVES,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2009- 4170
CIVIL TERM
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
TRUE COPY FROM RECORD
In Testimony whereof, I here unto set my hand
and the seal of said Court at Carlisle, Pa.
This ........ IK.... day of..p,../..,r..?
7 Prothonotary
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
EMILY R. GROVES,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2009-
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, Emily R. Groves, is an adult individual with a residence address of 35
Country View Estates, Newville, Cumberland County, Pennsylvania 17241.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
4. On or about October 3, 2006, Emily R. Groves sought to be admitted to the
Shippensburg Health facility.
5. On or about October 3, 2006, Emily R. Groves executed an Admission Agreement
at the facility. A true and correct copy of a portion of the Admission Agreement is attached
hereto as Exhibit "A" and is incorporated. Upon information and belief the full Admission
Agreement was executed by the parties, however, Plaintiff has been unable to locate all pages of
the Admission Agreement.
6. Pursuant to the Admission Agreement, Emily R. Groves would be responsible to
pay any costs of care which were not covered by a third party payer.
7. On or about October 3, 2006, Emily R. Groves became a resident of the
Shippensburg Health facility and remained a resident to December 16, 2006.
8. As of the date of discharge, Emily R. Groves owed Shippensburg Health the sum
of $6,450.75 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 Emily R. Groves to pay the amount due for the costs
of care provided to her.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. EMILY R. GROVES
10. Plaintiff incorporates by reference paragraphs one through nine as though set forth
at length.
11. Emily R. Groves 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
$6,450.75 plus interest.
13. The accrued debt consists of the private pay obligation of Emily R. Groves.
14. The Admission Agreement bound Emily R. Groves 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 $2,709.28 as of May 31,
2009 and continue to accrue at the rate of $3.18 per diem.
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 Emily R. Groves for
the sum of $6,450.75 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
SHIPPENSBURG HEALTH v. EMILY R. GROVES
UNJUST ENRICHMENT
17. Plaintiff incorporates paragraphs one through seventeen as though set forth at
length herein.
18. Despite demand therefore, Emily R. Groves has failed and refused to pay the costs
of her care accruing during her residency at the facility.
19. Emily R. Groves has been unjustly enriched through her receipt of the care and
services provided without making payment therefore.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the
sum of $6,450.75, interest, costs and expenses and attorney fees.
Respectfully submitted,
3N, BC JR
v '
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/groves/complaint.pld
06/10/2009 16:49 7172495755 OBS PAGE 06
VERII?'I, CATYQN
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they are fte and correct to the best of my knowledge, inlbmwdon and
belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §
4904 relating to unsworn falsifications to authorities.
DATE: d?? la&?
Deb Black
Business Office Coordinator
HEALTH CARE CENTER
121 Vahrut Bottom Road
Sip?eosbutg; Pennsylvania
1' 7-9005'
(717) 530-8300
EAX (717) 530-830:4
Tff 1.800-654-5984
ADMISSION AGR
meat iA'betweea 8bippensburg au th Care Center (the "Fadlity -or "ave'x and)
(the `peddwe or "pcx') and; if you or the court have
dedmosAd an individual to set on your behalf of these i8 another in? to act on Y=
("Your, ?+giresve''?: A
o nights and ' '4s applicable to your repress is listed is wit 1
gild i$ incorporated into this Agreement.
Px & for Your Care
If you .are apptgng to this facft as a private-pay resident, you must Fuvide all financial
info naatian rbq mated by us.- If we Igter find dot the information you or your ,,%x 1o tive
pro'vided' WN ate or hzccdmtt? we will consider that as a breach of this Agreement
which gives us tho right to pursue all legal remedies against you or your repreaentatim
who Can Be a2mked to Pav for Your Care
Onlyyou and your inswer caa be required tb pay for your care. No.other . , (Le. a famay
member, fifend, neigbbor, legal- repmon wive or guardian) ban be ;eel Bred to pay fiom **
own fiords for your care, although he or she may lmowWy and vohmtarfiy agree to gtr ee
payment for the cost of your care. We require the person respona<ble for maUP Payments on
your behalf to pay for- yaw care under the terms ofthis coirtiact in a timely manner.
If ybu -are a beneficiary of Medicare, Medicaid or any otbw third pastY Payer Pla% Your
represemlatrve agrees td make all necmary payments from your funds. Your representative
'could fke a civil penalty for intentionally faft to pay required ainounts from your fiends and
could face a criminal penalty for- abusing your fiords.
Private Pao Resldeats
The items and services included in our daffy rate is bode room, board and gwrd met cam as
requited by your m}ediod condition. Payment for how and services -that am Adaded is the
daily rate.and is payable one month. in advance and due on the fast of each month. Rems and
services included in your daily raze are listed in Exhibit Z.A.
Yoi; will, be charged separately for additional items.and services not induded in our daffy rates
such at special nhaftg cares tpecial equipment, pharmacy charges, .tsbotatory charges, medical
transpoxtation and additional services such as telephone expensef dry cleamnX beauty and barber
samces•and newspapers. • Iteims and services for which you will be charged so lided in Emit
2B. Payaneat for 6=6 additional i'tem's and services are due after you have Muested them, and;
you have received and have been bled for them. Within 30 days of rig an item or service,
EXHIBIT "A"
If you or your represeataxive do not pay the money you owe us and we hire a collection agency
or attorney, you agree to be liable for their foes and count costs.
Private Daft Mlles Ce c ides
If you want a prh*e duty muse or a pnvate duty geriatrib aide,. you are responsible for selecting
a person licensed and/or •cerdfied according to Pennsylvania laws and repWim. You are also
resporusible for paying bim or her and for lofting us ]avow that you have hired one. The person
you bire is not an employee or agent of the Aci ty, but he or she must meet our standards and
follcyw our policies and procedures..Bmployees of the Fac ty may- not servo as private duty
mxrses?or private dusty geriatric aideb.
ad sour asea U x o u .Leave tae 1?agriCv
If you ate hospitalitod or on leave ttom the Facility, we will hold your bbd. for you as EDRows.
A. If you are private-pay resident, or arc rooeiving inpatumt care reimbursed under
Program (and you are not covered under Medicaid), unless you nq* us o*e wise, we
wW hold your bed for as long as you pay for it at the daily rate you are aarentty being
di rg
B. If Medicaid pays for part or all of your nursing h6me we and you need to be
hospitalized, we will hold your bed fur up to the maximum. number of days required by
this datN -currently 15 days. If you leave for any other reason, wee will hold your bed for
up to the ma7rimum number of days required by this state, cu lady 18 days. You have a
right to be readmitted to the facility to the first available approptWe bed. We we are
holding your bed, you are stilt required to pay the Facility any. amount for vtirich you ate
liable w determined by the Medicaid Prograar.
C. Ifyou have applied for Medicaid, your bed will be reserved in accordance with Paragraph
B. However, if you are found to be ineligible for Medicaid, then you are required to pay
for the bed as a private pay resident as described in Paragraph A.
D. Other third party payers may or may not have a becl hold policy. We will discuss this if it
applies to you.
Your ltinht to Wake Complaints and Supirest Chances in PoUdes and Services
As a nursing home resident, you have many rights acqordmg to State and Federal law. These are
deem'bed in detail in Exhibit 6, which is attached std is part of this Contract.
You may make complaints about your care in the Facility and you may also sup,geat changes in
lba policies and services of the Faa'lity. You will not be harassed or discriminated ageing for
making a complaint or suggesting a change in a policy or servos. You may present your
complaints to f mil", management company or to one of the following State ageccier
Cynibia L. Hartman
Administrator
Shippensburg Health Care Center
121 Walnut Bottom Road
Shippensburg, PA 17257
717-530-8300
Ombudsman
Office of Aging
16 West High Street
Carlisle, PA 17013
717-240-6110
717-532-7286 Ext. 6110
Peter E. Perini, Sr.
President
Magnolia Management, Inc.
1710 Underpass Way
Hagestowa, MD 21740
301-745-8700
Department of Health
100 North Cameron Street
2°d Floor
Harrisburg, PA 17101
717-783-3790
Your Right p M.ah Decisions
You have the right to matte your own medical decisions and to manage your personal affairs. If
you become disabled, it any be necessary for someone else to make decisions for you. For this
reason, we r4oommend ft you have a living will and/or advance directive for medical decisions
and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a
description of your legal right's to decide about your future medical treatment.
Truster: Relocation and Discharge
You have the right to remain here, and you may not be transfenred, relocated or discharged
against your will, except for the following reasons; (1) A medical reason (i.e. the facility can not
provide the kind of care that you need, your condition has improved so that you no longer need
the care that we provide, or a medical emergency arises; (2) Your welfare or the welfare of other
residents or staf (3) Nonpayment for stay, or (4) the Facility ceases to operate.
If we decide that you should be transferred or discharged, we will notify you, and an immediate
family member or legal representative, by letter 30 days in advance. If you are transfened
because. of an emergency situation, we will provide the required notice as soon as practicable.
The letter will contain the reasons for the transfer or discharge and its effective daze. The letter
will also tell you how you can appeal our decision to transfer or discharge you.
If you are discharged involuntarily, we will attempt to make other appropriate arrangements for
your care. However, if other arrangements are not available, your representative agrees to accept
you in his or her custody if it is medically appropriate.
Your B,iaht to End Contract
If you decide to and this Contract and leave the Facility, you must pay your bill before you leave.
You must give us five (5) days written notice to terminate this contract. If you leave before the
end of that time, you must still pay for each day of the required notice.
In the evert you die while a resident of the Acidity, yoiu' inpi cro is responsible for making
the hzend arrangemeats. We wM notify your representative u a*. If we are unable to
reach your repr ativey we wi'tl bontict the Smeral home of your choice to. fan-litate
rgqn.
Aeldl[tioa:l Docamenfs .
It is not poste to cover everyWng that is important to your'stay in our Facility in the body of
ft Contract. Therefore, we have mcladed additional important doc umeaW as Fahibita. These
bits are part of this Contract. Please "verify that you received the Hd*b and that the
conbmts of the Exhibits were explained to ybu by placing - Your - h0dals on- the line-nest to the
description of each D&Ut.
Exhibit 1. Rights and Obligations ofRWesentatives.
Exhibit 2. For Private Pay Residents:
(a) Items and services covered by daily rate.
(b) Items and services not covered by daily rate.
Exhibit 3. How to Apply For and Use Medicare and Medicaid Bets.
f
Extnbit 4. (a) Items arid Services Covered by M,edic0d.
(c) Items and Services Not Covered by Medicaid.
Eat 1U 5. Physicians Who Practice at the Faca'h'ty.
Exhibit 6. Legal Rights ofPeuusylvarhto Decide FuN a Medical Treatment.
Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your
Personal Property.
Bxhibit 8. Services Provided by Outside Health Cate Providers.
gin= in "W
Any Provision Qf this Contract that is found to be invalid or unenforceable as a result of a change
in. State or Federal law will not invabdate the remAiniag provisions of this Contract If there are
services we have agreed to provide that are later found to be impossible to render as -a result of a
change is State or Federal law, it is agreed that to the extent possible, the Resided and the
Facsb'ty will continue to fulfill our respective obligations under this Contract consistent with the
taw.
SHTPPENS'BURG HEALTH CARE CENTER
PHOTOGRAPHIC RELEASE FORM Fj-niI l - Gl?
(RBSEDERMAMILY MMER)
Phereby provider to Shippensburg Health Care Center CShippenkurg" -) my, consent (Xmsear)
thaV, ill phatogmPlis, videotapes or film. footage taken of me•anftr:*kpearsonal. beloq pip
and/or. reconfixo made of my, voice may be used by Sbippeasburg- ov.iWaffliates4'or the
ptuposer of ill station, a hwhs'io& -publcrdon? promotion, or any, other•jAason,.-4 indmt9xd
tbat d6.Consent mh-4ves•my death. I further understand.that.this Conser isrnotxe *edfiw the
r photograph that.is taken for identification purposes and planed in my:medliaWYacardii am it. wN
4?? - A,
NAME:
L°% o?
Signature) Date
(S e) Date
Otte-
(]Print)
As a representative for the resident, I authorize the above Consent. "1 031,3;
NAME; Y. E._
(Signature) Date
(Print)
RELATIONSHIP:
11? •
HEALTH CARE CENTER
6/3/2009
121 Walnut Bottom Road
Shippensburg, Pennsylvania
17257-9005
(717) 530-8300
FAX (717) 530-8304
Page 1 of 2
Resident Account: EMILY R. GROVES
29& Item Descriution Amount BAIA=
10/23/2006 Co-Insurance 1 day 119.00 119.00
10/24/2006 Co-insurance 8 days 952.00 1,071.00
11/1/2006 Co-Insurance 1 day 119.00 1,190.00
11/2/2006 Co-Insurance 29 days 3,451.00 4,641.00
11/6/2006 Barber/Beauty 8.25 4,649.25
1113012006 Interest (10106 Charges) 16.07 4,665.32
12/1/2006 Co-Insurance 1 day 119.00 4,784.32
12/2/2006 Co-Insurance 14 days 1,666.00 6,450.32
12/4/2006 Barber/Beauty 8.25 6,458.57
12/11/2006 Barber/Beauty 8.25 6,466.82
1213012006 Interest (11106 Charges) 53.67 6,520.49
113012007 Interest (12106 Charges) 27.02 6,547.5],
212812007 Interest 96.76 6,644.27
313012007 Interest 96.76 6,741.03
413012007 - Interest 96.76 6,837.79
513012007 Interest 96.76 6,934.55
613012007 Interest 96.76 7,031.31
713012007 interest 96.76 7,128.07
813012007 Interest 96.76 7,224.83
*Interest calculated at 1.5% per month or 18% per annum.
11
EXHIBIT "B"
6/332009 Resident Account: EMILY R. GROVES Page 2 of 2
913012007 Interest 96.76 7,321.59
1013012007 Interest 96.76 7,418.35
1113012007 Interest 96.76 7,515.11
1213012007 Interest 96.76 7,611.87
113012008 Interest 96.76 7,708.63
212812008 Interest 96.76 7,805.39
313012008 Interest 96.76 7,902.15
413012008 Interest 96.76 7;998.91
513012008 Interest 96.76 8,095.67
613012008 Interest 96-76 8,192.43
713012008 Interest 96.76 8,289.19
813012008 Interest 96.76 8,385.95
913012008 Interest 1 96.76 8,482.71
1013012008 Interest 96.76 8,579.47
1113012008 Interest 96.76 8,676.23
1213012008 Interest 96-76 8,772.99
1/30/2009 Interest 96.76 8,869.75
212812009 Interest 96.76 8,966.51
313012009 Interest 96.76 9,063.27
413012009 Interest , 96.76 9,160.03
513012009 Interest 96.76 9,256.79
Resident Total $9,256.79
*Total Resident
Account Balance
$6,450.75
*Total interest on
Account $2,806.04
*Interest calculated at 1.5% per month or 18% per annum.
G :? V 1 "Ill, bH-z