HomeMy WebLinkAbout09-4200IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC
d/b/a FOREST PARK CENTER,
Plaintiff,
V.
MARK LEINAWEAVER,
Defendant.
COMPLAINT
No. 0q-t4-200 0'-waT"'M
CIVIL ACTION - EQUITY
AND NOW, COMES, Plaintiff, Guardian Elder Care Home and Community
Services, LLC d/b/a Forest Park Health Center ("Plaintiff"), by and through its
attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant,
Mark Leinaweaver ("Defendant"), and in support thereof, provides as follows:
1. Plaintiff is a domestic limited liability corporation, with its principle place
of business located at 1217 Slate Hill Road, Camp Hill, Pennsylvania 17011.
2. Defendant is an adult individual who currently resides at 1275 Creek
Road, Mechanicsburg, Pennsylvania, 17055.
3. On or about January 12, 2009, Defendant made application for the
admission of his mother, Mildred Leinaweaver ("Mrs. Leinaweaver"), to Plaintiff's
skilled nursing facility.
ORIGINAL
4. Plaintiff and Defendant entered into a written Admission Agreement
("Agreement"), pursuant to which Plaintiff agreed to provide Mrs. Leinaweaver with
skilled nursing services in exchange for Defendant's promise to pay a specific monetary
fee and the assignment to Plaintiff of Mrs. Leinaweaver's right to apply for and obtain
Medical Assistance benefits in the event that she became insolvent. In furtherance of
that assignment, Defendant agreed to assign Plaintiff, "all of Resident's rights to any
third-party payments now or subsequently payable to the extent of all charges due
under this Agreement" and to "cooperate fully" in securing those benefits. A true and
correct copy of the Agreement is attached hereto as Exhibit "A."
5. After Mrs. Leinaweaver became a resident of Plaintiff's skilled nursing
facility, she apparently became insolvent. As a result, pursuant to the Agreement,
Plaintiff notified Defendant that he needed to apply for Medical Assistance benefits,
and an application for Medical Assistance benefits subsequently was filed.
6. The application for Medical Assistance benefits was denied April 3, 2009,
because Defendant failed to spend down excess resources and did not provide the
information and documentation required by the Cumberland County Assistance Office
("CAO") in order to secure Medical Assistance benefits. See PA-162 attached hereto as
Exhibit "B."
7. Plaintiff has filed an appeal of this denial. However, if Defendant fails to
take the steps necessary to qualify his mother for Medical Assistance benefits, the
application will fail and Plaintiff will be precluded from receiving the Medical
Assistance benefits that have been contractually assigned to it.
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COUNTI
BREACH OF CONTRACT/ SPECIFIC PERFORMANCE
8. The allegations contained in Paragraphs 1 through 7 are incorporated
herein by reference as if fully set forth at length.
9. Defendant breached his Agreement with Plaintiff by failing to act in
accordance with the terms of the same, as he has failed to complete a spend down of
Mrs. Leinaweaver's excess resources and provide necessary documentation required to
process and approve Mrs. Leinaweaver's application for Medical Assistance benefits.
By doing so, Defendant has interfered with Plaintiff's right to receive Medical benefits
that have been contractually assigned to it.
10. The law is clear that an "assignee stands in the shoes of the assignor and
assumes the rights of the assignor." Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa.
1997).
11. As Defendant failed to provide the necessary documentation to the CAO
required to qualify Mrs. Leinaweaver for Medicaid benefits, Plaintiff is precluded from
exercising its rights under the Assignment Clause.
12. Upon information and belief, at all times material hereto, Mrs.
Leinaweaver has been financially unable to fully compensate Plaintiff for the services
that it has rendered and continues to render to her in accordance with the terms and
conditions of the Agreement.
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13. Defendant's breach of his Agreement with Plaintiff has irreparably
harmed Plaintiff.
14. Only a decree of specific performance will adequately protect the interests
of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders
specific performance of the Agreement between the parties.
Respectfully submitted,
SCHUTJER BOGAR LLC
7J o
Dated: G By:
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Anthony T. Lucido
Attorney I.D. No. 76583
(717) 909-0353
Arandon S. Williams
Attorney I.D. No. 200713
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
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VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing
document are true and correct to the best of my knowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C. S. § 4904, relating to unworn falsification to authorities.
Dated:
Dawn Jordan
Billing and Collections Coordinator
Guardian Elder Care
5
EXHIBIT "A"
GUARDIAN ELDER CARE
NURSING CARE ADMISSION AGREEMENT
This Nursing Care APT?,e.,mAent is made by and between Guardian Elder Care
(hereinafter called "Facility") , LZ1 . (hereinafter
called "Resident"),ZL" (hereinafter called
"Financial- Responsible Persoand (if any)
(-z)-t7' z I-- ?/? • (hereinafter called "Health Care Responsible
Person").
Resident, Financial Responsible Person, and Health Care Rc,.:ponsible Person (if
any) affirm that the information provided in all admission documents is true and
correct to the best of their knowledge, and acknowledge that the submission of any false
information and/or omission of material information may result in the termination of
this Agreement and personal financial liability, including attorney fee's, costs, interest
and lost revenue.
Therefore, Facility, Resident, Financial Responsible Person and Health Care
Responsible Person agree to the following terms and conditions:
1. PROVISION OF SERVICES.
1.1 Nursing Services. Beginning on the
designated admission date, Facility will provide Resident with (a) the routing nursing
services described in the Rate Schedule.. attached to this Agreement and incorporated by
reference; (b) private or L-"' semi-private accommodations; (c) three meals
each day and snatks, except as otherwise medically indicated; (d) blankets, bed linens,
towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services;
(g) activity progr«ms and social services as established by Facility; (h) routine personal
laundry; (i) hospital gowns and routine surgical dressings; and (j) certain type of over
the counter medications as provided by law. Not included in the daily rate are
intravenous services and supplies; oxygen and supplies; inca.-Itinence products;
ambulance costs; physician fees; most pharmaceutical drugs; personal dry cleaning;
medical tests; laboratory tests; private telephone/ services or t&_-vision; x-rays; or
special nursing supplies not considered routine.
1.2 Ancillary Services. Facility will provide ancillary services
identified in the Admission Package of information provided prior to or at the time of
admission at the option and upon the request of the Resident, or upon the direction of
Resident's treath* physician or Facility's. Medical Director. The ancillary services and
associated charge's are identified in the Admission Package of information and are
subject to change 11t the-discretion of Facility.
Rc?idertt/f:espnrtsihle ['•?r11•...'?? ?...?' ._ ._._
1.3 Services of Other Providers. The services of outside providers
such as a licensed physician, dentist, licensed pharmacy for : the provision of
pharmaceutical supplies, a licensed hospital, diagnostic services, laboratory, x-ray,
podiatry, optometry, medications, ambulance services and hearing aid repair may be
available from time to time at the Facility. These services are available under guidelines
and procedures established by Facility and may be utilized by Resident at his or her
own expense. Resident may choose to utilize providers of his or her own choice;
however, the services and goods provided must meet the standards established by
Facility.
1.4 Role of Primary Medical Physician and Medical Director. The
Resident shall obtain the services of a qualified physician who will provide medical care
during the resident's stay at Facility. The Resident's physician is an independent
licensed professional who is not an employee of the Facility but who shall comply with
Facility's rules, regulations, policies and procedures. Facility is not obligated to provide
Resident with any medicines, treatments, special diets or equipment without specific
orders or directions from Resident's Primary Medical Physician. 11.1 the event Resident's
personal physician is unavailable, Facility's Medical Director may issue appropriate
orders. Resident is responsible to pay for all services or equipment ordered by
Resident's Primary Medical Physician or Facility's Medical Director for Resident's care.
2. CHARGES.
'2.1 Recurring/Periodic Charges for Routine Nursing Services.
Resident shall pay the Basic Daily Rate, specified in the rate schedule in effect at the
time the service is rendered, for routine nursing services provided to Resident. The
Basic Daily Rate may be changed from time-to-time in accordance with the provisions
of Section 3.3. Charges for a resident whose payor source is other than Medicare Part A
or Medical Assistance will begin on the designated admission date or actual ad.rnission,
whichever is sooner; charges for a resident whose payor source is Medicare Part A or
Medical Assistance will begin no sooner than the date of admission. (The term "Medical
Assistance" is a reference to Pennsylvania's Medicaid program.)
2.2 Additional Charges for Ancillary Services. Resident shall pay for
other services and supplies provided by or through the Facility, whch are not covered
by the Basic Daily Rate as set forth in the Admission Package of information provided
prior to or at the time of admission and in effect at the time such ancillary services are
rendered. '
2.3 Charges for Outside and Non-Facility Services. In addition to
Facility's charges, Resident shall pay all fees and costs for goods or services furnished to
or for Resident by anyone other than Facility as described in Subsection 1.4 (Role of
Primary Medical Physician and Medical Director) unless otherwise. covered in full by
Medicare or Medical Assistance or another third-party payor. Resident or Responsible
Person is obligated to- pay such fees and costs whether the goods and services are
i
2 resident/ Responsible Party ?------
r
furnished by a person or provider made available by Facility, or by a person or provider
selected by Resident, and whether the goods or services are provided at Facility or
elsewhere. These fees and costs are not included in the Basic Daily Rate. Fees for
professional services rendered by a physician are not included in the Basic Daily Rate
and will be charged directly to the Resident by the physician.
3. PERIODIC BILLINGS AND PAYMENT DUE DATE.
3.1 Monthly Statements and Other Billings. When permitted by law,
prepayment for the basic monthly rate of the current month is required at the time of
admission. Facility will mail to Resident or Financial Responsible Person at the
beginning of each month a billing statement reflecting charges for nursing services for
the upcoming month and charges for ancillary services and supplies, which 'were
incurred in the prior month. Statements are due and payable on receipt. All payments
shall be directed to:
GUARDIAN LTC MANAGEMENT INC.
PO BOX 240
BROCKWAY, PA 15824
3.2 Late Charges and Cost of Collection. Any invoices not paid
within thirty (30) days of the date of the invoice are subject to a late:charge of one and
one-half percent (1.50%) per month, for the annual rate of eighteen percent (18%), and
Resident or Financial Responsible Person is obligated to pay any late charges. In the
event Facility `initiates any legal actions or proceedings to collect payments due from
Resident under this Agreement; Resident or Financial Responsible Person shall be
responsible to pay all attorney's fees, costs, interest and lost revenue incurred by
Facility in pursuing the enforcement of Resident and/or Financial Responsible person's
obligations under this Agreement.
3.3 Modification of Charges. Facility reserves the right to
change the Room Rate Schedule reflecting the amount of any of its charges or
how and 'when charges are computed, billed or become due. Facifity shall
provide thirty (30) days advance written notice of any such changes.
3.4 Obligations of Resident's Estate and Assigni?ient of Property.
Resident and Financial Responsible Person acknowledge that the charges for services
provided under this Agreement and any and all costs incurred by Facility to enforce
this Agreement remain due and payable until fully satisfied. In the event of Resident's
discharge for any reason, including death, this, Agreement shall operate as an
assignment, transfer and conveyance to Facility of so much of Resident's property as is
equal in value to the amount of any unpaid obligations under this Agreement. This
assignment shall bean obligation of Resident's estate and may be enforced against
Resident's estate. Resident's estate shall be liable to and. shall pay to '-acility an amount
equivalent to any unpaid obligations of Resident under this Agreement.
v
3 Resident/Resparuihlcparty._. ?' ?
4. OBLIGATIONS OF FINANCIAL RESPONSIBLE PERSON.
4.1 General. Resident shall have the right to identify a Health Care
Responsible Person (usually this person is the Resident's Power of Attorney or
Guardian of his or her Person), who shall be entitled to receive nofice in the event of
transfer or discharge or material changes in the Resident's condition, and changes to the
Admission Agreement. Resident is not required to name a Health Care Responsible
Person. Resident elects to name Yl?t_?s ; z ?7?6 ra?. f r _ _ as 1,,i&/ her
Health Care Responsible Person. Resident shall identify a Financial Responsible Person
(usually this person is the Resident's Financial Power of Attorney or Guardian of
W-j/her Estate) at the time of admission. Resident elects to name-.
A as Wher Financial Responsible Person.
Resident's Financial Responsible Person shall sign this Agreement iri' recognition of this
designation with the intent to be legally bound by all provisions in this Agreement. The
Financial Responsible Person shall be obligated to fulfill the financial.:duties on behalf of
the Resident imposed by this Agreement. The Facility may petition court to appoint a
Guardian and take other legal action if Facility reasonably believes that the Resident's
needs are not being properly met or the duties imposed by this Agreement are not
being fulfilled by either the Health Care or Financial Responsible Person. Resident,
Resident's estate, or Health Care or Financial Responsible Person shall pay the cost of
such Guardianship proceedings, including attorneys' fees.
4.2 - Obligations and Potential Liability. This Agreement sh31I not be
construed or operate as a third party guaranty. Financial Responsible Person is
obligated to pay Facility from Resident's financial resources for services and supplies
provided to Resident in accordance with this Agreement. If the Financial Responsible
Person has previously transferred, converted and/or withholds dr misappropriates
Resident's financial resources for personal benefit or gifts, or otherwise has not or does
not use the Resident's financial resources to fulfill Resident's financial obligations to the
Facility for services and supplies provided to Resident in accordance with this
Agreement, then Financial Responsible Person shall be liable for payment up to the
value of the misused or misappropriated property. Financial Responsible Person is also
obligated to pay Facility for all losses or damages incurred by Facility by the failure of
the Financial Responsible Person to fulfill his/her duties under this Agreement. Failure
to do so will result in legal action or other proceedings consistent with this Agreement
by Facility to assure payment for amounts that are Resident's obligations. In the event
Facility initiates any legal actions or proceedings to collect pay?nents:due from Resident
and/or Financial Responsible Person under this Agreement, or to enforce Responsible
Person's obligations under this Agreement and/or the Responsible Person Agreement,
then Resident and Financial Responsible Person shall pay all damages, attorney's fees
and costs incurred by Facility in pursuing the enforcement of Resident's and/or
Financial Responsible Person's financial or other obligations under this Agreement.
Such damages, fees and costs may include, in the discretion of
f=acility, an amount equivalent to revenue lost by Facility due to Financial Responsible
4 Resident/Responsible Hart'.
Person's failure to timely submit or complete a Medical Assistance application or to
cooperate with the Pennsylvania Department of Public Welfare (hereinafter "DI'W") in
the Medical Assistance eligibility determination. The failure to,. initiate, make or
complete the Medical Assistance application process on the Resident's behalf may result
in the discharge of Resident for non-payment and personal liability to Financial
Responsible Person for losses incurred by Facility for Financial Responsible Person's
failure to apply timely for Medical Assistance benefits. Facility reserves the right to
assist Financial Responsible Person in making application for Medical Assistance. If
Facility, in its sole discretion, however, decides to assist the Financial Responsible
Person in the Medical Assistance application process, Resident and the Financial
Responsible Person are still fully obligated to initiate, make and complete the Medical
Assistance application. The Facility's assistance in the Medical Assistance application
process does not waive resident's or Financial Responsible .Person's duty or
responsibility to timely complete and submit a Medical Assistance application if the
Resident's financial resources become insufficient to pay amounts due under this
Agreement. When Financial Responsible Person makes application for Medical
Assistance benefits, Financial Responsible Person shall assign the Patient Pay amount to
the Facility as estimated by Facility and County Assistance Office in accordance with
DPW Regulations. See Section 5.3. If Resident is determined to be ineligible for Medical
Assistance because Financial Responsible Person fails to provide or submit necessary
documents or fails to appeal timely so that Facility is unable to obtain Medical
Assistance reimbursement, then Facility may terminate this Agreement for non-
payment of stay, and Financial Responsible Person shall be liable for any losses,
including attorney's fees, costs, interest and lost revenue, sustained by the Facility as a
result of such failure. Financial Responsible Person shall be responsible for compliance
with all other applicable terms of this Agreement.
5. r%4EDICARF,/MEDICAL ASSISTANCE PROGRAMS.
5.1 Participation in Programs. Facility currently participates in the
Pennsylvania Medicaid program ("Medical Assistance") and the federal Medicare
program. Facility reserves the right to withdraw from the Medical Assistance or
Medicare programs at any time in accordance with law.
5.2 Actions of Medical Assistance and Medicare Agencies. The
Pennsylvania Department of Public Welfare ("DPW") is responsiblrr for administering
benefits under the Medical Assistance program. The Centers for Medicare and Medical
Assistance Services ("CMS"), of the United States Department of Heath and Human
Services, is responsible for administering the Medicare program through an
intermediary. Resident and Financial Responsible Person acknowledge that Facility is
not responsible for, and has made no representations regarding, the actions or decisions
of DPW, CMS or the Medicare intermediary in administering the profxams.
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5.3 Medical Assistance Benefits.
(a) Obligations of Resident. Resident is obligated to make full
and complete disclosure regarding all financial resources and income during the
application process, including all transfers of assets and/or financial resources having
taken place within the preceding five years of the .date of application for admission to
Facility. Failure to identify all resources, income, and transfers or the submission of
false information may result in the termination of this Agreement and financial liability.
Resident and/or Financial Responsible Person is obligated to notify.Facility when only
Fifteen Thousand Dollars ($15,000), or the value thereof, exists to satisfy the Resident's
financial obligations under this Agreement. Resident is obligated to apply for Medical
Assistance benefits at such time as Resident's resources will no longer be sufficient to
pay all Facility charges for Resident's care and stay.
(b) Patient Pay Amount. For residents approved for Medical
Assistance benefits, Facility will accept payment from DPW and; if applicable, the
Resident's Patient, Pay Amount as determined by DPW as payment in full only for those
services covered by the Medical Assistance program. During the period of time that the
application for Medical Assistance benefits is pending, Resident and/or Financial
Responsible Person is obligated to assign such Patient Pay Amount as estimated by
Facility and the Local County Assistance Office, less any qualified medical expense
deductions, on a monthly basis at the time of application for Medical Assistance
benefits. Services not covered by Medical Assistance are identified in the Medicaid
Handout, and Resident remains obligated to pay for such services.
(c) Determination of Eli ibility. Resident and Financial
Responsible Person are obligated to cooperate fully in any Medical Assistance eligibility
determination or redetermination process. In the event that Resident's eligibility for
Medical Assistance benefits is denied, interrupted or terminated due to the failure of
Resident or Financial Responsible Person to cooperate in the Medical Assistance
application, redetermination or appeal process, the Resident and Financial Responsible
Person shall be liable for the applicable Basic Daily Rate plus charges for ancillary
services and supplies, during any period of noh-payment.
(d) Authorization to Apply for and/or Appeal (Medical
Assistance). In the event of Resident's incapacity and in situations where Resident's
resources are depleted or appear to be depleted to the extent that Resident can no
longer pay privately for nursing care, and it appears that Resident has become or will
become eligible for Medical Assistance benefits to cover the cost of Resident's continued
stay in the Facility; and if there is no other legal representative of Resident known to the
Facility or other friend or relative known to the Facility who is authorized and/or is
available or willing to act on Resid*ent's behalf, after the Facility has made a good faith
effort to identify such persons; then Resident hereby authorizes the Facility to request,
file and/or apply for Medical Assistance benefits on behalf of Resident for the limited
purpose of assisting Resident to secure payment through the Medical Assistance
6 Residenl/Responsible Piny -11._.?_ L
program for Resident's continued stay in the Facility. In the event the application for
Medical Assistance benefits filed on behalf of the Resident is denied, or in the event
Medical Assistance benefits are granted and subsequently discontinued, Resident
hereby authorizes the Facility to file on Resident's behalf an appeal of any such denial
of Medical Assistance eligibility or discontinuance of Medical Assistance benefits, and
to take such actions to secure Resident's Medical Assistance benefits as the Facility
deems reasonably necessary or appropriate and consistent with law. Resident warrants
and represents that the financial information disclosed in the admission documents is
true and accurate and may be relied on by the Facility in pursuing Medical Assistance
benefits on behalf of Resident.
5.4 Medicare Part A and. Part B Benefits. To the extent that Resident is
a beneficiary- under either Medicare Part A or Medicare Part B (insurance and the
nursing services or ancillary services or supplies ordered by a physician are covered by
such insurance, the Facility or other provider will bill the charges for the covered
services or supplies to the Medicare program. The Resident is responsible for and shall
pay any co-insurance or deductible amounts under Medicare Part A or Part B
insurance. Facility shall accept payment from the Medicare intermediary as payment in
full only for those services deemed to be covered in full under the Medicare Part A or
the Medicare Part B program. Services not covered by Medicare are identified in the
Admission Package of information provided prior to or at the time of admission.
5.5 Non-Covered Services. Resident is and remains obligated to pay
Facility for services and supplies not covered by the Medical Assistance or the Medicare
programs
5.6 Medicare Part D Prescription Drug Benefits.
(a) Enrollment in Medicare Part D Plan. If Resident is an eligible
beneficiary under the Medicare Part D insurance program and has enrolled or has been
lnandatorily enrolled in a Medicare Part D Prescription Drug or Medicare Advantage
Plan ("PDP"), Resident shall advise Facility in writing of Resident's chosen PDP upon
admission. In the event that Resident becomes an eligible beneficiary under Medicare
Part D after admission, or subsequently chooses to enroll in a PDP following admission,
Resident shall notify Facility in writing of Resident's chosen PDP prior to enrollment in
the PDP. Resident'shaIl advise Facility if Resident elects to change PDPs, and shall
provide written notice of such election., including the name/identity of the newly-
selected.PDP prior to the effective date of the change in the PDP.
(b) Resident's Responsibility to Pay for Pharmaceuticals. Resident is
responsible to pay the charges for all prescription and other drugs or medications while
a resident in Facility, except to the extent that such drugs and medications are covered
in whole or in part by any applicable government reimbursement program. Some or all
of the charges for prescription drugs and other drugs and medications may be covered
by certain benefits available through Medicare Part D or other private insurance oi-
Resident/Responsible Parh, r ?..'
governmental insurance/benefit programs, including Medicare Part A or B. In the
event that coverage for any prescription drug, supply, medication -or pharmaceutical
provided to Resident is denied by any applicable governmental reimbursement
program or other potentially available third party payor or insurance program, then
Resident or Responsible Person shall remain responsible to pay for all such prescription
drugs, supplies, other medications or pharmaceuticals.
(c) Actions of Medicare Part D Plan. Facility is not responsible for and
has made no representations regarding the actions or decisions of any PDP, including,
but not limited to, decisions relating to the establishment of the PDP formulary, denial
of coverage issues, or contractual arrangements between the PDP and the Resident, and
with respect to any decisions made by the PDP relating to any long term care pharmacy
provider that may be under contract with Facility.
(d) Dually Eligible Residents. If Resident becomes eligible for
Medicaid at any time during Resident's stay at Facility, and also qualifies for benefits
under the Medicare Program, then Resident shall be required to enroll in a PDP to
ensure coverage of Resident's prescription drug needs. Resident and/or Responsible
Person shall take all necessary action to enroll Resident in a PDP, and shall advise
Facility of such enrollment upon Resident's acceptance into the PDP. Resident
acknowledges that should Resident and/or Responsible Person fail to select a PDP, then
the federal Centers for Medicare and Medicaid Services ("CMS") will assign Resident to
a PDP. Resident shall provide. written notice to Facility of the name of the Resident's
PDP and the effective date of enrollment.
(e) Billing and Resident Cost Sharing Obligations. 1-o the extent that
Resident is a beneficiary under Medicare Part D, and the pharmacy prescriptions
and/or services ordered by a physician are covered by Medicare Part D, then the
Pharmaceutical Provider (as required by law) shall bill. the charges for the covered
services to the Resident's PDP. Resident is responsible for and shall pay any and all
cost-sharing amounts. applicable under Medicare Part D insurance. Facility shall not be
responsible to pay for any fees or cost-sharing amounts, including` co-insurance and
deductibles, relating to the provision of covered Medicare Fart D pharmaceuticals to
Resident. To the extent that Resident may qualify as a "subsidy eligible individual" who
would be entitled to a reduction or elimination of some or all of the cost-sharing or
premium amounts under the Medicare Part D benefit, Resident and/or Responsible
Person has the sole responsibility to apply for such benefits.
(f) ' Authorization to Request and/or AR eal Coverage
Determinations. In the event that Resident is denied coverage under Resident's PDP for
pharmaceutical services or supplies prescribed by Resident's attending physician, then
the following shall apply:
(1) Resident and/or Responsible Person may independently (i)
request an exception from Resident's PDP to cover non-formulary or non-covered
$ Resident/ Responsible Party... ?f? I •. ??... ?^ ... _. _.
Medicare Part D drugs that are otherwise needed or required by Resident; (ii) file a
request for a redetermination of any coverage denial issued by Resident's PDP ; (iii) file
an appeal with the appropriate agency and judicial tribunals to challenge any denial of
a request for redetermination.
(2) in the event of Resident's incapacity, and if there is no other
legal representative of Resident known to the Facility or any other friend or relative
known to the Facility who is authorized and/or is promptly available or willing to act
timely on behalf of Resident, or if Resident's physician is unable or unwilling to act on
behalf of Resident, then Resident authorizes Facility to (i) request an exception from
Resident's PDP to cover non-formulary or non-covered Medicare Part D drugs that are
otherwise neededlor required by Resident; (ii) file a request for a redetermination of
any coverage denial issued by Resident's PDP; (iii) file an appeal with the appropriate
agency and judicial tribunals to challenge any denial of a request for redetermination.
[(3) In the event of an initial denial of coverage by the Resident's
PDP, then pending the outcome of an exception request, a request for redetermination,
or an appeal, and in the event that Resident's attending physician fails to prescribe a
clinically and reasonably acceptable substitute prescription medication, Resident
authorizes the Facility's Medical Director to prescribe a clinically and reasonably
acceptable substitute prescription medication which is covered by Resident's PDP, if
such clinically and reasonably acceptable substitute is available.]
(4) If a request for exception (filed by Resident, Facility or any
other authorized representative) is ultimately denied following either reconsideration
by the PDP or appeal to an appropriate tribunal, and if the requested pharmaceuticals
are deemed medically necessary by Resident's physician, and no reasonably acceptable
substitute, as determined by Facility's Medical Director, from the formulary of
Resident's PDP exists, then Facility shall make arrangements to provide the requested
pharmaceuticals to Resident through. an arrangement with an outside pharmacy. In
any such situation, Resident shall be responsible to pay all fees and costs for the non-
covered pharmaceuticals, consistent with the requirements of this Section.
(g) No Effect on Medicare Part A Covered Nursing Services.
Resident's Medicare Part D prescription drug benefits do not apply ivl-iile the Resident's
stay in Facility is covered under Medicare Part A. While Resident is in Facility on a
Medicare Part A stay, Resident's pharmaceutical needs generally are covered by the
Medicare Part A program.
6. MANAGED CARE ORGANIZATIONS.
6.1 Participation in Managed Care Organizations. Facility inay
be an authorized provider of skilled nursing services to members of certain managed
care organizations ("MCOs"). The MCOs for whom Facility is an authorized provider
9 Resident/Responsible Pany?
are identified in the Admission Package of information provided prior to or at the time
of admission
6.2 Enrollment in a Managed Care Organization. Resident shall
notify Facility in writing prior to enrolling with a MCO or switching Resident's ]vtCO
enrollment.
6.3 Actions of Managed Care Organizations. Resident acknowledges
that an MCO for whom Facility is not an authorized provider may not approve
payment for services provided by Facility. Resident acknowledges that Facility is not
responsible for and has made no representations regarding the actions or decisions of
any MCO for whom Facility is an authorized provider, including decisions relating to
denial of coverage.
6.4 Obli ag tions of Resident. Facility will accept payment from the
MCO as payment in full only for those services and supplies covered by the MCO and
determined to be paid in full by Agreement between Facility and MCO. Resident is
responsible for any co-payments or other costs assigned to Resident under the specific
terms of the managed care plan. Resident also shall pay for any services or supplies not
covered by the MCO under the specific terms of the managed care plan. Co-payments
and other costs assigned to Resident and charges for services or supplies not covered by
the specific terms of the managed care plan are identified in the Admission Package of
information provided prior to or at the time of admission. Managed care plans typically
require pre-authorization of services by the MCO. If Resident chooses to have services
which the MCO refuses to pre-authorize, Resident shall pay Facility for those services.
Resident shall pay the Facility in a timely manner for all non=covered -services
retroactive to the date of the initial delivery of services.
6.5 Withdrawal from Participation in the MCO. Facility reserves the
right to terminate its contractual relationship and its status as an authorized provider
with one or more of the listed MCOs at any time in accordance with law and the terms
of the applicable agreement. In the event that Facility terminates its contractual
relationship with the MCO in which Resident is enrolled, Resident may convert his or
tier coverage to a health plan for whom Facility is an. authorized provider or transfer to
a Facility that is an authorized provider for Resident's MCO. Facility shall provide
thirty (30) days advance notice of its decision to withdraw as a participating provider
from Resident's MCO so Resident and the MCO can coordinate a transfer to another
Facility.
6.6 Notice of Change in Insurance Coverage. -Resident and/or
Financial Responsible Person shall notify the Facility immediately of any change in
Resident's insurance status or coverage-
Resident/Responsible
10
7. DURABLE FINANCIAL POWER-OF-ATTORNEY.
Resident is strongly encouraged to furnish to Facility, no later than the
date of admission or within five day(s) of admission, a Durable Financial Power-of-
Attorney executed by Resident relating to financial decisions and payment for services.
The Durable Financial Power-of-Attorney shall be maintained in the files of Facility.
The name, address and phone number of Attorney-in-Fact:
!•i
(-717)- - L /_
In the event a Durable Financial Power-of-Attorney does not exist and if
Resident is competent or becomes competent to declare an individual to serve as
Power-of-Attorney, every effort will be expended to obtain such authorization as soon
as practicable. In the event Resident fails to designate an Agent under a Power-of-
Attorney, Resident shall be responsible to pay for any guardianship proceedings related
to the appointment of someone or a legal entity to make decisions on behalf of Resident,
if and when Resident'lacks capacity to make such decisions as determined by Facility.
8. THIRD-PARTY PAYMENTS.
8.1 Eligibility for Third-Party. Payments. Resident may be or may
become eligible to receive financial assistance, reimbursement, or other benefits from
third parties, such as private insurance, employee benefit plans, Medical Assistance
benefits under the Pennsylvania Medical Assistance Program, Medicare benefits,
managed care coverage, supplementary medical or other health insurance.,
supplemental security income insurance, or old-age survivors' or disability insurance.
It is the responsibility of the Resident to apply for these benefits. If Resident is or
becomes eligible to receive payments from any third parties for Resident's stay and
care, Facility reserves the right to collect such payments directly from the third-party
source. The Resident and Financial Responsible Person shall at all times cooperate full),
with Facility and each third-party payor to secure payment. Cooperation includes
providing information, signing and delivering documents, and assigning to Facility (to
the extent permitted by law) any payments for the Resident from Fedcrral Social Security
benefits or from any other federal or state governmental assistance programs,
reimbursement or benefits to the extent of all amounts due the Facility. Resident and
Financial Responsible Person agree to reimburse Facility for any and' all costs incurred
by Facility to collect such payments directly from the third-party source.
8.2 Assignment of Payments. Although it is the responsibility of
Resident and Financial Responsible Person to secure payment from third-party
resources, including but not limited to Medical Assistance 5ei nefits, Resident
irrevocably authorizes Facility to makes such claims and to take such actions as it
deems necessary to'secure for the Facility receipt of third-party payments, including but
1 1 Resident/ Responsible Party _
not limited to Medical Assistance Benefits, to reimburse Facility for its charges for the
stay and care of Resident. (This includes but is not limited to filing an application for
Medical Assistance Benefits and pursuing any and all appeals there from in the event
the application is denied.) To the fullest extent permitted by law, as security for
payment of Facility's charges, Resident hereby assigns to Facility all of Resident's rights
to any third-party payments now or subsequently payable to the extent of all charges
due under this Agreement. (This includes but is not limited to Medical Assistance
Benefits.) Resident or Financial Responsible Person promptly shall endorse and horn
over to Facility any payments received from third parties other than Medical Assistance
Benefits which are paid directly to Facility to the extent necessary to satisfy the charges
under this Agreement.
8.3 Authorization for Payment of Medicare Benefits.
In authorizing Facility to seek payment of Medicare Benefits on Resident's
behalf, Resident and/or Authorized Legal Representative hereby certifies that the
information provided as to Resident in conjunction with Resident's application for
payment under Title XIII of the Social Security Act is correct. Moreover, Resident
and/or Authorized Legal Representative hereby authorizes the release of any
information needed to act on this request, and requests that payment of authorized
benefits be made on Resident's behalf.
In addition to the foregoing, Resident and/or Authorized Legal Representative
authorizes the release of any information concerning this, and/or any. other related
Medicare claim, to the Centers for Medicare and Medicaid Services by any holders of
medical and/or other information concerning Resident.
8.4 Insurance. In the event of an initial or subsequent denial of
coverage by the Resident's insurance company, Resident shall pay Facility timely for all
noncovered services retroactive to the date of the initial delivery of services.
9. PERSONAL FINANCES.
9.1 Personal Funds Management. Resident is responsible to provide
his or her personal funds, and Resident has the right to manage his or her personal
funds. Resident may authorize Facility, in writing on a document provided by Facility,
to hold Resident's personal funds, and may revoke at any time Facility's authorization
by providing Facility with a written notice signed and dated by Resident or either
Responsible Person. If Resident authorizes Facility to hold Resident's personal funds,
the Facility shall hold, safeguard and account for Resident's personal funds in
accordance with applicable provisions of Facility Policy. This section does not refer to
the financial assets of the Resident except for those funds required by law or established
by Facility policy as the minimal personal funds of. Resident. The Facility does not
assume any obligation to provide financial or investment advice, nor to file any tax
12 i:esiSent/P.espar??ibte Party. r?'_i ?f c ?_, _„ . _
documents . or other reporting documents except as required by the
I icensure/ certification regulations governing nursing facilities.
9.2 Refunds of Personal Funds. Any personal funds or valuables of
Resident held by Facility will be refunded within thirty (30) days after deductions for
payment of any outstanding bills or other amounts due the Facility after Resident's
discharge or death. In the event of Resident's death, such refund will be made to the
duly authorized representative of Resident's estate or to such entities or persons
entitled to the refund under current law.
9.3 Refunds of Prepayments or Overpayments. Any prepayments or
overpayments made by Resident and held by Facility will be refunded -within thirty (30)
days after Resident's discharge or death after deductions for. payment of any
outstanding bills or other amounts due the Facility. In the event of Resident's death,
such refund will be made to the duly authorized representative of Resident's estate or
to such other entities or persons entitled to the refund under current law. No interest
shall accrue on any funds required to be refunded under this Agreement.
10. CHANGES IN ROOM ASSIGNMENTS.
Facility reserves the right and discretion to transfer resident to another
room or bed within the Facility consistent with the safety, care and welfare needs of
Resident. Facility reserves the right and discretion to transfer Resident's roornrnate, if
any, at any time consistent with the needs of the Facility.
11. TERMINATIONS, TRANSFER OR DISCHARGE.
11.1 Resident Initiated. Resident may terminate this Agreement upon
fifteen (15) days written notice to Facility. If Resident leaves Facility for any reason
other than a medical emergency or death, Resident must give written notice to Facility
at least fifteen (15) days in advance of transfer, discharge or termination of this
Agreement. If advance written notice is not given to Facility, there will be due to
Facility the applicable Basic Daily Rate and other charges then in effect for Resident's
stay and care for the required fifteen (15) day notice period. T°he charge applies
whether or not the Resident remains at Facility during the fifteen (15) day notice period.
The charge specified in this section does not apply to a resident whose payor source is
Medicare Part A or Medical Assistance.
11.2 Facility Initiated. Facility may terminate this Agreement and
Resident's stay and transfer or discharge Resident if:
(a) Transfer or discharge is necessary to meet Resident's
Welfare, and Resident's needs cannot be met in Facility.
13 Resident/Responsible Pariq__. , I --
(b) , Resident's health has improved sufficiently so that Resident no
longer needs the services provided by Facility;
(c) The safety or health of individuals in Facility is
or otherwise would be endangered;
(d) Resident has failed, after notice, to pay for (or to have paid
or treated as paid under the Medicare or Medical Assistance
Programs) charges for Resident's care and stay at Facility;
(e) Facility ceases to operate.
11.3 Notice and Waiver of Notice. Facility will notify Resident and
Health Care Responsible Person (or if none, a family member or legal representative of
Resident, if known to Facility)* at least thirty (30) days in advance of transfer or
discharge. However, in any case described in Subparagraphs (a), (b), (c) above. Facility
will give only such notice before transfer or discharge as is reasonable or as required by
applicable law under the circumstances.
11.4 Withdrawal against Advice. [n the event Resident withdraws from
the Facility against the advice of his/her attending physician and/or without approval
of the Facility, all of Facility's responsibilities for the care of Resident are terminated,
effective at such time as Resident withdraws from the Facility.
12. READMISSION - BCD HOLD POLICY.
12.1 Private Pay Residents. If Resident leaves Facility for a period of
hospitalization, therapeutic leave, or any other reason (other than Resident's death),
and if Resident is not eligible for, or receiving, Medical Assistance benefits, Resident's
bed will be reserved through payment of the Basic Daily Rate. Facility will continue to
hold the bed until notified in writing by Resident or both Responsible Persons that the
bed is no longer desired. If Resident elects in writing not to reserve a bed, then
Resident will be discharged from Facility and feadmission to Facility shall be subject to
bed availability.
12.2 Medical Assistance Residents. If Resident is eligible for, or is
receiving Medical Assistance benefits, and Resident leaves Facility for a period of
hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable
maximum nurnber of days, paid for a reserved bed under the Penrl'sylvania Medical
Assistance Program. The bed reservation period may be subject to change in accordance
with any changes in the Programs. If the period of hospitalization or! therapeutic leave
exceeds the maximum time for reservation of a bed under the Programs, Resident will
be entitled to the first available accommodation suitable for Resident's level of care if, at
the time of readmission, Resident requires the services provided by the Facility.
Alternatively, following the lapse of the bed reservation period covered by the Medical
4 Resident/Responsible Par1y"J1 1. tom.
i _.
Assistance Program, Resident may reserve a bed by electing N-5 pay the Medical
Assistance per diem rate charged inunediately prior to the leave, and by providing
written notice and advance payment for the days included in the reservation period.
12.3 Medicare Residents: In the event that a Resident eligible for
Medicare Part A benefits is transferred to or readmitted to a hospital, Medicare Part A
eligibility will be terminated on the day the Resident is admitted to the hospital.
Resident's bed will be reserved at Basic Daily Rate, unless Resident or Responsible
Person elects, in writing, not to reserve a bed.
13. FACILITY RULES, REGULATIONS, POLICIES AND PROCEDURES.
Resident shall comply fully with all governmental laws and regulations,
the provisions of this Agreement, and FaciIity's rules, regulations, policies and-
procedures as made available by Facility. Facility reserves the right to amend or change
its rules, regulations, policies and procedures. Facility's rules, regulations, policies and
procedures shall not be construed as imposing contractual obligations on Facility or
granting any contractual rights to Resident, and are subject to change from time-to-time.
14. PERSONAL AND OTHER PROPERTY.
14.1 Responsibility for Maintenance and Loss. Resident is responsible
for furnishing and maintaining his or her own clothing and other items of property as
needed or desired. Resident may obtain at his or her own expense,- casualty insurance
to cover potential damage to or loss of any of Resident's personal property. If damage
or loss occurs to resident property, the Facility will investigate each incident of loss or
damage to determine liability and assess responsibility depending on the facts and
circumstances of each incident. Facility shall be responsible for only such losses or
damages as are attributed by Facility to the negligence or culpability of the Facility.
14.2 Disposition and Storage Upon Resident's Death. In the event of
Resident's death, Facility shall contact Resident's authorized representative within
twenty-four (^4) hours to arrange for an inventory of Resident's personal property. The
Facility is authorized to transfer Resident's personal property to a duly authorized
representative of Resident's estate or to such parties or persons entitled to the property
under current law. The duly authorized representative of Resident's estate or other
persons entitled to property under current law must acknowledge, in writing, the
receipt of the personal property transferred to his or her custody by Facility. After
completing an inventory, Facility, in its sole discretion, may move and place Resident's
personal property into storage at Facility's expense. If property held in storage is not
claimed within tlurty (30) days, Facility shall send a notice to the authorized
representative via certified mail that if items in storage are not removed within fourteen
(14) days, Facility may dispose of Resident's property.
15 Resident/ Responsible Parly_n . l.,?;., ,L..•_...
14.3 Disposition and Storage Upon Resident's Transfer or Discharge.
If Resident's personal property is not claimed or removed within twenty-four (24) hours
of Resident's permanent transfer or discharge, Facility shall move and place Resident's
personal property in storage until claimed. If Resident's personal property remains
unclaimed for seven (7) days after permanent transfer or discharge, Resident shall be
obligated to pay a storage fee as assessed by Facility. After a thirty (30) day period in
storage, the Facility may dispose of Resident's property. The Facility is not responsible
for any damages incurred to Resident's property if storage becomes necessary.
Resident or Resident's estate shall be obligated to pay all costs of storage or disposition
and shall bear the risk of loss or damage to the property.
14.4 Damage to Room or Facili Property. Resident or Resident's
estate is responsible for any damages caused to Facility property beyond normat wear
and tear, and shall pay for the repair and replacement of damaged property, based on
the actual charge to Facility for such repair or replacement.
15. RESIDENT RECORDS.
Resident records shall be handled in accordance with the facility's Privacy
Policy that Resident hereby acknowledges receiving.
16. MEDICAL TREATMENT AUTHORIZATION.
Resident authorizes Facility to provide care and treatment in accordance
with orders of Resident's personal physician and consistent with the terns of this
Agreement.
17. DEATH OF RESIDENT.
In the event of Resident's death, Facility shall notify the person(s)
designated by Resident. Facility is authorized to arrange for the transfer of Resident's
body to the designated funeral home. Resident's estate is responsible for the payment of
all costs associated with the transfer and funeral expenses and Facility reserves the right
to require proof of financial responsibility for payment of burial expense prior to
admission. Person or Funeral Horne to be notified:
r
'F ?1/11
Resident shall notify Facility of any change of Person or Funeral Home to be notified.
18. CAPACITY OF RESIDENT AND GUARDIANSHIP. '
?r t^
16 Resident/I2espcinsible Parry___ y ?? f, 1-,L
If Resident is, or becomes unable, to understand or communicate, and is
determined after admission to be incapacitated by Resident's Physician or Facility's
Medical Director, Facility shall have the right, in the absence of. Resident's prior
designation of an authorized legal representative, or upon the unwillingness or inability
of the legal representative to act, to commence a legal proceeding to adjudicate Resident
incapacitated and to have a court appoint a guardian for Resident. The cost of the legal
proceedings, including attorney's fees, shall be paid by Resident or Resident's estate.
19. FACILITY'S GRIEVANCE PROCEDURE.
19.1 Reporting Complaints. If Resident, Responsible Persons, or
Resident's attorney-in-fact believe(s) that Resident is being mistreated in any way or
Resident's rights have been or are being violated by staff or another resident, Resident
Responsible Persons, or Resident's attorney-in-fact shall make his/her complaint
known to Facility's staff. Resident, Responsible Persons, or Resident's attorney-in-fact
must first notify Facility of any such complaints, and provide the Facility with sixty (60)
days to resolve the complaint satisfactorily to Resident before the Resident may pursue
mediation. This notice requirement is not intended to preclude Resident, Responsible
Persons, or Resident's attorney-in-fact from filing a complaint v'rith any appropriate
governmental regulatory agency.
19.2 Facility's Obli ations. Facility will review and investigate the
complaint and provide a- response to Resident/ Resident's Attorney-in-fact or
Responsible Persons-
19.3 Mandatory Mediation. The parties agree that they shall in good
faith attempt to resolve any controversy, dispute or disagreement arising from or
relating in any way to this Agreement and/or the provision of services by the Facility
under this Agreement through negotiation. Should the parties be' unable to reach a
resolution within sixty (60) days of initial notice of the dispute, the parties shall submit
the controversy, dispute or disagreement to mediation before an impartial mediator,
which mediation shall be conducted at the Facility or at a site within a reasonable
distance of Facility, in accordance with the Rules of Procedure utilized by Scanlon ADR
Services, or an alternative neutral, third-party arbitrator selected by Guardian Elder
Care. The mediator will assist the parties with their negotiations and attempt to
facilitate an amicable resolution of the controversy, dispute or disagreement. In the
event the parties are unable to resolve their dispute through mediation, and Resident
and/or his/her authorized legal representative has voluntarily elected to submit to
binding arbitration pursuant to the terms of the Voluntary Arbitration Agreement, then
the dispute shall be submitted for resolution by arbitration as provided within the
separate Voluntary Arbitration Agreement. The parties agree that they may Ilot
proceed to arbitration unless and until the matter is first submitted to mediation under
this provision and the mediation is completed.
17 Resident/P.c-spoasif.ife Party.. _a.I F
The parties agree that this provision does not cover issues relating to
Medical Assistance eligibility, applications and/or appeals and does not affect any civil
or judicial actions which seek to compel compliance with the Resident's or their
responsible parties' duties to undertake, complete and cooperate with the Medical
Assistance application and appeal process. Further, the parties agree that this provision
does not apply to any guardianship proceedings resulting from the alleged incapacity
of the Resident.
The costs of the mediation will be split equally betcNeen the parties.
However, both parties will be responsible for their own attorney's fees should either
decide to retain legal counsel. The mediator shall have the right to suggest or negotiate
for the redistribution of the costs between the parties if it is deemed %appropriate during
mediation.
if a resolution is reached at mediation, the parties agree that such
resolution will be reduced to writing in the form of a settlement agreement and signed
by both parties. The signed settlement agreement will be the final resolution of the
controversy, dispute or disagreement.
(a) Exception From Mediation. Those disputes which have
been excluded from mandatory mediation (i.e., guardianship proceedings, and issues
relating to Medical Assistance eligibility, applications and/or appeals) may be resolved
through the use of the judicial system. In situations involving any of the matters
excluded from mandatory mediation, neither you nor the Facility is required to use the
mediation process. Any legal actions related to those matters may be filed and litigated
in any court which may have jurisdiction over the dispute.
(b) Right to Legal Counsel. Resident has the right to be
represented by legal counsel in any proceedings initiated under this mediation
provision. Because this mediation provision addresses important legal rights, Facility
encourages and recommends that Resident obtain the advice and assistance of legal
counsel to review the legal significance of this mandatory mediation provision prior to
signing this Agreement. i
: (c) Time Limitation for Mediation- Any request for mediation
of a dispute must be requested. and submitted to the.Facility prior to the lapse of one (1)
year from the`date on which the event giving rise to the dispute occurred. The failure to
submit a request for mediation to the Facility within the designated time shall operate
as a bar to any subsequent request for Mediation, or for any claim for' relief or a remedy,
or to any arbitration, action or legal proceeding of any kind or nature, and the parties
will be forever barred from mediating, arbitrating, or litigating a resolution to any such
dispute.
19.4 VoluntM Binding Arbitration. The parties agree that the election
by Resident and/or his/her authorized legal representative to submit to binding
is Rasident/Responsible Yarty_-t-? J-? .?'... ..--
arbitration in accordance with the terms of the separate Voluntary Arbitration
Agreement is not a requirement for admission to the Facility. Further, the Facility and
Resident and/or his/her authorized legal representative also agree that election to
participate in binding arbitration as a means of alternative dispute resolution precludes
them from pursuing any litigation relating to all past and/or future claims and known
and/or unknown damages arising from any period of residency by Resident at the
Facility (past and future) and, in exchange for waiving that right, the parties receive
those benefits which arbitration offers including, but not limited to, confidentiality,
decreased litigation expense and/or expedited dispute resolution. In the event that the
Resident and/or his/her authorized legal representative has elected to sign the
Voluntary Arbitration Agreement, the entirety of the attached Voluntary Arbitration.
Agreement is hereby incorporated as though fully set forth at length herein.
(a) Exception From .Arbitration. Those disputes which have
been excluded from arbitration (i.e., guardianship proceedings, and issues relating to
Medical Assistance eligibility, applications and/or appeals) may be resolved through
the use of the judicial system. In situations involving any of the matters excluded from
arbitration, neither you nor Facility are required to use the arbitration process, Any
legal actions related to those matters may be filed and litigated in any court which may
have jurisdiction over the dispute. This arbitration provision shall ne-3t impair the rights
of Resident to appeal any transfer and/or discharge action initiated by the Facility to
the appropriate administrative agency, and after the exhaustion of such administrative
appeals, to appeal to the court exercising appellate jurisdiction over'the administrative
agency.
(b) Right to Legal Counsel. Resident has the right to be
represented by legal counsel in any proceedings initiated under an executed Voluntary
Arbitration Agreement. Because arbitration addresses important legal rights, Facility
encourages and recommends that Resident obtain the advice and assistance of legal
counsel to review the legal significance of the Voluntary Arbitration Agreement before
executing same.
20. NOTICE.
Wherever written notice is required to be given to Facility under this
Agreement, it shall be sufficient if notice is provided by personally delivering it or by
first-class mail, return receipt requested.
(717 )Z5?E'- 4, 51-111-
19 Resident/Rcspuns:blt P,irty__..?Jc`%..? .'---. .
Notice to Resident will be provided by personal delivery to Resident's room, or where
applicable, by first-class mail to Responsible Person(s) or other designated person.
21. RESIDENT OBLIGATIONS.
If Resident is responsible for any actions or omissions that cause damage or
injury to other persons and residents or the property of other persons or residents, then
Resident shall be liable for such damage to the fullest extent permitted by law.
22. INDEMNIFICATION.
Resident is responsible to pay for any damages or injuries caused by resident to
other persons, residents or staff and shall indemnify and hold Facility harmless froin
any claims, actions or proceedings against Facility resulting from Resident's actions or
oill iss i o ns.
23. MISCELLANEOUS PROVISIONS.
23.1 Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the Commonwealth of Pennsylvania and shall
be binding upon and inure to the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
23.2 * Severability. The various provisions of this Agreement shall be
severable one from another. If any provision of this Agreement is found by a court or
administrative body of proper jurisdiction and authority to be invalid, the other
provisions shall remain in full force and effect as if the invalid provision had not been a
part of this Agreement.
23.3 Captions. The captions used in connection with the sections and
subsections of 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, nor shall such captions be
given any legal effect.
23.4 Entire Agreement. The Admission Agreement consists of the
entire Agreement between the parties and supersedes, merges and ;replaces, all prior
negotiations, offers, warranties and previous representations, understandings or
agreements, oral or written, between the parties.
23.5 Modifications. Facility reserves the right to modify unilaterally the
terms of this Agreement to conform to subsequent changes in law or regulation. To the
extent reasonably possible, the Facility will give Resident and Resident's Responsible
Person(s) thirty (30) days advance written notice of any such modifications.
20 Resident/Resprnisible Party?.I
23.6 Waiver of Provisions. Facility reserves the right to waive any
obligation of Resident under the provisions of this Agreement in its sole and absolute
discretion. No term, provision or obligation of this Agreement shall; be deemed to have
been waived by Facility unless such waiver is in writing by Facility. Any waiver by
facility shall not be deemed a waiver of any other term, provision or obligation of this
Agreement, and the other obligations of Resident and this Agreement shall remain in
full force and effect.
24. ACKNOWLEDGMENTS.
24.1 Facility Charge Schedules. Resident and Responsible Person(s)
acknowledge the receipt of a copy of the Facility Charge Schedules provided with the
Admission Package and the opportunity to ask questions about Facility's charges.
24.2. Resident Rights. Resident and Responsible Person(s) acknowledge
being informed orally and in writing of Resident's Rights as specified in the current
publication required by law and further acknowledge having an opportunity to ask
questions about those rights. The Notice of Rights of Nursing Facility is subject to
change from time-to-time and shall not be construed as imposing any contractual
obligations on Facility or granting any contractual rights to Resident.
24.3 Advance Directives. Resident and Responsible Person(s)
acknowledge being informed, orally and in writing, of Facility's policy on advance
directives and medical treatment decisions.
24.4 Agreement. Resident and Responsible Person(s) acknowledge that
they have read and understand .the terms of this Agreement, that the terms have been
explained to them by a representative of Facility, and that they have had an opportunity
to ask questions about this Agreement.
24.5 Admissions Package. Resident and Responsible Person(s)
acknowledge the receipt of a copy of the Facility's Admission Package and the
opportunity to ask questions about Facility's policies contained therein. The Admission
Package content is subject. to change from time-to-time and shall not be construed as
imposing any contractual obligations on Facility or granting any contractual rights to
Resident.
21 Resident/Responsible Part?_l Y L?.? ?_
IN WITNESS W11EREOF, the parties, intending to be legally bound, have
Signed this Nursing ?7Fracility Agreement on this day C.l
Witness Resident
/I f1
C 14
/ I \
/
Witness Financial Responsible Person
Witness Health Care Res risible Person (if any)
Facility
t-- `7
_
By.
22 Resident/Respunible Party . _' {?'? c L_
E
ctaaeERLnr?D coo MEDICAID
P.O. BOX 599 NOT ELIGIBLE
33 WEST14INSTER DRIVE NOTICE
CARLISLE PA 17013-0599
0036
GAO RETURN ADDRESS CSLD
•0zozz?99oo?
MILDRED LEINAWEAVER
t' FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM RD
{ CARLISLE PA 17013
Notice ID: 93465369
21 0124189 0 PAN 09
WORKER: i PEIPER
TELEPHONE: (900) 69-0173
MAIL DATE: 04/03/2009
NOT: 079 OPT: 0 TYPE: N
IF YOU DD NOT UNDERSTAND OUR DECISION OR HAVE ANY
QUESTIONS, PLEASE CONTACT YOUR WOR1fER IMMEDIATELY,
you
ther$20001resource1eim t. Please reapply3whennyourhresoources aregbslowxtheds
$8000 Resource limit.
Available resources:
F&M Trust checking account - $13B2.50
Cash value of Genworth Life and Annuity - $32,833.80
REGULATIONS:55 pA Code 178.1; 178.3
If you disagree with our decision, you have the right to appeal. _1313 attacneo rorm
far a carnal to exalanatlon of your right to ?Aeal and to a fair hearing. If you are
currently receiving benefits and your oral request for a hearing is received in the
County Assistance office or your written request is postrnazked or received on or
before 04/16/2009 your assistance will continue pending the hearing decision,
except when the change is due to State or Federal law.
PAGE 1 OF 1
MIDPER14 LEGAL SERVICES
401-405 LOUTHER STREET
CARLISLE PA 17013
(717) 243-9400
AILED r '
ARY
22 P i' E
-* 18.5o PO ATT4
C?? q$to
RXT oUIQUO
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
a
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC T f -a
d/b/a FOREST PARK CENTER, i'
Plaintiff, No. 9 - _
"C1" r
V.
MARK LEINAWEAVER, CIVIL ACTION - EQUITY
Defendant.
PETITION FOR PRELIMINARY INTUNCTION
AND NOW, COMES, Plaintiff, Guardian Elder Care Home and Community
Services, LLC d/b/a Forest Park Health Center ("Petitioner'), by and through its
attorneys, SCHUTJER BOGAR LLC, and files the within Petition against Respondent, Mark
Leinaweaver ("Respondent"), and in support thereof, provides as follows:
1. Respondent entered into an Admission Agreement ("Agreement") with
Petitioner as a condition of the admission of his mother Mildred Leinaweaver ("Mrs.
Leinaweaver"), to Petitioner's skilled nursing facility. See Admission Agreement of
Complaint attached hereto as Exhibit "A."
2. In the Agreement, Petitioner was assigned Mrs. Leinaweaver's rights to
Medical Assistance benefits and Respondent agreed to cooperate fully in securing
Medical Assistance benefits (hereinafter "the Assignment Clause").
ORIGINAL
3. Accordingly, Petitioner now stands in the shoes of Mrs. Leinaweaver and
has assumed her rights with respect to her Medical Assistance benefits. See Horbal v.
Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) ("[A]ssignee stands in the shoes of the
assignor and assumes the rights of the assignor.")
4. Petitioner cannot exercise its rights to Mrs. Leinaweaver's Medical
Assistance benefits until the Cumberland County Assistance Office ("CAO") processes
and approves the application for Medical Assistance benefits. This cannot be
accomplished until Respondent completes a spend-down of Mrs. Leinaweaver's excess
resources and provides to Petitioner the documentation the CAO requires, to secure
benefits for Mrs. Leinaweaver.
5. Respondent's failure to spend down the excess resources and provide the
documentation that the CAO requires to secure Medical Assistance benefits for his
mother breaches the Assignment Clause and his promise to secure benefits, thereby
interfering with Petitioner's rights to the Medical Assistance benefits.
6. An Administrative Law Hearing before the Department of Public
Welfare's Bureau of Hearings and Appeals will be scheduled in the near future to
address the appeal of the denial of Medical Assistance benefits to Respondent's mother.
Failure by Respondent to comply with the terms of the Agreement and provide the
verification of a spend down required by the CAO to grant his mother's application for
Medical Assistance benefits before that hearing will result in the dismissal of the Appeal
and the denial of Medical Assistance benefits.
2
7. The very nature of Respondent's breach presents an issue of immediate
and irreparable harm to Petitioner, as Petitioner cannot realize the benefit of the bargain
promised to it under the Assignment Clause - specifically, its right to Mrs.
Leinaweaver's Medical Assistance benefits, and by extension, its right to be
compensated for the skilled nursing services it has provided and continues to provide
to Mrs. Leinaweaver - until Respondent provides the CAO the documentation it needs
to process and approve his mother's application.
8. The requested injunction would restore the parties to the status quo as it
existed immediately prior to Respondent's breach of the Agreement.
9. Greater injury would result from the denial of the requested injunction
than from the granting of the same. Absent the injunction, without the documentation
necessary to secure Medical Assistance benefits, the Cumberland CAO will deny the
application for Medical Assistance benefits, and Petitioner's ownership rights in those
benefits and its ability to receive compensation for the skilled nursing services it has
provided and continues to provide to Mrs. Leinaweaver under the Agreement will be
forever lost.
10. Petitioner's right to relief is clear.
11. Petitioner lacks an adequate remedy at law, as upon information and
belief, at all times material hereto, Respondent and his mother have been financially
unable to fully compensate Petitioner for the services that it has rendered and continues
to render to Mrs. Leinaweaver.
3
12. A bond in the amount of $100.00 should be adequate in the event that it is
later determined that the issuance of the instant petition was in error.
WHEREFORE, Petitioner respectfully requests that the Court schedule a hearing
on its request for injunctive relief and thereafter issue a decree ordering specific
performance of the contractual duty of Respondent.
Respectfully submitted,
Dated: C' 1 -7' G By:
Attorney I.D. No. 83755
(717) 909-5920
Anthony T. Lucido
Attorney I.D. No. 76583
(717) 909-0353
Brandon S. Williams
Attorney I.D. No. 200713
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
4
SCHUTJER BOGAR LLC
EXHIBIT "A"
(TO PETITION FOR PRELIMINARY INJUNCTION)
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC
d/b/a FOREST PARK CENTER,
Plaintiff,
V.
MARK LEINAWEAVER,
Defendant.
COMPLAINT
No.
CIVIL ACTION - EQUITY
AND NOW, COMES, Plaintiff, Guardian Elder Care Home and Community
Services, LLC d/b/a Forest Park Health Center ("Plaintiff'), by and through its
attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant,
Mark Leinaweaver ("Defendant"), and in support thereof, provides as follows:
1. Plaintiff is a domestic limited liability corporation, with its principle place
of business located at 1217 Slate Hill Road, Camp Hill, Pennsylvania 17011.
2. Defendant is an adult individual who currently resides at 1275 Creek
Road, Mechanicsburg, Pennsylvania, 17055.
3. On or about January 12, 2009, Defendant made application for the
admission of his mother, Mildred Leinaweaver ("Mrs. Leinaweaver"), to Plaintiffs
skilled nursing facility.
4. Plaintiff and Defendant entered into a written Admission Agreement
("Agreement"), pursuant to which Plaintiff agreed to provide Mrs. Leinaweaver with
skilled nursing services in exchange for Defendant's promise to pay a specific monetary
fee and the assignment to Plaintiff of Mrs. Leinaweaver's right to apply for and obtain
Medical Assistance benefits in the event that she became insolvent. In furtherance of
that assignment, Defendant agreed to assign Plaintiff, "all of Resident's rights to any
third-party payments now or subsequently payable to the extent of all charges due
under this Agreement" and to "cooperate fully" in securing those benefits. A true and
correct copy of the Agreement is attached hereto as Exhibit "A."
5. After Mrs. Leinaweaver became a resident of Plaintiffs skilled nursing
facility, she apparently became insolvent. As a result, pursuant to the Agreement,
Plaintiff notified Defendant that he needed to apply for Medical Assistance benefits,
and an application for Medical Assistance benefits subsequently was filed.
6. The application for Medical Assistance benefits was denied April 3, 2009,
because Defendant failed to spend down excess resources and did not provide the
information and documentation required by the Cumberland County Assistance Office
("CAO") in order to secure Medical Assistance benefits. See PA-162 attached hereto as
Exhibit "B."
7. Plaintiff has filed an appeal of this denial. However, if Defendant fails to
take the steps necessary to qualify his mother for Medical Assistance benefits, the
application will fail and Plaintiff will be precluded from receiving the Medical
Assistance benefits that have been contractually assigned to it.
2
COUNTI
BREACH OF CONTRACT/ SPECIFIC PERFORMANCE
8. The allegations contained in Paragraphs 1 through 7 are incorporated
herein by reference as if fully set forth at length.
9. Defendant breached his Agreement with Plaintiff by failing to act in
accordance with the terms of the same, as he has failed to complete a spend down of
Mrs. Leinaweaver's excess resources and provide necessary documentation required to
process and approve Mrs. Leinaweaver's application for Medical Assistance benefits.
By doing so, Defendant has interfered with Plaintiff's right to receive Medical benefits
that have been contractually assigned to it.
10. The law is clear that an "assignee stands in the shoes of the assignor and
assumes the rights of the assignor." Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa.
1997).
11. As Defendant failed to provide the necessary documentation to the CAO
required to qualify Mrs. Leinaweaver for Medicaid benefits, Plaintiff is precluded from
exercising its rights under the Assignment Clause.
12. Upon information and belief, at all times material hereto, Mrs.
Leinaweaver has been financially unable to fully compensate Plaintiff for the services
that it has rendered and continues to render to her in accordance with the terms and
conditions of the Agreement.
3
13. Defendant's breach of his Agreement with Plaintiff has irreparably
harmed Plaintiff.
14. Only a decree of specific performance will adequately protect the interests
of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders
specific performance of the Agreement between the parties.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: 67V 7, O Y By:
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Anthony T. Lucido
Attorney I.D. No. 76583
(717) 909-0353
Brandon S. Williams
Attorney I.D. No. 200713
417 Walnut Street, 4+h Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
4
VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing
document are true and correct to the best of my knowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C. S. § 4904, relating to unswom falsification to authorities.
r
Dated: --
Dawn Jordan
Billing and Collections Coordinator
Guardian Elder Care
5
EXHIBIT "A"
GUARDIAN ELDER CARE
NURSING CARE ADMISSION AGREEMENT
This Nursing Care Agreement is made by and between Guardian Elder Care
(hereinafter called "Facility"),fir '???/f/,//e ,y zE (hereinafter
called "Resident"), (.hereinafter called
"Financial Responsible Person"), and (if any)
(hereinafter called "Health Care Responsible
Person").
Resident, Financial Responsible Person, and Health Care Responsible Person (if
any) affirm that the information provided in all admission documents is true and
correct to the best of their knowledge, and acknowledge that the submission of any false
information and/or omission of material information may result in the termination of
this Agreement and personal financial liability, including attorney fee's, costs, interest
and lost revenue.
Therefore, Facility, Resident, Financial Responsible Person and Health Care
Responsible Person agree to the following terms and conditions:
1. PROVISION OF SERVICES.
1.1 Nursing Services. Beginning on / _ f^ L the
designated admission date, Facility will provide Resident with (a) the routine nursing
services described in the Rate Schedule * attached to this Agreement and incorporated by
reference; (b) private or ? semi-private accommodations; (c) three meals
each day and snacks, except as otherwise medically indicated; (d) blankets, bell linens,
towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services;
(g) activity progrcros and social services as established by Facility; (ii) routine personal
laundry; (i) hospital gowns and routine surgical dressings; and (j) certain type of over
the counter med_cations as provided by law. Not 'included in the daily rate are
intravenous services and supplies; oxygen and supplies; inco:-itinence products;
ambulance costs; physician 'fees; most pharmaceutical drugs; personal dry cleaning;
medical tests; laboratory tests; private telephone/ services or teRtvision; x-rays; or
special nursing supplies not considered routine.
1.2 Ancillary Services. Facility will provide ancillary services
identified in the Admission Package of information provided prior to or at the time of
admission at the option and upon the request of the Resident, or upon the direction of
Resident's treating physician or Facility's. Medical Director. The an--illary services and
associated charges are identified in the Admission Package of information and are
subject to change it the- discretion of Facility.
Resident/Responsible P.'rh•...' `... -' .- .-.-
1.3 Services of Other Providers. The services of outside providers
such as a licensed physician, dentist, licensed pharmacy for. the provision of
pharmaceutical supplies, a licensed hospital, diagnostic services,. laboratory, x-ray,
podiatry, optometry, medications, ambulance services and hearing aid repair may be
available from time to time at the Facility. These services are available under guidelines
and procedures established by Facility and may be utilized by Resident at his or her
own expense. Resident may choose to utilize providers of his or her own choice;
however, the services and goods provided must meet the standards established by
Facility.
1.4 Role of Primary Medical Physician and Medical Director. The
Resident shall obtain the services of a qualified physician who will provide medical care
during the resident's stay at Facility. The Resident's physician ,is an independent
licensed professional who is not an employee of the Facility but who shall comply with
Facility's rules, regulations, policies and procedures. Facility is not obligated to provide
Resident with any medicines, treatments, special diets or equipment without specific
orders or directions from Resident's Primary Medical Physician. 1 n the event Resident's
personal physician is unavailable, Facility's Medical Director may issue appropriate
orders. Resident is responsible to pay for all services or equipment ordered by
Resident's Primary Medical Physician or Facility's Medicat Director for Resident's care.
2. CHARGES.
2.1 Recurring/Periodic Charges for Routine Nursing Services.
Resident shall pay the Basic Daily Rate, specified in the rate schedule in effect at the
time the service is rendered, for routine nursing services provided to Resident: The
Basic Daily Rate may be changed from time-to-time in accordance with the provisions
of Section 3.3. Charges for a resident whose payor source is other than Medicare Part A
or Medical Assistance will begin on the designated admission date or actual admission,
whichever is sooner; charges for a resident whose payor source is Medicare Part A or
Medical Assistance will begin no sooner than the date of admission. (The term "Medical
Assistance" is a reference to Pennsylvania's Medicaid program.)
2.2 Additional Charges for Ancillary Services. Resident shall pay for
other services and supplies provided by or through the Facility, whch are not covered
by the Basic Daily Rate as set forth in the Admission Package of information provided
prior to or at the time of admission and in effect at the time such aricillary services are
rendered.
2.3 Charges for Outside and Non-Facility Services. In addition to
Facility's charges," Resident shall pay all fees and costs for goods or services furnished to
or for Resident by anyone other than Facility as described in Subsection 1.4 (Role of
Primary Medical Physician and Medical Director) unless otherwise. covered in full by
Medicare or Medical Assistance or another third-party payor. Resident or Responsible
Person is obligated to- pay such fees and costs whether the goods and services are
.i
2 Resident/1:2spnnsil?le Parly _ j !1 ?,?- ? ----
r..
furnished by a person or provider made available by Facility, or by a person or provider
selected by Resident, and whether the goods or services are provided at facility or
elsewhere. These fees and costs 'are not included in the Basic Daily Rate. Fees for
professional services rendered by a physician are not included in the Basic Daily Pate
and will be charged directly to the Resident by the physician.
3. PERIODIC BILLINGS AND PAYMENT DUE DATE.
3.1 Monthly Statements and Other Billings. When permitted by law,
prepayment for the basic monthly rate of the current month is required at the time of
admission. Facility will mail to Resident or Financial Responsible Person at the
beginning of each month a billing statement reflecting charges for nursing services for
the upcoming month and charges for ancillary services and supplies, which were
incurred in tIi? prior month. Statements are due and payable on receipt. All payments
shall be directed to:
GUARDIAN LTC MANAGEMENT INC.
PO BOX 240
BROCKWAY, PA 15824
3.2 Late Charges and Cost of Collection. Any invoices not paid
within thirty (30) days of the date of the invoice are subject to a late:charge of one and
one-half percent (1.50%) per month, for the annual rate of eighteen percent (18%), and
Resident or Financial Responsible Person is obligated to pay any late charges. In the
event Facility initiates any legal actions or proceedings to collect payments due from
Resident under this Agreement; Resident or Financial Responsible Person shall be
responsible to pay all attorney's fees, costs, interest and lost revenue incurred by
Facility in pursuing the enforcement of Resident and/or Financial Responsible person's
obligations under this Agreement.
3.3 Modification of Charges. Facility reserves the right to
change the Room Rate Schedule reflecting the amount of any of its charges or
how and -when charges are computed, billed or become due. Facility shall
provide thir=ty (30) days advance written notice of any such changes.
3.4 Obligations of Resident's Estate and Assigni?_ient of Property.
Resident and Financial Responsible Person acknowledge that the cliarges for services
provided under this Agreement and any and all costs incurred by Facility to enforce
this Agreement remain due and payable until fully satisfied. In the event of Resident's
discharge for any reason, including death, this- Agreement shall operate as an
assignment, transfer and conveyance to Facility of so much of Resident's property as is
equal in value to the amount of any unpaid obligations under this Agreement. This
assignment shall be. an obligation of Resident's estate and lnay be enforced against
Resident's estate. Resident's estate shall be liable to and. shall pay to ?-'-acility an amount
equivalent to any unpaid obligations of Resident under this Agreement.
_,? }
3 Resident /Responsible Party.
4. OBLIGATIONS OF FINANCIAL RESPONSIBLE PERSON.
4.1 General. Resident shall have the right to identify a Health Care
Responsible Person (usually this person is the Resident's Power of Attorney or
Guardian of his or her Person), who shall be entitled to receive nofice in the event of
transfer or discharge or material changes in the Resident's condition, and changes to the
Admission Agreement. Resident is not required to name a Health Care Responsible
Person. Resident elects to named?r -4:. as 114-s/her
Health Care Responsible Person. Resident shall identify a Financial Responsible Person
(usually this person is the Resident's Financial Power of Attorney or Guardian of
Wi3/her Estate) at the time of admission. Resident elects to name
11:176GC4.), tO Zas hW her Financial Responsible Person.
Resident's Financial Responsible Person shall sign this Agreement id recognition of this
designation with the intent to be legally bound by all provisions in this Agreement. Tile
Financial Responsible Person shall be obligated to fulfill thefinancial-:duties on behalf of
the Resident imposed by this Agreement. The Facility may petition -11 court to appoint a
Guardian and take other legal action if Facility reasonably believes that the Resident's
needs are not being properly met or the duties imposed by this Agreement are not
being fulfillers by either the Health Care or Financial Responsible Person. Resident,
Resident's estate, or Health Care or Financial Responsible Person shall pay the cost of
such Guardianship proceedings, including attorneys' fees.
4.2 - Obligations and Potential Liability. This Agreement shall not be
construed or operate as a third party guaranty. Financial Responsible Person is
obligated to pay Facility from Resident's financial resources for services and supplies
provided to Resident in accordance with this Agreement. If the Financial Responsible
Person has previously transferred, converted and/or withholds 6r misappropriates
Resident's financial resources for personal benefit or gifts, or otherwise has not or does
not use the Resident's financial resources to fulfill Resident's financial obligations to the
Facility for services and supplies provided to resident in accordance with this
Agreement, then Financial Responsible Person shall be liable for payment up to the
value of the misused or misappropriated property. Financial Responsible Person is also
obligated to pay Facility for all losses or damages incurred by Facility by the failure of
the Financial Responsible Person to fulfill his/her duties under this Agreement. Failure
to do so will result in legal action or other proceedings consistent with this Agreement
by Facility to assure payment for amounts that are Resident's obligations. In the event
Facility initiates any legal actions or proceedings to collect paycnents:due from Resident
and/or Financial Responsible Person under this Agreement, or to enforce Responsible
Persons obligations under this Agreement and/or the Responsible Person Agreement,
then Resident and Financial Responsible Person shall pay all damages, attorney's fees
and costs incurred by Facility in pursuing the enforcement of Resident's and/or
Financial, Responsible Person's financial or other obligations under this Agreement.
Such damages, fees and costs may include, in the discretion of
Facility, an amount equivalent to revenue lost by Facility due to Financial Responsible
4 Resident/ Responsible Parh
Persons failure to timely submit or complete a Medical Assistance application or to
cooperate with the Pennsylvania Deparhment of Public Welfare (hereinafter "DPW") in
the Medical Assistance eligibility determination. The failure to,. initiate, make or
complete the Medical Assistance application process on the Resident's behalf may result
in the discharge of Resident for non-payment and personal liability to Financial
Responsible Person for losses incurred by Facility for Financial Responsible Person's
failure to apply timely for Medical Assistance benefits. Facility reserves the right to
assist Financial Responsible Person in making application for Medical Assistance. If
Facility, in its sole discretion, however, decides to assist the Financial Responsible
Person in the Medical Assistance application process, Resident -and the Financial
Responsible Person are still fully obligated to initiate, make and complete the Medical
Assistance application. The Facility's assistance in the Medical Assistance application
process does not waive Resident's or Financial Responsible :Person's duty or
responsibility to timely complete and submit a Medical Assistance application if the
Resident's financial resources become insufficient to pay amounts due under this
Agreement. When Financial Responsible Person makes application for Medical
Assistance benefits, Financial Responsible Person shall assign the Patient Pay amount to
the Facility as estimated by Facility and County Assistance Office in accordance with
DPW Regulations. See Section 5.3. If Resident is determined to be ineligible for Medical
Assistance because Financial Responsible Person fails to provide or submit necessary
documents or fails to appeal timely so that Facility is unable to obtain Medical
Assistance reimbursement, then Facility may terminate this Agreement for non-
payinent of stay, and Financial Responsible Person shall be liable for any losses,
including attorney's fees, costs, interest and lost revenue, sustained by the Facility as a
result of such failure. Financial Responsible Person shall be responsble for compliance
with all other applicable terns of this Agreement.
5. MEDICARF/MEDICAL ASSISTANCE PROGRAMS.
5.1 Participation in Programs. Facility currently participates in the
Pennsylvania Medicaid program ("Medical Assistance") and the federal Medicare
program. Facility reserves the right to withdraw from the Medical Assistance or
Medicare programs at any time in accordance with law-
5.2 Actions of Medical Assistance and Medicare Agencies. The
Pennsylvania Department of Public Welfare ("DPW") is responsibld for administering
benefits under the Medical Assistance program. The Centers for Medicare and Medical
Assistance Services ("CMS"), of the United States Department of Heath and Human
Services, is responsible for adn-dnisterin; the Medicare program through an
intermediary. Resident and Financial Responsible Person acknowledge that Facility is
not responsible for, and has made no representations regarding, the actions or decisions
of DPW, CMS or the Medicare intermediary in administering the programs.
5 Rcsi?lcnt/R?s?nsih3e Party -- _ .-`_. .. .
5.3 Medical Assistance Benefits.
(a) Obligations of Resident. Resident is obligated to make full
and complete disclosure regarding all financial resources and income during the
application process, including all transfers of assets and/or financial resources having
taken place within the preceding five years of the .date of application for admission to
Facility. Failure to identify all resources, income, and transfers or the submission of
false information may result in the termination of this Agreement and financial liability.
Resident and/or Financial Responsible Person is obligated to notify_Facility when only
Fifteen Thousand Dollars ($15,000), or the value thereof, exists to satisfy the Resident's
financial obligations under this Agreement. Resident is obligated to apply for Medical
Assistance benefits at such time as Resident's resources will no longer be sufficient to
pay all Facility charges for Resident's care and stay.
(b) Patient Pay Amount. For residents approved for Medical
Assistance benefits, Facility will accept payment from DPW and; if applicable, the
Resident's PatientTay Amount as determined by DPW as payment in full only for those
services covered by the Medical Assistance program. During the period of time that the
application for Medical Assistance benefits is pending, Resident' and/or Financial
Responsible Person is obligated to assign such Patient Pay Amount as estimated by
Facility and the Local County Assistance Office, less any qualified medical expense
deductions, on a monthly basis at the time of application for Medical Assistance
benefits. Services not covered by Medical Assistance are identified in the Medicaid
Handout, and Resident remains obligated to pay for such services.
(e) Determination of Eligibility. Resident and Financial
Responsible Person are.obligated to cooperate fully in any Medical Assistance eligibility
determination or redetermination process. In the event that Resident's eligibility for
Medical Assistance benefits is denied, interrupted or terminated due to the failure of
Resident or Financial Responsible Person to cooperate in the Medical Assistance
application, redetermination or appeal process, the Resident and Financial Responsible
Person shall be liable for the applicable Basic Daily Rate plus charges for ancillary
services and supplies, during any period of non-payment.
. (d) Authorization to AuRly for and/or Appeal (Medical
Assistance). In the event of Resident's incapacity and in situations where Resident's
resources are depleted or appear to be depleted to the extent that Resident can no
longer pay privately for nursing care, and it appears that Resident has become or will
become eligible for Medical Assistance benefits to cover the cost of Resident's continued
stay in the Facility; and if there is no other legal representative of Resident known to the
Facility or other friend or- relative known to the Facility who is authorized and/or is
available or willing to act on Resid'ent's behalf, after the Facility has made a good faith
effort to identify such persons; then Resident hereby authorizes the Facility to request,
file and/or apply for Medical Assistance benefits on behalf of Resident for the limited
purpose of assisting Resident to secure payment through the Medical Assistance
6 Resident/Responsible Party ?1.,1? ;„_ L
program for Resident's continued stay in the Facility. In the event the application for
Medical Assistance benefits filed on behalf of the Resident is denied, or in the event
Medical Assistance benefits are granted and subsequently discontinued, Resident
hereby authorizes the Facility to file on Resident's behalf an appeal of any such denial
of Medical Assistance eligibility or discontinuance of Medical Assistance benefits, and
to take such actions to secure Resident's Medical Assistance benefits as the Facility
deems reasonably necessary or appropriate and consistent with law. Resident warrants
and represents that the financial information disclosed in the admission documents is
true and accurate and may be relied on by the Facility in pursuing Medical Assistance
benefits on behalf of Resident.
5.4 , Medicare Part A and. Part B Benefits. To the extent that Resident is
a beneficiary under either Medicare Part A or Medicare Part B -insurance and the
nursing services or ancillary services or supplies ordered by a physician are covered by
such insurance, the Facility or other provider will bill the charges for the covered
services or supplies to the Medicare program. The Resident is responsible for and shall
pay any co-insurance or deductible amounts under Medicare- Part A or Part B
insurance. Facility shall accept payment from the Medicare intermediary as payment in
full only for those services deemed to be covered in full under the Medicare Part A or
the Medicare Part B program. Services not covered by Medicare are identified in the
Admission Package of information provided prior to or at the time of admission.
5.5 - Non-Covered Services. Resident is and remains obligated to pay
Facility for services and supplies not covered by the Medical Assistance or the Medicare
programs
5.6 Medicare Part D Prescription Drug Benefits.
(a) Enrollment in Medicare Part D Plan. If Resident is an eligible
beneficiary under the Medicare Part D insurance program and has enrolled or has been
mandatorily enrolled iiz a Medicare Part D Prescription Drug or Medicare Advantage
Plan ("PDP"), Resident shall advise Facility in writing of Resident's chosen PUP upon
admission. In the event that Resident becomes an eligible beneficiary under Medicare
Part D after admission, or subsequently chooses to enroll in a PDP following admission,
Resident shall notify Facility in writing of Resident's chosen PDP prior to enrollment in
the PDP. Resident"shall advise Facility if Resident elects to change PDPs, and shall
provide written notice of such election, including the name/identity of tlae newly-
selected.PDP prior to the effective date of the change in the PDP.
(b) Resident's Responsibility to Pay for Pharmaceuticals. Resident is
responsible to pay the charges for all prescription and other drugs or medications while
a resident in Facility, except to the extent that such drugs and medications are covered
in whole or in part by any applicable government reimbursement program. Same or all
of the charges for prescription drugs and other drugs and medications may be covered
by certain benefits available through Medicare Part D or other private insurance or
7 Resident/Respoasibief' art?
governmental insurance/benefit progranLS, including Medicare Part A or B. In the
event that coverage for any prescription drug, supply, medication ,or pharmaceutical
provided to Resident is denied by any applicable -governmental reimbursement
program or other potentially available third party payor or insurance program, then
Resident or Responsible Person shall remain responsible to pay for all such prescription
drugs, supplies, other medications or pharmaceuticals.
(c) Actions of Medicare Part D Plan. Facility is not responsible for and
has made no representations regarding the actions or decisions of any PDP, including,
but not limited to, decisions relating to the establishment of the PDP formulary, denial
of coverage issues, or contractual arrangements between the PDP and the Resident, and
with respect to any decisions made by the PDP relating to any long term care pharmacy
provider that maybe under contract with Facility.
(d) Dually Eligible Residents. If Resident becomes eligible for
Medicaid at any time during Resident's stay at Facility, and also qualifies for benefits
under the Medicare Program, then Resident shall be required to enroll in a PDP to
ensure coverage of Resident's prescription drug needs. Resident and/or Responsible
Person shall take all necessary action to enroll Resident in a PDP, and shall advise
Facility of such enrollment upon Resident's acceptance into the PDP. Resident
acknowledges that should Resident and/or Responsible Person fail to select a PDP, then
the federal Centers for Medicare and Medicaid Services ("CMS") will assign Resident to
a PDP. Resident shall provide. written notice to Facility of the name of the Resident's
PDP and the effective date of enrollment.
(e) Billing and Resident Cost Sharing Obligations. 7o the extent that
Resident is a beneficiary under Medicare Part D. and the pharmacy prescriptions
and/or services ordered by a physician are covered by Medicare Part D, then the
Pharmaceutical Provider (as required by law) shall bill the charges for the covered
services to the Resident's PDP. Resident is responsible for and shall pay any and all
cost-sharing amounts. applicable under Medicare Part D insurance. Facility shall not be
responsible to pay for any fees or cost-sharing amounts, including' co-insurance and
deductibles, relating to the provision of covered Medicare Part D pharmaceuticals to
Resident. To the extent that Resident may qualify as a "subsidy eligible individual" who
would be entitled to a reduction or elimination of some or all of the cost-sharing or
premium amounts under the Medicare Part D benefit, Resident and/or Responsible
Person has the sole responsibility to apply for such benefits.
(f) ' Authorization to Request and/or Appeal Coverage
Determinations. In the event that Resident is denied. coverage under Resident's PDP for
pharmaceutical services or supplies prescribed by Resident's attending physician, then.
the following shall apply:
(1) Resident and/or Responsible Person may independently (i)
request an exception from Resident's PDP to cover non-formulary or non-covered
8 Resident/ Responsible Party. _. Z`_?_?z... ??._._...._..
Medicare Part D drugs that are otherwise needed or required by Resident; (ii) file a
request for a redetermination of any coverage denial issued by Resident's PDP ; (iii) file
an appeal with the appropriate agency and judicial tribunals to challenge any denial of
a request for redetermination.
(2) In the event of Resident's incapacity, and if there is no other
legal representative of Resident known to the Facility or any other friend or relative
known to the Facility who is authorized and/or is promptly available or willing to act
timely on behalf of Resident, or if Resident's physician is unable or unwilling to act on
behalf of Resident, then Resident authorizes Facility to (i) request an exception from
Resident's PDP to cover non-formulary or non-covered Medicare Part D drugs that are
otherwise neededlor required by Resident; (ii) file a request for a redetermination of
any coverage denial issued by Resident's PDP; (iii) file an appeal with the appropriate
agency and judicial tribunals to challenge any denial of a request for redetermination.
[(3) In the event of an initial denial of coverage by the Resident's
PDP, then pending the outcome of an exception request, a request for redetermination,
or an appeal, and in the event that Resident's attending physician fails to prescribe a
clinically and reasonably acceptable substitute prescription medication, Resident
authorizes the Facility's Medical Director to prescribe a clinically and reasonably
acceptable substitute prescription medication which is covered by Resident's PDP, if
such clinically and reasonably acceptable substitute is available.]
(4) If a request for exception (filed by Resident, Facility or any
other authorized representative) is ultimately denied following either reconsideration
by the PDP or appeal to an appropriate tribunal, and if the requested pharmaceuticals
are deemed medically necessary by Resident's physician, and no reasonably acceptable
substitute, as determined by Facility's Medical Director, from the formulary of
Resident's PDP exists, then Facility shall make arrangements to provide the requested
pharmaceuticals to Resident through an arrangement with an outside pharmacy. In
any such situation, Resident shall be responsible to pay all fees and costs for the non-
covered pharmaceuticals, consistent with the requirements of this Section_
(g) No Effect on Medicare Part A Covered Nursing Services.
Resident's Medicare Part D prescription drug benefits do not apply tivlaile the Resident's
stay in Facility is covered under Medicare Part A. While Resident is in Facility on a
Medicare Part A stay, Resident's pharmaceutical needs generally are covered by the
Medicare Part A program.
6. MANAGED CARE ORGANIZATIONS.
6.1 Participation in Managed Care Organizations. Facility may
be an authorized provider of skilled nursing services to members of certain irnanaged
care organizations ("MCOs"). The MCOs for whom Facility is an authorized provider
9 resident/Responsible Partyp
are identified in the Admission Package of information provided prior to or at the time
of admission
6.2 Enrollment in a Managed Care Organization. Resident shall
notify Facility in writing prior to enrolling with a MCO or switching Resident's NiCO
enrollment.
6.3 Actions of Managed Care Organizations. Resident acknowledges
that an MCO for whom Facility is not an authorized provider may not approve
payment for services provided by Facility. Resident acknowledges that Facility is not
responsible for and has made no representations regarding the actions or decisions of
any MCO for whom Facility is an authorized provider, including decisions relating to
denial of coverage.
6.4 Obligations of Resident. Facility will accept payment from the
MCO as payment in full only for those services and supplies covered by the MCO and
determined to be paid in full by Agreement between Facility and M(fO. Resident is
responsible for any co-payments or other costs assigned to Resident under the specific
terms of the managed care plan. Resident also shall pay for any services or supplies not
covered by the MCO under the specific terms of the managed care plan. Co-payments
and other costs assigned to Resident and charges for services or supplies not covered by
the specific terms of the managed care plan are identified in the Admission Package of
information provided prior to or at the time of admission. Managed care plans typically
require pre-authorization of services by the MCO. If Resident chooses to have services
which the MCO refuses to pre-authorize, Resident shall pay Facility for those services.
Resident shall pay the Facility in a timely manner for all non-covered -services
retroactive to the date of the initial delivery of services.
6.5 Withdrawal from Participation in the MCO. Facility reserves the
right to terminate its contractual relationship and its status as an authorized provider
with one or more of the listed MCOs at any time in accordance with law and the terms
of the applicable agreement. In the event that Facility terminates its contractual
relationship with the MCO in which Resident is enrolled, Resident may convert his or
her coverage to a health plan for whom Facility is an. authorized provider or transfer to
a Facility that is an authorized provider for Resident's MCC. Facility shall provide
thirty (30) days advance notice of its decision to withdraw as a participating provider
from Resident's MCO so Resident and the MCO can coordinate a transfer to another
Facility.
6.6 Notice of Change in Insurance Coverage. "Resident and/or
Financial Responsible Person shall notify the Facility immediately of any change in
Resident's insurance status or coverage.
4?? -
1n Pe SidCJ1t/ReSPOf'1Si1)1O Part"}I V 41.
7. DURABLE FINANCIAL POWER-OF-ATTORNEY.
Resident is strongly encouraged to furnish to Facility, no later than the
date of admission or within five day(s) of admission, a Durable Financial Power-of-
Attorney executed by Resident relating to financial decisions and payment for services.
The Durable Financial Power-of-Attorney shall be maintained in the files of Facility.
The name, address and phone number of Attorney-in-Fact:
X71/ l70
?i` - Lf'7f
1n the event a Durable Financial Power-of-Attorney does not exist and if
Resident is competent or becomes competent to declare an individual to serve as
Power-of-Attorney, every effort will be expended to obtain such authorization as soon
as practicable. In the event Resident fails to designate an Agent under a Power-of-
Attorney, Resident shall be responsible to pay for any guardianship proceedings related
to the appointment of someone or a legal entity to make decisions on behalf of Resident,
if and when Resident lacks capacity to make such decisions as determined by Facility.
8. THIRD-PARTY PAYMENTS.
8.1 - Eligibility for Third-Party Payments. Resident may be or may
become eligible to receive financial assistance, reimbursement, or other benefits from
third parties, such as private insurance, employee benefit plans, Medical Assistance
benefits under the Pennsylvania Medical Assistance Program, Medicare benefits,
managed care coverage, supplementary medical or other health insurance,
supplemental security income insurance, or old-age survivors' or disability insurance.
It is the responsibility of the Resident to apply for these benefits. If Resident is or
becomes eligible to receive payments from any third parties for Resident's stay and
care, Facility reserves the right to collect such payments directly from the third-par. ty
source. The Resident and Financial Responsible Person shall at all times cooperate fully
with Facility and each third-party payor to secure payment. Cooperation includes
providing information, signing and delivering documents, and assigning to Facility (to
the extent permitted by law) any payments for the Resident f-roin Federal Social Security
benefits or from any other federal or state governmental assistance programs,
reimbursement or benefits to the extent of all amounts due the Facility. Resident and
Financial Responsible Person agree to reimburse Facility for any and ail costs incurred
by Facility to collect such payments directly from the third-party source.
8.2 Assignment of Payments. Although it is the responsibility of
Resident and Financial Responsible Person to secure payment from third-party
resources, including but not limited to Medical Assistance Ei`nefits, Resident
irrevocably authorizes Facility to makes such claims and to take such actions as it
deems necessary to: secure for the Facility receipt of third-party payments, including but
11 resident/Responsible Parly ? .?•.
not limited to Medical Assistance Benefits, to reimburse Facility for its charges for the
stay and care of Resident. (This includes but is not limited to filing an application for
Medical Assistance Benefits and pursuing any and all appeals there from in the event
the application is denied.) To the fullest extent permitted by lacy, as security for
payment of Facility's charges, Resident hereby assigns to Facility all of Resident's rights
to any third-party payments now or subsequently payable to the extent of all charges
due under this Agreement. (This includes but is not limited to Medical Assistance
Benefits.) Resident or Financial Responsible Person promptly shalt endorse and turn
over to Facility any payments received from third parties other than Medical Assistance
Benefits which are paid directly to Facility to the extent necessary to satisfy the charges
under this Agreement.
8.3 Authorization for Payment of Medicare Benefits.
In authorizing Facility to seek payment of Medicare Benefits on Resident's
behalf, Resident and/or Authorized Legal Representative hereby certifies that the
information provided as to Resident in conjunction with Resident's. application for
payment under Title XIII of the Social Security Act is correct. Moreover, Resident
and/or Authorized Legal Representative hereby authorizes the release of any
information needed to act on this request, and requests that payment of authorized
benefits be made on Resident's behalf.
in addition to the foregoing, Resident and/or Authorized Legal Representative
authorizes the release of any information concerning this, and/or any. other related
Medicare claim, to the Centers for Medicare and Medicaid Services by any holders of
medical and/or other information concerning Resident.
8.4 * Insurance. In the event of an initial or subsequent denial of
coverage by the Resident's insurance company, Resident shall pay Facility timely for all
noncovered services retroactive to the date of the initial delivery of services.
9. PERSONAL FINANCES.
9.1 Personal Funds Management. Resident is responsible to provide
his or her personal funds, and Resident has the right to manage his or her personal
funds. Resident may authorize Facility, in writing on a document provided by Facility,
to hold Resident's personal funds, and may revoke at any time Facility's authorization
by providing Facility with a written notice signed and dated by Resident or either
Responsible Person. If Resident authorizes Facility to hold Resident's personal funds,
the Facility shall "hold, safeguard and account for Resident's personal funds in
accordance with applicable provisions of Facility Policy. This section does not refer to
the financial assets of the Resident except for those funds required by law or established
by Facility policy as the minimal personal funds of. Resident. The Facility does not
assume any obligation to provide financial or investment advice, nor to file any tax
i:esidenl/Respar?siL•Ee Par?y_. !? ^_„
12
?c
documents . or other reporting documents except as required by the
I icensure/ certification regulations governing nursing facilities.
9.2 Refunds of Personal Funds. Any personal funds or valuables of
Resident held by Facility will be refunded within thirty (30) days after deductions for
payment of any outstanding bills or other amounts due the Facility after Resident's
discharge or death. In the event of Resident's death, such refund will be made to the
duly authorized representative of Resident's estate or to such entities or persons
entitled to the refund under current law.
9.3 Refunds of Prepayments or Overpayments. Any prepayments or
overpayments made by Resident and held by Facility will be refunded within thirty (30)
days after Resident's discharge or death after deductions for- payment of any
outstanding bills or other amounts due the Facility. In the event of Resident's death,
such refund will be made to the duly authorized representative of Resident's estate or
to such other entities or persons entitled to the refund under current law. No interest
shall accrue on any funds required to be refunded under this Agreement.
10. CHANGES IN ROOM ASSIGNMENTS.
Facility reserves the right and discretion to transfer Resident to another
room or bed within the Facility consistent with the safety, care and welfare needs of
Resident. Facility reserves the right and discretion to transfer Resident's roommate, if
any, at any time consistent with the needs of the Facility.
11. TERMINATIONS, TRANSFER OR DISCHARGE.
11.1 Resident Initiated. Resident may tort-ninate this Agreement upon
fifteen (15)) days written notice to Facility. If Resident leaves Facility for any reason
other than a medical emergency or death, Resident must give written notice to Facility
at least fifteen (15) days in advance of transfer, discharge or termination of this
Agreement. If advance written notice is not given to Facility, there will be due to
Facility the applicable Basic Daily Rate and other charges then in effect for Resident's
stay and care for the required fifteen (15) day notice period. The charge applies
whether or not the Resident remains at Facility during the fifteen (15) day notice period.
The charge specified in this section does not apply to a resident whose payor source is
Medicare Part A or Medical Assistance.
11.2 Facility Initiated. Facility may terminate this Agreement and
Resident's stay and transfer or discharge Resident if:
(a) Transfer or discharge is necessary to meet Resident's
Welfare, and Resident's needs cannot be met in Facility.
13 Resident/responsible PariJ_
(b) Resident's health has improved sufficiently so that Resident no
longer needs the services provided by Facility;
(c) The safety or health of individuals in Facility is
or otherwise would be endangered;
(d) Resident has failed, after notice, to pay for (or to have paid
or treated as paid under the Medicare or Medical Assistance
Programs) charges for Residents care and stay at Facility;
(e) Facility ceases to operate.
11.3 Notice and Waiver of Notice. Facility will notify Resident and
Health Care Responsible Person (or if none, a family member or legal representative of
Resident, if known to Facility)* at least thirty (30) days in advance of transfer or
discharge. However, in any case described in Subparagraphs (a), (b), (c) above. Facility
will give only such notice before transfer or discharge as is reasonable or as required by
applicable law under the circumstances.
11.4 Withdrawal against Advice. In the event Resident withdraws from
the Facility against the advice of his/her attending physician and/or without approval
of the Facility, all of Facility's responsibilities for the care of Resident are terminated,
effective at such time as Resident withdraws from the Facility.
12. READMISSION - BBD HOLD POLICY.
12.1 Private Pay Residents. If Resident leaves Facility for a period of
hospitalization, therapeutic leave, or any other reason (other than Resident's death),
and if Resident is not eligible for, or receiving, Medical Assistance benefits, Resident's
bed will be reserved through payment of the Basic Daily Rate. Facility will continue to
hold the bed until notified in writing by Resident or both Responsible Persons that the
bed is no longer desired. If Resident elects in writing not to reserve a bed, then
Resident will be discharged from Facility and readmission to Facility shall be subject to
bed availability.
12.2 Medical Assistance Residents. If Resident is eligible for, or is
receiving Medical Assistance benefits, and Resident leaves Facility for a period of
hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable
maximum number of days, paid for a reserved bed under the Pennsylvania Medical
Assistance Program. The bed reservation period may be subject to change in accordance
with any changes in the Programs. If the period of hospitalization or! therapeutic leave
exceeds the maximum time for reservation of a bed under the Programs, Resident will
be entitled to the first available accommodation suitable for Resident's?level of care if, at
the time of readmission, Resident requires the services provided by the Facility.
Alternatively, following the lapse of the bed reservation period covered by the Medical
14 Resident/Responsible Party_ J ! ^_L7--,
Assistance Program, Resident may reserve a bed by electing tci pay the Medical
Assistance per diem rate charged invnediately prior to the leave, and by providing
ivritten notice and advance payment for the days included in the reservation period.
12.3 Medicare Residents: In the event that a Resident eligible for
Medicare Part A benefits is transferred to or readmitted to a hospital, Medicare Part A
eligibility will be terminated on the day the Resident is admitted to the hospital.
Resident's bed will be reserved at Basic Daily Rate, unless Resident or Responsible
Person elects, in writing, not to reserve a bed.
13. FACILITY RULES, REGULATIONS, POLICIES AND PROCEDURES.
Resident shall comply fully with all governmental laws and regulations,
the provisions of this Agreement, and Facility's rules, regulations, policies anal.
procedures as made available by Facility. Facility reserves the right to amend or change
its rules, regulations, policies and procedures. Facility's rules, regulations, policies and
procedures shall not be construed as imposing contractual obligations on Facility or
granting any contractual rights to Resident, and are subject to change from time-to-time.
14. PERSONAL AND OTHER PROPERTY.
14.1 Responsibility for Maintenance and Loss. Resident is responsible
for furnishing and maintaining his or her own clothing and other items of property as
needed or desired. Resident may obtain at his or her own expense,' casualty insurance
to cover potential damage to or loss of any of Resident's personal property. If damage
or loss occurs to resident property, the Facility will investigate each incident of loss or
damage to determine liability and assess responsibility depending on the facts and
circumstances of each incident. Facility shall be responsible for only such losses or
damages as are attributed by Facility to the negligence or culpability of the Facility.
14.2 Disposition and Storage Upon Resident's Death. In the event of
Resident's death, Facility shall contact Resident's authorized representative within
twenty-four (24) hours to arrange for an inventory of Resident's personal property. The
Facility is authorized to transfer Resident's personal property to a duly authorized
representative of Resident's estate or to such parties or persons entided to the property
under current law. The duly authorized representative of Resident's estate or other
persons entitled to property under current law must acknowledge, in writing, the
receipt of the personal property transferred to his or her custody by Facility. After
completing an inventory, Facility, in its sole discretion, may move and place Resident's
personal property into storage at Facility's expense. If property held in storage is not
claimed within thirty (30) days, Facility shall send a notice to the authorized
representative via certified mail that if items in storage are not removed within fourteen
(14) days, Facility may dispose of Resident's property.
15 14-sidmt/ResponsiblePalty.1 1J ,-.L___,_
14.3 Disposition and Storage Upon Resident's Transfer or Discharge.
If Resident's personal property is not claimed or removed within twenty-four (24) hours
of Resident's permanent transfer or discharge, Facility shall move and place Resident's
personal property in storage until claimed. If Resident's personal property remains
unclaimed for seven (7) days after permanent transfer or discharge, Resident shall be
obligated to pay a storage fee as assessed by Facility. After a thirty (30) day period in
storage, the Facility may dispose of Resident's property. The Facility is not responsible
for any damages incurred to Resident's property if storage becomes necessary.
Resident or Resident's estate shall be obligated to pay all costs of storage or disposition
and shall bear the risk of lass or damage to the property.
14.4 Damage to Room or Facility Propel. Resident or Resident's
estate is responsible for any damages caused to Facility property beyond normal wear
and tear, and shall pay for the repair and replacement of damaged property, based on
the actual charge to Facility for such repair or replacement.
15. RESIDENT RECORDS.
Resident records shall be handled in accordance with the Facility's Privacy
Policy that Resident hereby acknowledges receiving.
16. MEDICAL TREATMENT AUTHORIZATION.
Resident authorizes Facility to provide care and treatment in accordance
with orders of Resident's personal physician and consistent with the terms of this
Agreement.
17. DEATH OF RESIDENT.
In the event of Resident's death, Facility shall notify the person(s)
designated by Resident. Facility is authorized to arrange for the transfer of Resident's
body to the designated funeral home. Resident`s estate is responsible for the payment of
all costs associated with the transfer and funeral expenses and Facility reserves the right
to require proof of financial responsibility for payment of burial expense prior to
admission. Person or Funeral Home to be notified:
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t ) 1
Resident shall notify Facility of any change of Person or Funera I Home to be notified.
18. CAPACITY OF RESIDENT AND GUARDIANSHIP. '
16 Resident/RLsronsible Party_._ 1/r,
. ?? . - -
If Resident is, or becomes unable, to understand or coninlunicate, and is
determined after admission to be incapacitated by Resident's Physician or Facility's
Medical Director, Facility shall have the right, in the absence of Resident's prior
designation of an authorized legal representative, or upon the unwillingness or inability
of the legal representative to act, to commence a legal proceeding to adjudicate Resident
incapacitated and to have a court appoint a guardian for Resident. The cost of the legal
proceedings, including attorney's fees, shall be paid by Resident or Resident's estate.
19. FACILITY'S GRIEVANCE PROCEDURE.
19.1 Reporting Complaints. If Resident, Responsible Persons, or
Resident's attorney-in-fact believe(s) that Resident is being mistreated in any way or
Resident's rights have been or are being violated by staff or another resident, Resident
Responsible Persons, or Resident's attorney-in-fact shall make his/her complaint
known to Facility's staff. Resident, Responsible Persons, or Resident's attorney-in-fact
must first notify Facility of any such complaints, and provide the Facility with sixty (60)
days to resolve the complaint satisfactorily to Resident before the Resident may pursue
mediation. This notice requirement is not intended to preclude Resident, Responsible
Persons, or Resident's attorney--in-Fact from filing a complaint with any appropriate
governmental regulatory agency.
19.2 Facility's Obligations. Facility will review and investigate the
complaint and provide a- response to Resident/ Resident's Attorney-in-fact or
Responsible Persons.
19.3 Mandatory Mediation. The parties agree that they shall in good
faith attempt to resolve any controversy, dispute or disagreement arising from or
relating in any way to this Agreement and/or the provision of services by the Facility
under this Agreement through negotiation. Should the parties be", unable to reach a
resolution within sixty (60) days of initial notice of the dispute, the parties shall submit
the controversy, dispute or disagreement to mediation before an impartial mediator,
which mediation shall be conducted at the Facility or at a site within a reasonable
distance of Facility, in accordance with the Rules of Procedure utilized by Scanlon ADR
Services, or an alternative neutral, third-party arbitrator selected by Guardian Elder
Care. The mediator will assist the parties with their negotiations and attempt to
facilitate an amicable resolution of the controversy, dispute or disagreement. In the
event the parties are unable to resolve their dispute through mediation, and Resident
and/or his/her authorized legal representative has voluntarily elected to submit to
binding arbitration pursuant to the terms of the Voluntary Arbitration Agreement, then
the dispute shall be submitted for resolution by arbitration as provided within the
separate Voluntary Arbitration Agreement. The parties agree that they may not
proceed to arbitration unless and until the matter is first submitted to mediation under
this provision and the mediation is completed.
17 Resident/Rc-spornsitale early,. _.LLI_i;• ;L
The parties agree that this provision does not cover issues relating to
Medical Assistance eligibility, applications and/or appeals and does not affect any civil
or judicial actions which seek to compel compliance with the Resident's or their
responsible parties' duties to undertake, complete and cooperate with the Medical
Assistance application and appeal process. Further, the parties agree that this provision
does not apply to any guardianship proceedings resulting from the alleged incapacity
of the Resident.
The costs of the mediation will be split equally behVeen. the parties.
However, both parties will be responsible for their own attorney's fees should either
decide to retain legal counsel. The mediator shall have the right to suggest or negotiate
for the redistribution of the costs between the parties if it is deemed ;appropriate during;
mediation.
if a resolution is reached at mediation, the parties agree that such
resolution will be reduced to writing in the form of a settlement agreement and signed
by both parties. The signed settlement agreement will be the final resolution of the
controversy, dispute or disagreement.
(a) Exception From Mediation. Those disputes which have
been excluded from mandatory mediation (i.e., guardianship proceedings, and issues
relating to Medical Assistance eligibility, applications and/or appeals) may be resolved
through the use of the judicial system. In situations involving any of the matters
excluded from mandatory mediation, neither you nor the Facility is required to use the
mediation process. Any legal actions related to those matters may be filed and litigated
in any court which may have jurisdiction over the dispute.
(b) Rifht to Legal Counsel. Resident has the right to be
represented by legal counsel in any proceedings initiated under this mediation
provision. Because this mediation provision addresses important legal rights, Facility
encourages and recommends that Resident obtain the advice and assistance of legal
counsel to review the legal significance of this mandatory mediation provision prior to
signing this Agreement. i
(c) Time Limitation for Mediation- Any request for mediation
of a dispute must be requested. and submitted to the.Facility prior to the lapse of one (1)
year from the"date on which the event giving rise to the dispute occurred. The failure to
submit a request for mediation to the Facility within the designated time shall operate
as a bar to any subsequent request for Mediation, or for any claim for' relief or a remedy,
or to any arbitration, action or legal proceeding of any kind or nature; and the parties
will be forever barred from mediating, arbitrating, or litigating a resolution to any such
dispute.
19.4 Voluntary Binding Arbitration. The parties agree that the election
by Resident and/or Hs/her authorized legal representative to submit to binding
18 Resident/responsible Party
arbitration in accordance with the terms of the separate Voluntary /Arbitration
Agreement is not a requirement for admission to the Facility. Further, the Facility and
Resident and/or his/her authorized legal representative also agree that election to
participate in binding arbitration as a means of alternative dispute resolution precludes
them from pursuing any litigation relating to all past and/or future claims and known
and/or unknown damages arising from any period of residency by Resident at the
Facility (past and future) and, in exchange for waiving that right, the parties receive
those benefits which arbitration offers including, but not limited to, confidentiality,
decreased litigation expense and/or expedited dispute resolution. In the event that the
Resident and/or his/her authorized legal representative has elected to sign the
Voluntary Arbitration Agreement, the entirety of the attached Voluntary Arbitration.
Agreement is hereby incorporated as though fully set forth at length herein.
(a) Exception From Arbitration. 'Those disputes which have
been excluded from arbitration (i.e., guardianship proceedings, and issues relating to
Medical Assistance eligibility, applications and/or appeals) may be resolved through
the use of the judicial system. In situations involving any of the matters excluded from
arbitration, neither you nor Facility are required to use the arbitration process. Any
legal actions related to those matters may be filed and litigated in any court which may
have jurisdiction over the dispute. `t`his arbitration provision shall not impair the rights
of Resident to appeal any transfer and/or discharge action initiated by the Facility to
the appropriate administrative agency, and after the exhaustion of such administrative
appeals, to appeal to the court exercising appellate jurisdiction over'the administrative
agency.
(b) Right to Legal Counsel. Resident has the right to be
represented by legal counsel in any proceedings initiated under an executed Voluntary
Arbitration Agreement. Because arbitration addresses important legal rights, Facility
encourages and recommends that Resident obtain the advice and assistance of legal
counsel to review the legal significance of the Voluntary Arbitration Agreement before
executing same.
20. NOTICE.
Wherever written notice is required to be given to Facility under this
Agreement, it shall be sufficient if notice is provided by personally delivering it or b_y
first-class mail, return receipt requested.
`)'emlmk L=. L ?,.-?cz Y ?'
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19 Residerit/Rvspo lslWe Party. _../
Notice to Resident will be provided by personal delivery to Resident's room, or where
applicable, by first-class mail to responsible Person(s) or other designated person.
21. RESIDENT OBLIGATIONS.
If Resident is responsible for any actions or omissions that cause damage or
injury to other persons and residents or the property of other persons or residents, then
Resident shall be liable for such damage to the fullest extent permitted by law.
22. INDEMNIFICATION.
Resident is responsible to pay for any damages or injuries caused by resident to
other persons, residents or staff and shall indemnify and hold Facility harmless from
any claims, actions or proceedings against Facility resulting from Resident's actions or
omissions.
23. MISCELLANEOUS PROVISIONS.
23.1 Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the Commonwealth of Pennsylvania and shall
be binding upon and inure to the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
23.2 - Severabili!y The various provisions of this Agreement shall be
severable one from another. If any provision of this Agreement is found by a court or
administrative body of proper jurisdiction and authority to be invalid, the other
provisions shall remain in full force and effect as if the invalid provision had not been a
part of this Agreement.
23.3 Captions. The captions used in connection with the sections and
subsections of 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, nor shall such captions be
given any legal effect.
23.4 Entire Agreement. The Admission Agreement consists of the
entire Agreement between the parties and supersedes, merges and :replaces, all prior
negotiations, offers, warranties and previous representations, understandings or
agreements, oral or written, between the parties.
23.5 Modifications. Facility reserves the right to modify unilaterally the
terms of this Agreement to conform to subsequent changes in law or regulation. To the
extent reasonably possible, the Facility will give Resident and Resident's Responsible
Person(s) thirty (30) days advance written notice of any such modifical.ians.
20 Residenl/PcvE?onsit?le Par' ? r .C ..`
23.6 Waiver of Provisions. Facility reserves the right to waive any
obligation of Resident under the provisions of this Agreement in its sole and absolute
discretion. No term, provision or obligation of this Agreement shall;•be deemed to have
been waived by Facility unless such waiver is in writing by Facility. Any waiver by
Facility shall not be deemed a waiver of any other term, provision or obligation of this
Agreement, and the other obligations of Resident and this Agreement shall remain in
full force and effect.
24. ACKNOWLEDGMENTS.
24.1 Facility Charge Schedules. Resident and Responsible Person(s)
acknowledge the receipt of a copy of the Facility Charge Schedules provided with the
Admission Package and the opportunity to ask questions about Facility's charges.
24.2. Resident Rights. Resident and Responsible Person(s) acknowledge
being informed orally and in writing of Resident's Rights as specified in the current
publication required by law and further acknowledge having an opportunity to ask
questions about those rights. The Notice of Rights of Nursing Facility is subject to
change from time-to-tinge and shall not be construed as imposing any contractual
obligations on Facility or granting any contractual rights to Resident.
24.3 Advance Directives. Resident and Responsible Person(s)
acknowledge being informed, orally and in writing, of Facility's policy on advance
directives and medical treatment decisions.
24.4 Agreement. Resident and Responsible Person(s) acknowledge that
they have read and understand .the terms of this Agreement, that the terms have been
explained to them by a representative of Facility, and that they have had an opportunity
to ask questions about this Agreement.
24.5 Admissions Package. Resident and Responsible Person(s)
acknowledge the receipt of a copy of the Facility's Admission Package and the
opportunity to ask questions about Facility's policies contained therein. The Admission
Package content is subject to change from time-to-time and shall not be construed as
imposing any contractual obligations on Facility or granting any contractual rights to
Resident.
21 Resident/Responsible Party f C L 1 - Y1;.,
` !_
IN WITNESS tAv9--IEREOF, the parties, intending to be legally bound, leave
signed this Nursing Facility Agreement on this i._`3? day of
Witness
Resident
Witness Financial Responsible Person
Witness Health Care Res ? nsit)le Person (if any)
Facility
By.
P%esidenl/Rcsponil,le? Party
EXHIBIT "B"
MEDICAID Notice ID: 93465389 PAGE 1 OF 1
P . 0. EBOX 599CAO NOT ELIGIBLE
P.O. BOX 5
33 WEST14INSTER DRIVE NOTICE -
CARLISLE PA 17013-0599
ADDRESS :'..0036 21 0124189 0 PAII 00
CAO RETURN
+01022318900*
MILDRED LEINAWEAVER
FOREST PARK HEALTH CENTER
7 0 0 WJUNUT BOTTOM RD
CARLISLE PA 17013
WORKER: 3 PEIPER
TELEPHONE: (800) 269-0173
MAIL DATE: 04/03/2009
NOT: 079 OPT: 0 TYPE: N
IF YOU V NOr UNDERSTAND QUR DECISION OR NAVE ANY
QUESTIONS, ALEASE CONTACT YOUR W01M INNEOIATELY.
Your total available resources $34,216.3 when minus yaur the. $6000 lare gbslowxtheds
the $2000 resource limit. Please reapply
$8000 Resource limit.
Available resources:
F&M Trust checking account - $1382.50
Cash value of Genworth Life and Annuity - $32,833.80
REGULATIONS:55 PA Code 178.1; 178.3
If you disagree with our decision, you have the right to appeal. Sea attacriao Torm
for a m lets ex lanation of ur ri ht to a eat and to a fair heath . If you are
currently receiving benefits and your oral request for a hearing is received in the
County Assistance office or your written request is postmarked or received on or
befora 04/16/2009 your assistance will continue pending the hearing decision,
except when the change is due to State or Federal law.
r! ' ;-?1
t4IDPEM4 LEGAL SERVICES
401-405 LOUTHE.R STREET
CARLISLE PA 17013
(717) 243-9400
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Petition for
Preliminary Injunction was served via fist-class, United States mail, postage prepaid,
upon the following:
Mark Leinaweaver
1275 Creek Road
Mechanicsburg, PA 17055
Dated: (° (6 °?
By:
William Keslar, Paralegal
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC
d/b/a FOREST PARK CENTER,
Plaintiff,
V.
MARK LEINAWEAVER, :
Defendant.
ORDER
No. oq - qa oo
c
JUN 2 4 2009 ?
l??Vc,I Crk
CIVIL ACTION - EQUITY
AND NOW, this day of 2009, a hearing in the
above-captioned matter on Plaintiff's Petition for the issuance of a Preliminary
Injunction is scheduled for 2009, at 9 . c) .m.
in Court Room No. 5 . Cumberland County Courthouse, Carlisle,
Pennsylvania.
BY THE COURT:
FLED-OtTICE
OF 7HE P OTK TARY
ZW9 JUN 2b PM 2: 10
W V W1?i.; ,f i?wt''•X'•?`!w; /?J, iL41p11
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC
d/b/a FOREST PARK CENTER,
Plaintiff, No. 09-4200
V.
MARK LEINAWEAVER, CIVIL ACTION - EQUITY
Defendant.
PRAECIPE TO WITHDRAW
PETITION FOR PRELIMINARY INJUNCTION
TO THE PROTHONOTARY:
Kindly withdraw, without prejudice, the Petition for Preliminary Injunction filed
on June 22, 2009.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: By: -?
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Brandon S. Williams
Attorney I.D. No. 200713
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
ORIGINAL
41
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to
Withdraw Petition for Preliminary Injunction was served via fist-class, United States
mail, postage prepaid, upon the following:
Mark Leinaweaver
1275 Creek Road
Mechanicsburg, PA 17055
Dated: a q
By:
VJ___
William Keslar, Paralegal
FILED- I -? (;E=
TNL E
F,
2009 JUL - I r„ 12: 5 1
c??,a
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE HOME
AND COMMUNITY SERVICES, LLC
d/b/a FOREST PARK CENTER,
Plaintiff,
V.
No. 09-4200
MARK LEINAWEAVER, CIVIL ACTION - EQUITY
Defendant.
PRAECIPE TO WITHDRAW, DISCONTINUE AND END
To the Prothonotary:
Kindly mark the above-captioned action withdrawn, discontinued and ended.
Respectfully submitted,
Dated: 8.2 S
SCHUT,t' BOGAR LLC
By:
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No.: (717) 909-5925
Attorneys for Plaintiff
ORIGINAL
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to
Withdraw, Discontinue, and End was served via fist-class, United States mail, postage
prepaid, upon the following:
Mark Leinaweaver
1275 Creek Road
Mechanicsburg, PA 17055
Dated: 'g 1'- 5- ' 9
By:
V_ _
William Keslar, Paralegal
FILED
OF THE
2009 AUG 27 Fl 14
jNi,
a tiJ,? ?'.1's
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