HomeMy WebLinkAbout09-4845IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No.
V.
G. LUCILLE LUCE and
GORDON LUCE,
aWATem
CIVIL ACTION - EQUITY
Defendants.
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims
set forth in the following pages, you must take action within twenty (20) days after this
complaint and notice are served, by entering a written appearance personally or by
attorney and filing in writing with the court your defenses or objections to the claims set
forth against you. You are warned that if you fail to do so the case may proceed without
you and a judgment may be entered against you by the court without further notice for
any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A
LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166 or (800) 990-9108
ORIGINAL
EN LA CORTE DE ALEGATOS COMON DEL
CONDADO DE CUMBERLAND, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No.
v.
G. LUCILLE LUCE and
GORDON LUCE,
CIVIL ACTION - EQUITY
Defendants.
AVISO PARA DEFENDER
Conforme a PA RCP Num. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de
las demandas que se presentan mas adelante en las siguientes paginas, debe tomar
accion dentro de los proximos veiente (20) dias despues de la notificacion de esta
Demanda y Aviso radicando personalmente o por medio de un abogado una
comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee
a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de
tomar accion como se describe anteriormente, el caso puede proceder sin usted y un
fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra
reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya
por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros
derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A
CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telefono: (717) 249-3166 or (800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No. D Q- q F y S' & T?
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants.
COMPLAINT
AND NOW, COMES, Plaintiff, Guardian Elder Care at Carlisle, LLC d/b/a Forest
Park Health Center ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and
files the within complaint against Defendants, G. Lucille Luce and Gordon Luce
(collectively, "Defendants"), 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 G. Lucille Luce is an adult individual who is a resident at
Plaintiff's skilled nursing facility, located at 1217 Slate Hill Road, Camp Hill,
Pennsylvania 17011.
3. Defendant Gordon Luce, husband to G. Lucille Luce, is an adult individual
who currently resides at 1 West Penn Street, Carlisle, Pennsylvania 17013.
4. On or about February 6, 2009, Defendant G. Lucille Luce applied for
admission to Plaintiff's skilled nursing facility.
5. On or about February 6, 2009, Plaintiff and Defendant G. Lucille Luce
entered into a written Nursing Care Admission Agreement ("Agreement"). Pursuant to
the Agreement, Plaintiff agreed to provide Defendant G. Lucille Luce with skilled
nursing services in exchange for Defendant G. Lucille Luce's promise to pay a specific
monetary fee from her assets, to assign to Plaintiff her right to apply for and obtain
Medical Assistance benefits in the event that she became insolvent, and, in furtherance of
that assignment, she agreed to cooperate fully and secure Medical Assistance benefits.
See a true and correct copy of the Agreement attached hereto as Exhibit "A."
6. At all times material hereto, Defendant Gordon Luce has had a statutory
duty to financially support his wife, G. Lucille Luce. See 23 Pa. C.S. § 4603(a).
7. After Defendant G. Lucille Luce's admission to Plaintiff's skilled nursing
facility, she allegedly became insolvent. As a result, Plaintiff filed an application for
Medical Assistance benefits on Defendant G. Lucille Luce's behalf.
8. The application for Medical Assistance benefits referred to above was
denied because Defendants did not provide the Cumberland County Assistance Office
("CAO") with the information and documentation needed to verify Defendant G. Lucille
Luce's eligibility for Medical Assistance benefits. A copy of the form PA-162 issued by
the CAO denying Defendant G. Lucille Luce's application for Medical Assistance benefits
is attached hereto as "Exhibit B."
2
9. Subsequently, Plaintiff filed an appeal of the CAD's denial of the above-
referenced application for Medical Assistance benefits, and said appeal is currently
pending before the Pennsylvania Department of Public Welfare Bureau of Hearings and
Appeals.
10. If Defendants fail to provide the documents required by the Cumberland
County Assistance Office to determine Defendant G. Lucille Luce's eligibility for Medical
Assistance benefits prior to or at the time of the appeal hearing on the above-referenced
appeal, her application for Medical Assistance benefits will be denied, and any further
appeal to the Commonwealth Court will be without merit.
COUNTI
BREACH OF CONTRACT/ SPECIFIC PERFORMANCE
Plaintiff v. G. Lucille Luce
11. The allegations contained in Paragraphs 1 through 10 are incorporated
herein by reference as if fully set forth at length.
12. Defendant G. Lucille Luce breached her Agreement with Plaintiff by failing
to act in accordance with the terms of the same, as she failed to provide the necessary
documentation to the Cumberland County Assistance Office to determine her eligibility
for Medical Assistance benefits. By doing so, Defendant G. Lucille Luce has interfered
with Plaintiff's right to receive the Medical Assistance benefits that have been
contractually assigned to it.
3
13. 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).
14. As Defendant G. Lucille Luce has failed to provide the necessary
documentation to the Cumberland County Assistance Office as required to process and
approve her application for Medical Assistance benefits, Plaintiff is precluded from
receiving the benefit she assigned to it.
15. Upon information and belief, at all times material hereto, G. Lucille Luce
has been financially unable to fully compensate Plaintiff for the services that it has
rendered to her in accordance with the terms and conditions of the Agreement.
16. Defendant G. Lucille Luce's breach of the Agreement with Plaintiff has
irreparably harmed and continues to cause Plaintiff irreparable harm.
17. 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.
4
COUNT II
SPECIFIC PERFORMANCF,/STATUTORY DUTY OF SUPPORT
Plaintiff v. Gordon Luce
18. The allegations contained in Paragraphs 1 through 17 are incorporated
herein by reference as if fully set forth at length.
19. Defendant Gordon Luce is the husband of G. Lucille Luce.
20. At all times material hereto, upon information and belief, G. Lucille Luce
has been indigent.
21. At all times material hereto, Defendant Gordon Luce has had a statutory
duty to financially support his wife, G. Lucille Luce. See 23 Pa. C.S. § 4603(a).
22. At all times material hereto, Defendant Gordon Luce has failed to
financially support his wife.
23. The statutory duty of Defendant Gordon Luce to support his wife must
reasonably include the duty to assist with securing financial support through the Medical
Assistance benefits system and the duty to not actively work against Medical Assistance
benefits approval.
24. At all times material hereto, Defendant Gordon Luce failed to care for,
maintain or financially assist his wife by refusing to provide the information and
documents requested by the Cumberland County Assistance Office to determine the
eligibility of his wife for Medical Assistance benefits.
5
WHEREFORE, Plaintiff respectfully requests that this Honorable Court order
Defendant Gordon Luce to specifically perform his statutory duty and obligation, and to
produce the information and documents to the Cumberland County Assistance Office
required to secure Medical Assistance benefits for his wife, G. Lucille Luce.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: -7' 6 , 2009 By:
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schut erbo ag_r.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
6
VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing
Complaint are true and correct to the best of my lalowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C.S.A. § 4904, relating to unsworn falsification to authorities.
1
Dated:
Dawn Jordan ? 3
Billing and Collections Coordinator
Guardian Elder Care
EXHIBITA"'A"
GUARDIAN ELDER CARE
NURSING CARE ADMISSION AGREEMENT
This Nursing Care Agreement is made by and between Guardian l-Jder Care
(hereinafter called "Facility"), (11Creinaf ter
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) affirin 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 Dist 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 oil 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 _ v' semi-private accommodations; (c) three meals
each clay and snacks, except as otherwise medically indicated; (d) blankets, bed linens,
towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping; services;
(g) activity programs 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 rite are
intravenous services and supplies; oxygen and supplies; incontinence products;
arnbulance costs; physician fees; most pharmaceutical drugs; personal dry cleaning;
medical tests; laboratory tests; private telephone/ services or television; 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 tune 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 ancillary services and
associated charges, are identified in the Admission Package of information and are
subject to change at the discretion of Facility.
rvsidcnt/Responsible Pam-
1.3 Services of Other Providers. The services of outside providers
such as a licensed physician, dentist, licensed pharmacy for the prevision of
pharmaceutical supplies, a licensed hospital, diagnostic services, labor4atorv, x-ray
podiatry, optometry, medications, ambulance services and hearing aid repair naay bc?
available from time to time at the Facility. These services are available under guidel,iaes
and procedures established by Facility and may be utilized by Resident at llis or her
own expense. Resident may choose to utilize providers of his or her own c}ac?ice-;
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. In the event Resident's
personal physician is unavailable, Facility's Medical Director may. issuQ apl?i-opriate
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 rare.
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. Tile
Basic Daily Rate cnay 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,
cti,hichever 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 terns "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, whiff h 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.=1 (Role of
Primary Medical Physician and Medical Director) unless otlherNv-ise covered in full bN:
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
2 Resident/Responsible Part!'.:"???
furnished by a person or provider made available by Facility, or by a person (-)l- provider
selected by Resident, and whether the goods or services are provided at Iacility or
else«,here. 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 laiv,
prepayment for the basic monthly rate of the current month is required at the tine 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, Lvhich 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
BROCI WAY, PA 15824
3? Late Charges and Cost of Collection. Any invoices not paid
N•vithin thirty (30) days of the date of the invoice are subject to a late charge of one and
()ne-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 thirty (30) days advance written notice of any such changes.
3.4 • Obligations of Resident's Estate and Assignment 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 be an obligation of Resident's estate and may be enforced against
Resident's estate. Resident's estate shall be liable to and shall pay to Facility an amount
equivalent to any unpaid obligations of Resident under this Agreement.
3 Resident/Responsible
4. OBLIGATIONS OF FINANCIAL RESPONSIBLE PERSON.
4.1 General. Resident shall have the right to identify a 1-lealth Mare
Responsible Person (usually this person is the Resident's Poi ver of Attorney or
Guardian of his or her Person.), who shall be entitled to receive notice in the event o[
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 as his/her
l--lealth Care Responsible Person. Resident shall identify a Financial Responsible Person
(usually this person is the Resident's Financial Power of Attorney or Guardian of
his/her Estate) at the time of admission. Resident elects to name
_ as his/her Financial Responsible Person.
Resident's Financial Responsible Person shall sign this Agreement in 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 a 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 cast of
such Guardianship proceedings, including attorneys' fees-
. 4.2 Obligations and Potential Liability. This Agreement shall not Lie
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 or misappropriates
Resident's financial resources for personal benefit or gifts, or otherwise has not or does
nt?t use the Resident's financial resources to fulfill Resident's financial obligations to the
Facility for services and supplies provided to Resident in accordance I- vith this
Agreement, then Financial Responsible Person shall be liable for payment Lip 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 failuro 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 i vith 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 payments 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 anti/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 Fina'ncial Responsible
c?
i ?-
hesidenl/i:??spo??sihte
Person's failure to timely submit or complete a Medical Assistance application or to
cooperate with the Pennsylvania Department 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 nlay 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 clue 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 subinit necessary-
documents or fails to appeal timely so that Facility is linable to obtain N-'l edical
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 con-1plia lice
with all other applicable terns of this Agreement.
5. MEDICAREIMEDICAL ASSISTANCE PROGRAMS.
5.1 Participation in Programs. Facility currently participates in the
1:1ciansylvania Medicaid program ("Medical Assistance") and the federal Medicare
progTain. Facility reserves the right to withdraw from the Medical Assistance or
Medicare programs at any time in accordance with law.
12 Actions of Medical Assistance and Medicare Agencies- The
Pennsylvania Department of Public Welfare ("DPW") is responsible 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 l-iu.nian
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 programs.
Resinlent/Res,<,nr:?hi?l'art?.._'t
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 N1vithin 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 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 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 Resident'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 ) ssistance
6 resident/ Respons ibk• Pa
rty_..,.__ ?_
prograrn 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, Iesident
hereby authorizes the Facility to file on Resident's behalf an appeal of ally such denial
of Medical Assistance eligibility or discontinuance of Medical Assistance bc1-3 efits, and
to take such actions to secure Resident's Medical Assistance benefits as the Facility
deems reasonably necessary or appropriate and consistent with lain. 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 payrnent 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
ti~acility 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 in a Medicare Part D Prescription Drug or Medicare Advantape
Plan ("PDP"), Resident shall advise Facility in writing of Resident's chosen PDP upc7n
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 PD.Ps, 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 vd-lile
a resident in Facility, except to the extent that such drugs and rnedications are covered
in whole or in part by any applicable goverrunent reimbursement prograrn. 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 or
Resideftt/ RL-SpOiL fibre Party
governmental insurance/ benefit programs, including Medicare Part A or B. 111 the
event that coverage for any prescription drug, supply, medication or pharmaceutical
provided to Resident is denied by any applicable governmental reiinbursernent
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 PUP, 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
cinder 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 PUP, then
the federal Centers for Medicare and Medicaid Services ("CMS") will assign Resident Lo
a PDP. [resident shall provide written notice to Facility of the narn? of the Resident's
PDP and the effective date of enrollment.
(e) Billing and Resident Cost Sharing Obligations. To 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/car 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 u rider 1esident's PUP for
pharmaceutical services or supplies prescribed by Resident's attending physician, then
the following shall apply;
(1) Resident and/or Resporisible Person may 'independently (i)
request an exception from Resident's PDP to cover non-formulary cv,non-covered
}icsiJcnt/Res}?rnisible tart} .;: __ __ ._
8
IMedicare 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 challente 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 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.
[(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 reasonable
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 pro' ide the requested
pharmaceuticals to Resident through an arrangement with an outside pharmacy. 11.1
any such situation, Resident shall be responsible to pay all fees and .casts 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 while 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 managed
care organizations ("MCOs"). The MCOs for whom Facility is an authorizdf-?
provider
9 i?csidcnt/Rec:pt3nseUlcParly_
are identified in. the Admission Package of information provided pi-io>• to or at the time
cif 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 LOCO
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 MCO. Resident is
responsible for any co-payments or other costs assigned to Resident under the specific
terns of the managed care plan. Resident also shall pay for any services or supplies not
covered by the MCO under the specific tens of the managed care plan. Co-payments
and other costs assigned to Resident and charges for services or supplies not covered by
[lie 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 tale
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 niay 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 MCO. Facility shall provide
thirty (30) days advance notice of its decision to withdraw as a participating provider
from Resident's MCC) 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.
f`
1o Resident/Responsible Party___
7. DURABLE FINANCIAL POWER-OF-ATTORNEY.
Resident is strongly encouraged to furnish to Facility, no later th=in [lie
date of admission or within five day(s) of admission, a Durable Financial Polver-of-
Attorney executed by Resident relating to financial decisions and payment fi_11• services.
The Durable Financial Power-of-Attorney shall be maintained in the fibs of Facility.
The name, address and phone number of Attorney-in-Fact:
In the event a Durable Financial Power-of-Attorney floes not exist and if
Resident is competent or becomes competent to declare an individual to serve Z,s
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-Par!y 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 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 from Federal Social Security
benefits or from :any other federal or state governmental assistance profrrams,
reimbursement or benefits to the extent of all amounts due the Facility. Resident and
Financial Responsible Person agree to reimburse Facility for any andali 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 Benefits, Resident
irrevocably authorizes Facility to snakes such claims and to take such actions as it
deems necessary to secure for the Facility receipt of third-party payments, including but
1 ResidenI/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
clue under this Agreement. (This includes but is not limited to Medical Assistance
Benefits.) Resident or Financial Responsible Person promptly shall 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 (-.)f 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 Representativc,
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 fi'lt any tax
T
12 Resident/Responsible Par4V
C ...---- . _..
documents or other reporting documents except as regUired 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 deciuctionti for
payment of any outstanding bills or other amounts clue 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 pei:sons
enti tied 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 (0)
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 late. 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 roominate, if
any, at any time consistent with the needs of the Facility.
11. TERMINATIONS, TRANSFER OR DISCHARGE.
11.1 Resident Initiated. Resident may tern-Linate this Agreement upon
fifteen (15) days vvritten 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 clue 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.
.y
G,
13 Resident/Responsit,)r r'.r1y'...:.:_ - -
(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 v6ll 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 l.aw 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 - BED 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's halI 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 Prog2-Jms, 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 th'c Medical
14 Resident/Responsible Partyl !?'.._?_...__ ..
Assistance Program, Resident may reserve a bed by electing to pay the Medical
Assistance per diem rate charged immediately 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 fart 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 and
procedures as made available by Facility. Facility reserves the right _o amend or chars e
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 tine-to-time.
1.4. 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 p`itoperty. If damage
or loss occurs to resident property, the Facility will investigate each incident of loss or
damage to determine liability and assess responsibility dependin on the facts and
circumstances of each incident. Facility shall be responsible for dilly 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 entitled to the property
under current law. The duly authorized representative of Residei'tt's estate or other
persons entitled to property under current law must acknowledge, in whiting, 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. C' -i
r t
15 Resident/Respcm:;sole l'art}'__ .. _.. ___ _..
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 I'Nliaiils
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 an), 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 Facility Property. 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 resen?es the right
to require proof of financial responsibility for payment of burial expense prior to
admission. Person or Funeral Horne to be notified:
Resident shall notify Facility of any change of Person or Funeral Home to be notified.
18. CAPACITY OF RESIDENT AND GUARDIANSHIP.
16 Kesidenl/Respomsble Party.
If Resident is, or becomes unable, to understand or corni-nunicate, and is
deterrnined 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 prig
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
1:1roceedings, 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 rake 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
govenimental 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 Mandatary 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
tinder 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 inediator,
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 ADP`
Services, or an alternative neutral, tlurd-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 el6cted 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 Re-Sider/ResponsiblePaity-`
The parties agree that this provision does not cover issues relating to
Nifedical Assistance eligibility, applications and/or appeals and does not affect any civil
or judicial actions which seek to compel compliance with the 'Resident': or their
respo nsi )le parties' duties to undertake, complete and cooperate with the Niedical
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 between the part es.
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. 31he signed settlement agreement will be the final resolution of the
contToversy, 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 HIC..
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.
(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 rriediating, arbitrating, or litigating a resolution. to any such
dispute.
19.4 Voluntary Binding Arbitration. The parties agree that the election
by Resident and/or his/her authorized legal representative to submit to binding
?8 Resident/Responsible Party__..);•;^'?. _
arbitr?ition 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 t-vhich 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 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 by
first-class mail, return receipt requested.
19 Resident/Responsible Party
Notice to Resident will be provided by personal delivery to Resident's roo n, or %vllere
applicable, by first-class mail to Responsible Person(s) or other designated per.sc- n.
21. RESIDENT OBLIGATIONS.
If resident is responsible for any actions or omissions that cause clanlage 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 an.d
construed in accordance with the lawns 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? 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 Aweement. 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 Resinlent/Re!-'Pmsiblepi, -.. -.---...----
23.6 Waiver of Provisions. Facility reserves the right to VVIElive ally
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 ivaiver 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 ill
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 A eement. 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. Tile 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
IN 1ti'I"fN[s_`?S WHEREOF, the parties, intending; to be legally bound, have
sii d this Nursing Facility Agreernent on t11ts L? day Of
L.,_.: L;
20
t (---
Witness Resident
Witness Financial Responsibl4 Pe Ysra11
Witness Health Care Responsible Person (if any)
Facility
y-....-____.._
22,
CUMBERLAND CAO
P.O. BOX 599
33 WESTMINSTER DRIVE MA
CARLISLE PA 17013-0599 NOT ELIGIBLE
.. RETURN ADDRESS NOTICE
G. LUCILLE LUCE
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM ROAD
CARLISLE PA 17013
pennsylvania
DEPARTMENT OF PUBLIC WELFARE
www.dpw.statv.pa.vs
OFFICE OF INCOME MAINTENANCE
COMPASS
www.cornpass.state.pa.us
Notice ID: 94148910
Record Number: 21 0125010
District: 0 Case Load: 0036
Worker: J PEIPER
Phone: 1-(800) 269-0173
Mailing Date: 06/19/2009
Reason: 042 Option: 0 Type: N
Category: PAN 'PSC: 80 TT:
You failed to provide the following information by 6/17/09:
1. Verification of dispostion of the following accounts Citizen's Bank
#6241-464782; Franklin County Teachers Credit Union #52140;2. Verification of
all resources sold transferred or given away over the past 36 months including
you AXA Equitable Life Insurance #3066073701A $1000 received in 2007
3. Complete statements for all bank accounts from 2/1109 to 3/11109
4. Verification of monthly or Annual PSERS income for Gertrude Luce
REGULATIONS:55 PA Code 201.1; 201.3
1 r t 1-
(?' t
f
t -` f
APPEAL 1 HEARING 1
If you disagree with our decision, you have the right to appeal. Sew attached farm for a Frimplate MIDPENN LEGAL SERVICES
explanation of yowrinht to agl&at and to it hearing 401-405 LOUTHER STREET
If you are currently receiving benefits and your oral request for a hearing is received in the County CARLISLE PA 17013
Assistance Office or your written request is postmarked or received on or before 0710212009 {717) 243 9400
.. .. ....:-.-_ -........1 ...N.•... it,, -konn Jl rims to Ctatn
FILED-t OE
OF THE PTTKMTARY
2t9 JUL 20 PM 3-- 36
PENIVSYLMA.
472.50 Po -AT"
G[,u gg8q
2T41 aaaa A
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No. O 9'
v.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants.
PETITION FOR PRELIMINARY INTUNCTION
AND NOW, COMES Petitioner, Guardian Elder Care at Carlisle, LLC d/b/a
Forest Park Health Center ("Petitioner'), by and through its attorneys, SCHUTJER BOGAR
LLC, and files the following Petition for Preliminary Injunction against Respondents, G.
Lucille Luce and Gordon Luce, pursuant to Pa. R.C.P. § 1531, and, in support thereof,
avers:
1. Contemporaneous with the filing of this Petition, Petitioner is filing its
Complaint against Respondents. See the Complaint attached hereto as Exhibit "1."
2. The Complaint sets forth an equitable claim against Respondent G. Lucille
Luce relating to her breach of the Nursing Care Admission Agreement ("Agreement")
that she signed in conjunction with her admission to Petitioner's skilled nursing facility.
The Complaint also sets forth an equitable claim against Respondent Gordon Luce for
breach of his statutory duty to support G. Lucille Luce, his wife, under Pa. 23 Pa. C.S. §
4603(a). See the Agreement attached to the Complaint as Exhibit "A."
ORIGNAL
3. Specifically, the Complaint alleges that Respondent G. Lucille Luce
breached the Agreement by failing to secure Medical Assistance benefits, by not
providing the necessary verification documentation to the Cumberland County
Assistance Office ("CAO"). See Exhibit "B" to the Complaint.
4. Moreover, in the Agreement, Respondent G. Lucille Luce assigned to
Petitioner her right to Medical Assistance benefits (hereinafter "the Assignment
Clause"). See Exhibit "A" to the Complaint.
5. Accordingly, Petitioner now stands in the shoes of the assignor and has
assumed G. Lucille Luce's 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.")
6. Respondent G. Lucille Luce's failure to provide the verification
documentation that the CAO requires to process and approve her application for
Medical Assistance benefits is a breach of the Agreement and interferes with
Petitioner's rights to the Medical Assistance benefits that have been contractually
assigned to it. See Exhibit "A" to the Complaint.
7. Respondent G. Lucille Luce's continued failure to comply with the terms
of the Agreement and provide the verification information required by the CAO to
render a decision on her eligibility for Medical Assistance benefits will result in a denial
of the pending application for Medical Assistance benefits.
8. Additionally, the Complaint alleges that Respondent Gordon Luce
breached his statutory duty of support with respect to G. Lucille Luce, which includes
2
his failure to assist with securing financial support for his wife through the Medical
Assistance benefits system, by providing the necessary financial documentation to the
CAO to secure Medical Assistance benefits for G. Lucille Luce.
9. Respondent Gordon Luce's statutory duty of support includes the duty to
not actively work against Medical Assistance benefits approval.
10. The very nature of the Respondents' breach of their respective contractual
and statutory obligations, i.e., the failure of Respondents to produce the information
and documents requested by the CAO to secure Medical Assistance benefits for G.
Lucille Luce, presents an issue of immediate and irreparable harm to Petitioner, because
Petitioner cannot realize the benefit of the bargain promised to it under the Assignment
Clause - specifically, its right to G. Lucille Luce'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 her - unless Respondents provide the CAO with the
documentation it needs to process and approve G. Lucille Luce's application.
11. The requested injunction would restore the parties to the status quo as it
existed immediately prior to Respondent G. Lucille Luce's breach of the Agreement and
Respondent Gordon Luce's breach of his statutory duty of support.
12. Greater injury would result from the denial of the requested injunction
than from the granting of the same, because, absent the injunction, without the
verification documentation necessary to secure Medical Assistance benefits, the CAO
will deny G. Lucille Luce's pending application for Medical Assistance benefits, and
Petitioner's ownership rights in those benefits and its ability to receive compensation
for the skilled nursing services it has provided under the Agreement will be forever
lost.
13. Petitioner's right to relief is clear. See Exhibit "A" to the Complaint.
14. Petitioner lacks an adequate remedy at law, as upon information and
belief, at all times material hereto, G. Lucille Luce has been financially unable to fully
compensate Petitioner for the services that it has rendered to her.
15. A bond in the amount of $100.00 should be adequate in the event that it is
later determined that the issuance of the instant petition was in error.
WHEREFORE, Petitioner respectfully requests that the Court schedule a hearing
on its request for injunctive relief and thereafter issue a decree ordering specific
performance of the contractual and statutory duties of Respondents.
Respectfully submitted,
Dated: 71 , 2009
SCHUTJER BOGAR LLC
By:
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schutjerbo ag r.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
4
EXHIBIT "A"
(TO PETITION FOR PRELIMINARY INJUNCTION
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No.
V.
G. LUCILLE LUCE and
GORDON LUCE,
CIVIL ACTION - EQUITY
Defendants.
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims
set forth in the following pages, you must take action within twenty (20) days after this
complaint and notice are served, by entering a written appearance personally or by
attorney and filing in writing with the court your defenses or objections to the claims set
forth against you. You are warned that if you fail to do so the case may proceed without
you and a judgment may be entered against you by the court without further notice for
any money claimed in the complaint or for any other claim or relief requested by the
plaintiff. You may lose money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A
LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166 or (800) 990-9108
EN LA CORTE DE ALEGATOS COMiJN DEL
CONDADO DE CUMBERLAND, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/ b/ a FOREST
PARK HEALTH CENTER,
Plaintiff, No.
V.
G. LUCILLE LUCE and
GORDON LUCE,
CIVIL ACTION - EQUITY
Defendants.
AVISO PARA DEFENDER
Conforme a PA RCP Num. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de
las demandas que se presentan mas adelante en las siguientes paginas, debe tomar
accion dentro de los proximos veiente (20) dias despues de la notificacion de esta
Demanda y Aviso radicando personalmente o por medio de un abogado una
comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee
a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de
tomar accion como se describe anteriormente, el caso puede proceder sin usted y un
fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra
reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya
por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros
derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A
CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telefono: (717) 249-3166 or (800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
V.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
COMPLAINT
CIVIL ACTION - EQUITY
AND NOW, COMES, Plaintiff, Guardian Elder Care at Carlisle, LLC d/b/a Forest
Park Health Center ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and
files the within complaint against Defendants, G. Lucille Luce and Gordon Luce
(collectively, "Defendants"), 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 G. Lucille Luce is an adult individual who is a resident at
Plaintiffs skilled nursing facility, located at 1217 Slate Hill Road, Camp Hill,
Pennsylvania 17011.
3. Defendant Gordon Luce, husband to G. Lucille Luce, is an adult individual
No.
who currently resides at 1 West Penn Street, Carlisle, Pennsylvania 17013.
4. On or about February 6, 2009, Defendant G. Lucille Luce applied for
admission to Plaintiff's skilled nursing facility.
5. On or about February 6, 2009, Plaintiff and Defendant G. Lucille Luce
entered into a written Nursing Care Admission Agreement ("Agreement"). Pursuant to
the Agreement, Plaintiff agreed to provide Defendant G. Lucille Luce with skilled
nursing services in exchange for Defendant G. Lucille Luce's promise to pay a specific
monetary fee from her assets, to assign to Plaintiff her right to apply for and obtain
Medical Assistance benefits in the event that she became insolvent, and, in furtherance of
that assignment, she agreed to cooperate fully and secure Medical Assistance benefits.
See a true and correct copy of the Agreement attached hereto as Exhibit "A."
6. At all times material hereto, Defendant Gordon Luce has had a statutory
duty to financially support his wife, G. Lucille Luce. See 23 Pa. C.S. § 4603(a).
7. After Defendant G. Lucille Luce's admission to Plaintiff's skilled nursing
facility, she allegedly became insolvent. As a result, Plaintiff filed an application for
Medical Assistance benefits on Defendant G. Lucille Luce's behalf.
8. The application for Medical Assistance benefits referred to above was
denied because Defendants did not provide the Cumberland County Assistance Office
("'CAC)") with the information and documentation needed to verify Defendant G. Lucille
Luce's eligibility for Medical Assistance benefits. A copy of the form PA-162 issued by
the CAO denying Defendant G. Lucille Luce's application for Medical Assistance benefits
is attached hereto as "Exhibit B."
2
9. Subsequently, Plaintiff filed an appeal of the CAO's denial of the above-
referenced application for Medical Assistance benefits, and said appeal is currently
pending before the Pennsylvania Department of Public Welfare Bureau of Hearings and
Appeals.
10. If Defendants fail to provide the documents required by the Cumberland
County Assistance Office to determine Defendant G. Lucille Luce's eligibility for Medical
Assistance benefits prior to or at the time of the appeal hearing on the above-referenced
appeal, her application for Medical Assistance benefits will be denied, and any further
appeal to the Commonwealth Court will be without merit.
COUNTI
BREACH OF CONTRACT/ SPECIFIC PERFORMANCE
Plaintiff v. G. Lucille Luce
11. The allegations contained in Paragraphs 1 through 10 are incorporated
herein by reference as if fully set forth at length.
12. Defendant G. Lucille Luce breached her Agreement with Plaintiff by failing
to act in accordance with the terms of the same, as she failed to provide the necessary
documentation to the Cumberland County Assistance Office to determine her eligibility
for Medical Assistance benefits. By doing so, Defendant G. Lucille Luce has interfered
with Plaintiff's right to receive the Medical Assistance benefits that have been
contractually assigned to it.
3
13. 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).
14. As Defendant G. Lucille Luce has failed to provide the necessary
documentation to the Cumberland County Assistance Office as required to process and
approve her application for Medical Assistance benefits, Plaintiff is precluded from
receiving the benefit she assigned to it.
15. Upon information and belief, at all times material hereto, G. Lucille Luce
has been financially unable to fully compensate Plaintiff for the services that it has
rendered to her in accordance with the terms and conditions of the Agreement.
16. Defendant G. Lucille Luce's breach of the Agreement with Plaintiff has
irreparably harmed and continues to cause Plaintiff irreparable harm.
17. 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.
4
COUNTII
SPECIFIC PERFORMANCFISTATUTORY DUTY OF SUPPORT
Plaintiff v. Gordon Luce
18. The allegations contained in Paragraphs 1 through 17 are incorporated
herein by reference as if fully set forth at length.
19. Defendant Gordon Luce is the husband of G. Lucille Luce.
20. At all times material hereto, upon information and belief, G. Lucille Luce
has been indigent.
21. At all times material hereto, Defendant Gordon Luce has had a statutory
duty to financially support his wife, G. Lucille Luce. See 23 Pa. C.S. § 4603(a).
22. At all times material hereto, Defendant Gordon Luce has failed to
financially support his wife.
23. The statutory duty of Defendant Gordon Luce to support his wife must
reasonably include the duty to assist with securing financial support through the Medical
Assistance benefits system and the duty to not actively work against Medical Assistance
benefits approval.
24. At all times material hereto, Defendant Gordon Luce failed to care for,
maintain or financially assist his wife by refusing to provide the information and
documents requested by the Cumberland County Assistance Office to determine the
eligibility of his wife for Medical Assistance benefits.
5
WHEREFORE, Plaintiff respectfully requests that this Honorable Court order
Defendant Gordon Luce to specifically perform his statutory duty and obligation, and to
produce the information and documents to the Cumberland County Assistance Office
required to secure Medical Assistance benefits for his wife, G. Lucille Luce.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: 2009 By:
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schut erbo ag r.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Plaintiff
6
VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing
Complaint are true and correct to the best of my Imowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C.S.A. § 4904, relating to unworn falsification to authorities.
Dated: 7I/I-/!J ?/%?- ------'".
Dawn Jordan ?
Billing and Collections Coordinator
Guardian Elder Care
EXHIBIT "A"
GUARDIAN ELDER CARE
NURSING CARE ADMISSION AGREEMENT
This Nursing Care Agreement is made by and between Guardian Gilder Care
(hereinafter called "Facility"),
called "Resident"), (hereinafter called
"Financial Responsible Person"), and (if any)
(hereinafter called "Health Care Responsibly
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 play result in the termination of
this Agreement and personal financial liability, including attorney tee's, costs, interest
and lost revenue.
Therefore, Facility, Resident, Financial Responsible Person and Health Care
Responsible Person ag ree to the following terms and conditions:
1. PROVISION OF SERVICES.
1.1 Nursing Services. Beginning on- t}Ze
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 _ v' semi-private accommodations; (e) three meals
each day and snacks, except as otherwise medically indicated; (d) blankets, bed linens,
towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services;
(g) activity programs 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 medicatioms as provided by law. Not included in the daily rate are
intravenous services and supplies; oxygen and supplies; incontinence products;
arnbulance costs; physician fees; most pharmaceutical drugs; personal dry cleaning;
medical tests; laboratory tests; private telephone/services or television; 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 ancillary services acid
associated charges, are identified in the Admission Package of information and are
subject to change at the discretion of Facility.
Rcrsidc.•nt/i:csjxur?ihli livty?;^.,` ?. _-;?% .."
1.3 Services of Other Providers. The services of outside proVi&J'S
such as a licensed physician, dentist, licensed pharmacy for the provision of
pharmaceutical supplies, a licensed hospital, diagnostic services, Iaboratorv, x-ray,
podiatry, optometry, medications, ambulance services and hearing aid repair ilia), 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;
hoi,vever, 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 anv medicines, treatments, special diets or equipment without specific
orders or directions from Resident's Primary Medical Physician. In 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 Recurrin OPeri odic 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 play be changed from time-to-time in accordance with the provisions
of Section 3.3. Charges for a resident whose payor source is other thtin Medicare Part A
or Medical Assistance will begin on the designated admission date or actual admission,
v,,hichever 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 shell pay for
other services and supplies provided by or through the Facility, which 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, Residentshall 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 anti services are
L i _,
2 Resident/ Responsible ParN.;_~
.
i
furnished by a person or provider made available by Facility, or by a person or provides
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 Date. Dees 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 laiv,
prepayment for the basic monthly rate of. the current month is required at the time of
admission. Facility will snail 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, %vllich 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
()ne-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 front
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 thirty (30) days advance written notice of any such changes.
3-4 • Obli ations of Resident's Estate and Assignment 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 be an obligation of Resident's estate and may be enforced against
Resident's estate. Resident's estate shall be liable. to and shall pay to Facility an aim.m lit
equivalent to any unpaid obligations of Resident under this Agreement.
3 t:esi?fent/Rcspc,nsiblr Party...____!L_.;
4. OBLIGATIONS OF FINANCIAL RESPONSIBLE PERSON.
4.T General. Resident shall have the right to identify a l-lealth Care
Responsible Person (usually this person is the Resident's Po,,ver of Attorney or
Guardian of his or her Person), who shall be entitled to receive notice in the event cal
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 Responsibl
Person. Resident elects to name _ as his/her
1--Teal th Care Responsible Person. Resident shall identify a Financial Responsible Person
(usually this person is the Resident's Financial Power of Attorney or Guardian of
his/her Estate) at the time of admission. Resident elects to nalnr
as his/her Financial Responsible Person.
Resident's Financial Responsible Person shall sign this Agreement in 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 a 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 LiabiiitX. 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 or 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 ivi'th this Agreement
by Facility to assure payment for amounts that are Residents obligations. In the event
Facility initiates any legal actions or proceedings to collect payments 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
Facility, an amount equivalent: to revenue lost by Facility due to Financial Responsible
r.?
i.
4 I:esidenl/3.esporitii?fef'arlp __!t.
Person's failure to timely submit or complete a Medical Assistance application or Lo
cooperate with the Pennsylvania Department of Public Welfare (hereinafter "DPV%/") in
the Medical Assistance eligibility determination. The failure to initiate, make or
complete the Medical Assistance application process on the Resident's behalf n -lay re,;uJt
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 malting 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 xvith
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 Nledical
Assistance reimbursement, then Facility may terminate this Agreement for non-
payment of stay, and Financial Responsible Person shall be liable for any losses,
including attorneys 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. MEDICARI/MI;DICAL ASSISTANCE PROGRAMS.
5.1 Participation in Programs. Facility currently participates in the
I'ennsylvartia Medicaid program ("Medical Assistance") and the federal Medicare
progn-atn. 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 A encies. The
Pennsylvania Department of Public Welfare ("DPW") is responsible 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 programs.
5 Resident/ Responsible [} ar3? .._'= -r-'.: r
5.3 Medical Assistance Benefits.
(a) Obligations of Resident. Resident is obligated to male 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. \.vithin the preceding five years of the date of application for acirnission 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 Residents
financial obligations under this Agreement. Resident is obligated to apple for Medical
Assistance benefits at such tirne 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 N'ledicaid
Handout, and Resident remains obligated to pay for such services.
(c) 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 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 Resident's behalf, after the Facility has rilade 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 ivIedicral Assistance
7
6 resident/ Responsible Partp_ j? _. ?
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 4varrants
and represents that the financial information disclosed in the admission doculnerrrs 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
S.G 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 in a Medicare Part D Prescription Drug or Medicare Advantage
Plan ("PDP"), Resident shall advise Facility in writing of Resident's chosen PDP upt:,n
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 PD.Ps, 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 ResponsibiIi to Pay for Pharmaceuticals. Resident is
responsible to pay the charges for all prescription and other drugs or inedication;s tivhile
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 or
?.
7 Resident Responsible Marty
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 reimbursen ent-
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 rnade no representations regarding the actions or decisions of any PDP, including,
but riot Iinuted 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 PUP to
ensure coverage of Resident's prescription drug needs. Resident and/or Responsibly
Person shall take all necessary action to enroll Resident in a PDP; and shall advise
f=acility of such enrollment upon Resident's acceptance into the PUP. 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. To 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" tvho
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 Coveragg
Determinations. In the event that Resident is denied coverage u nder Resident's PDl' for
pharmaceutical services or supplies prescribed by Resident's at-tenc-Iirg physician, then
the following shall apply:
(1) Resident and/or Responsible Person i-nay 'independently (i)
request an exception from Resident's PDP to cover non-formulary orrnoO covered
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 r10 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 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.
j(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-1,
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 PUP or appeal to an appropriate tribunal, and if the requested pharmaceuticals
are deemed m-dically necessary by Resident's physician, and no reasonably acceptable
substitute, as deterni.ined by Facility's Medical Director, from the formulary of
Resident's PDP exists, then Facility shall make arrangements to pro,: ide 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 while 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 managed
care organizations ("MCOs"). The MCOs for whom Facility is an authoriz -4i"provider
9 t.asidcnt/Rcr:punsiblc Pan),-
are identified in. the Admission Package of information provided prio
of admission r to or at the time
6.2 Enrollment in a Managed Care Organization. Resident shall
notify Facility in writing prior to enrolling with a MCO or Sivitching Resident's NICO
enroll>nent.
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 RICO. 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 MCC) 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 card plans typically
require pre-authorization of services by the MCO. If Resident chooses to have ser.-Vices
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 noii-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 au'thdrized provider
with one or more of the listed MCOs at any time in accordance with law and tale terms
of the applicable agreement. In the event that Facility terminates its contractual
relationship with the MCO in which Resident is enrolled, Resident niay 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 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.
t .tip
?? Resident/Hesponsihlc
7. DURABLE FINANCIAL POWER-OF-ATTORNEY.
Resident is strongly encouraged to furnish to Facility, no later than i-he.
date of admission or within five day(s) of admission, a Durable Financial PoNvex-of-
Attorney executed by Resident relating to financial decisions and payment fol, 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:
In the event a Durable Financial Power-of-Attorney floes 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 Elis?ibility far Thiad-Parf?! 1a- ents. 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 fully
with Facility and each third-party payor to secure payment. Cooperation includes
providing information, signing and delivering documents, and assigning to Facility (t(
the extent permitted by law) any payments for the Resident from 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 Facil#ty. Resident and
Financial Responsible Person agree to reimburse Facility for any and'alI costs incurred
by Facility to collect such payments directly from the third-party source,
8.2 Assignment of Pa ments. Although it is the responsibility of
Resident and Financial Responsible Person to secure payment from third-part:
resources, including but not limited to Medical Assistance Benefits, 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 Parh,....,?' _ +J, _ _
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 lacer, 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 charge:,
glue under this Agreement. (This includes but is not limited to Medical Assistance
I,enefi.ts.) Resident or Financial Responsible Person promptly shall endorse and hen,
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 tale
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 conceming this, and/or any other related
Medicare clairn, 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 fflb- any tax
12
(?esidcsit/Rcspnnsihle Partd.. , ,.
i,.
documents or other reporting documents except as required l.)y the
licensure/certification regulations governing nursing facilities;.
9.2 Refunds of Personal Funds. Any pt'rsonal fuilds or valuables of
Resident held by Facility will be refunded within thirty (30) hays after deductions for
payment of any outstanding bills or other amounts clue the Facility after Resident's
discharge or death. In the event of Resident's death, such refund will be made to tilt,
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)
clays after Resident's discharge or death after deductions for payment of any
outstanding bills or other amounts due the Facility. In the went 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 undercurrent 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 anti welfare needs of
Resident. Facility reserves the right and discretion to transfer Resident's roommate, if
piny, 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 roason
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.
.y
r
c.,
13 Resident/Respnn,04c Pas-i}.._ .:_.__-.. .-_-.- • _--
(b) Resident's health has improved sufficiently so that Resident no
longer needs the services provided by Facility;
(e) 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 feast 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 - BED HOLD POLICY.
12.1 Private Pa3L 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'shalI be subject to
bed availability.
122 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 tki'c; Medical
14 Resident/Responsitile
Assistance Program, Resident may reserve a bed by electing to pay the Medical
Assistance per diem rate charged immediately prior to the leave, and by providirng
vvi-itten 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 an 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 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 tir•ne-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 dependin7 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 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 custodylby 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 fourtebn
(14) days, Facility may dispose of Resident's property.
r,
15 Resident/Responsible Party- `_
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 shalt 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 an)r 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 Facility Property. 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 FaciIitS,'s Privacy=
Policy that Resident hereby acknowledges receiving.
16. MEDICAL TREATMENT AUTHORIZATION.
Resident authorizes Facility to provide care and treatrnent in accordance
with orders of Resident's personal physician and consistent with the ternis 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:
Resident shall notify Facility of any change of Person or Funeral Home to be notified.
13. CAPACITY OF RESIDENT AND GUARDIANSffIP.
16 -%:
ltesidcnt/Rcsp, insi blc Party. _r _.. _ -..._
If Resident is, or becomes unable,. to understand or cornrnunicate, 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 le-111
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 requirem.ent is not intended to preclude Resident, Responsible
Persons, or Resident's attorney-in-fact from filing a complaint with any appropriate
goventmentaI 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
tinder 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, Hurd-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 el6cted 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 Pesident/Responsible. Pilrtv"I _w ~ _
The parties agree that this provision does not cover issues relating to
NtedicaI 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 ivith 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 between the p;:rrties.
i--lowever, 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 su g Best or negotiate
for the redistribution of the costs between the parties if it is deemed appropriate during
mediation.
ff a resolution is reached at mediation, the parties agree that such
resolution will be reduced towriting in the form of a settlement agreement and signed
by both parties. f 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 Legg] 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 rnediatioh provision prior to
signing this Agreement.
(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 an), such
dispu te.
19.4 Voluntarv Binding Arbitration. The parties agree that the election
by Resident and/or his/her authorized legal representative to submit to binding
t; 1 ,vF
18 Resident/Responsible Party__.,t,-' ?f _
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 agi-ee that election to
participate in binding arbitration as a means of alternative dispute resolution precludes
them fron-i 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, u-i 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 sigg-1 tlae
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 di putes 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 relatbd to those matters may be filed and litigated in any court which may
have jurisdiction over the dispute. This arbitration provision shall not impair the rinl-Jts
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 his 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.
24. 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 oi• by
first-class mail, return receipt requested.
i u
19 Itesi?tent/Responsible Party
_.f
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 penion-
21. RESIDENT OBLIGATIONS.
If resident is responsible for any actions or omissions that cause dainage 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
oinissioFrs.
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 cormection with the sections and
subsections of this Agreement are inserted only for the purpose cif reference. Such
captions shall not be deemed to govern, limit, modify, or in any mariner 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 Ageement 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 :?..
Itrsidclii/Pc',pansiblal'art,
???_;:`T_-.. -.---...__-•
23.6 Waiver of Provisions. Facility reserves the right to i-valve: 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 A91-cement shall remain in
full force and effect.
24. ACKNOWLEDGMENTS.
24.1 Facility Charge Schedules. Resident and Responsible Person(s)
acknowledge they receipt of a copy of the Facility Charge Schedules provided %vith the
Admission Package and the opportunity to ask questions abou tFacility's charges.
24.2 Resident Rights. Resident and ResporLsible Person(s) acknovvi edge
being informed orally and in writing of Resident's Rights as specified in the current
publication required by late 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 rtesident/kesl"nsihIc P,..rty6_=
IN WITNI---SS WHEREOF, the parties, intending to be legally hound, have.
si X1-1 d this Nursing Facility Agreement on tllis
Witness Resident
Witness
Witness
c1 I -: i,t fs
Financial Responsible Pei,,son
Health Care Responsible Person (if any)
F-1 C-
Facility
y-..._-._.._ _
22
EXHIBIT "B"
9I
pennSytvama
- DEPARTMENT OF PUBLIC WELFARE
MA www,dpw.stale_pa.us
NOT ELIGIBLE OFFICE OF INCOME MAINTENANCE
NOTICE COMPASS
www.cornpass.state.pa.us
G. LUCILLE LUCE
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM ROAD
CARLISLE PA 17013
You failed to provide the following Information by 6/17109:
1. Verification of dispostion of the following accounts Citizen's Bank
tt6241-464782; Franklin County Teachers Credit Union #52140;2. Verification of
all resources sold transferred or given away over the past 36 months including
you AXA Equitable Life Insurance #3066073701A $1000 received in 2007
3. Complete statements for all bank accounts from 211109 to 3111/09
4. Verification of monthly or Annual PSERS income for Gertrude Luce
REGULATIONS:55 PA Code 201.1; 201.3
C..Ir V(-
C1,T) 1i
' t
i..5 t "• 1'.A i
t r' (7,1
i : f
ai
If you disagree with our decision, you have the right to appeal. See attached form for a comp Iete MIDPENN LEGAL SERVICES
erplanati of your daht to swilaw and io a fair hearina 401-405: LOUTHER STREET
If you are currently receiving benefits and your oral request for a hearing is received in the County CARLISLE PA 17013
Assistance Office or your written request is postmarked or received on or before 0710212009 (717) 243-9400
In Ctate
Notice ID: 94148910
Record Number: 21 0125010
District: 0 Case Load: 0036
Worker: J PEIPER
Phone: 1-(800) 269-0173
Mailing Date: 06119/2009
Reason: 042 Option: 0 Type: N
Category: PAN 'PSC: 80 TT:
CERTIFICATE OF SERVICE
I hereby certify that on this date a true and correct copy of the foregoing Petition
for Preliminary Injunction was served via first-class, United States mail, postage prepaid,
upon the following:
G. Lucille Luce
c/o Forest Park Care Center
1217 Slate Hill Road
Camp Hill, PA 17011
and
Gordon Luce
1 West Penn Street
Carlisle, PA 17013
Dated: 6 0 q
By:
William Keslar, Paralegal
OF
Mg juL 20 NI 3: 3
P8"4ar' fiat ;JA
I
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
v.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
No. g " Y' d 41.J Lf .? ?r ?4
A-IrQCdi?/ /
CIVIL ACTION - EQUITY
PRELIMINARY ORDER
2009, a
AND NOW, this 49 day of
hearing in the above-captioned matter on Petitioner's Petition for the Issuance of
7 t'/L' A7 2009, at
a Preliminary Injunction is scheduled for
O
o'clock A A m. in Court Room No. , Cumberland
County Courthouse.
OF 7(FIIEL tj E
OF i1"E ' ;ter r,
NARY
2009 JUL 24 PH 1: t, 7
r
)UNTY
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No. 09-4845
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants.
MOTION FOR CONTINUANCE
AND NOW, COMES, Petitioner, Guardian Elder Care at Carlisle, LLC
d/b/a Forest Park Health Center ("Petitioner'), by and through its attorneys,
SCHUTJER BOGAR LLC, and moves for a continuance of the hearing on the
Petitioner's Petition for the issuance of a Preliminary Injunction, and in support
thereof states:
1. On July 20, 2009, a Complaint, Petition for Preliminary Injunction,
and Brief in Support of Petition for Preliminary Injunction was filed in the above-
captioned matter.
2. On July 24, 2009, this Honorable Court entered an Order
scheduling a hearing on Petitioner's Petition for Preliminary Injunction for
August 7, 2009, at 9:30 a.m.
3. Due to an error on the part of the Court Administration,
timestamped copies of the pleadings were not returned to Petitioner until July
ORIGINAL
29, 2009. Promptly upon receipt, the Complaint, Petition, Brief, and Order were
forwarded to a Process Server, however, to date, service of the documents has
yet to be effectuated.
4. Petitioner's counsel was previously scheduled to present a Petition
to Make Rule Absolute before The Honorable William J. Ober in the
Westmoreland County Court of Common Pleas on August 7, 2009 at 9:00 a.m.,
conflicting with the hearing on Petitioner's Petition for Preliminary Injunction
scheduled with this Honorable Court.
WHEREFORE, Petitioner respectfully requests a brief continuance so that
service on Defendants G. Lucille Luce and Gordon Luce may be effectuated, and
additionally, so that Petitioner's counsel may attend the hearing and present the
Petitioner's Petition for Preliminary Injunction.
Respectfully submitted,
Dated: 7 ` ---:T 2009
SCHUTJER BOGAR LLC
By:
Brandon Sc. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schuberbo ag r.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4+h Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Petitioner
2
CERTIFICATE OF SERVICE
I hereby certify that on this date a true and correct copy of the foregoing
Motion for Continuance was served via first-class, United States mail, postage
prepaid, upon the following:
G. Lucille Luce
c/o Forest Park Care Center
700 Walnut Bottom Road
Carlisle, PA 17013
and
Gordon Luce
1 West Penn Street
Carlisle, PA 17013
Dated: 3 ` ° 9
By:
William Keslar, Paralegal
f,, THE
205-3 JU"L 3 1 rir 1; = 4
i A
AUG 0 3 2009
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
v.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
No. 09-4845
CIVIL ACTION - EQUITY
ORDER
d
AND NOW this 3 day of 2009, it is hereby
ORDERED that Petitioners Motion for Continuance is GRANTED and the
Hearing on Petitioner's Petition for Preliminary Injunction is hereby continued
4?7 P.
J?
• The hearing is continued to MONDAY, SEPTEMBER 14, 2009, at 2:00 p.m. in
Courtroom # 3.
ol
?C j DQ "" ?a t F,S' lY1a.l
U?,
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CASE NO.: 09-4845
AFFIDAVIT OF SERVICE
Guardian Elder Care at
Carlisle, LLC d/b/a Forest
Park Health Center
vs.
G. Lucille Luce; Gordon Luce
Commonwealth of Pennsylvania
County of Dauphin ss.
I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at 4:10 PM on
07/30/2009, I served G. Lucille Luce at Forest Park Care Center, 700 Walnut Bottum Road, Carlisle, PA 17013
in the manner described below:
0 Defendant(s) personally served.
? Adult in charge of Defendant(s) residence who refused to give name and/or relationship.
? Manager/Clerk of place of lodging in which Defendant(s) reside(s).
? Agent or person in charge of Defendant's office or usual place of business.
Adult family member with whom said Defendant(s) reside(s).
Relationship is
? Other:
an officer of said Defendant's company.
a true and correct copy of Notice to Defend; Complaint; Brief in Support of Petition for Preliminary Injunction;
Petition for Preliminary Injunction; Preliminary Order; Order issued in the above captioned matter.
Description:
Sex: Female - Age: 70 - Skin: White - Hair: Brown - Height: 5' 02" - Weight: 110
S orn to and sub cribed before me on this Timothy Ho
4kh day of 200ci. Shinkowsky Investigations
316 Fawn Ridge North
1A . U Harrisburg, PA 17110
(800) 276-0202
O AR PUBL
T Atty File#: - Our File# 8231
Law Firm: Schutjer Bogar LLC
Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102
Telephone: (717) 909-5925
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
Erin A Johnson, Notary Public
Lower Paxton Township, Dauphin County
My commission expilr:s November 18, 2012
ORIGINAL
FILET
OF Tt-: F
2099 AUG -7 Pi`s 2: 13
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CASE NO.: 09-4845
AFFIDAVIT OF SERVICE
Guardian Elder Care at
Carlisle, LLC d/b/a Forest
Park Health Center
vs
G. Lucille Luce; Gordon Luce
Commonwealth of Pennsylvania
County of Dauphin ss.
I, Timothy Hoot, a competent adult, being duly sworn according to law, depose and say that at 4:25 PM on
07/30/2009, I served Gordon Luce at 1 West Penn Street, Carlisle, PA 17013 in the manner described below:
r/
Defendant(s) personally served.
Adult family member with whom said Defendant(s) reside(s).
Relationship is
Adult in charge of Defendant(s) residence who refused to give name and/or relationship.
Manager/Clerk of place of lodging in which Defendant(s) reside(s).
Agent or person in charge of Defendant's office or usual place of business.
an officer of said Defendant's company.
? Other:
a true and correct copy of Notice to Defend; Complaint; Brief in Support of Petition for Preliminary Injunction;
Petition for Preliminary Injunction; Preliminary Order; Order issued in the above captioned matter.
Description:
Sex: Male - Age: 70 - Skin: White - Hair: White - Height: 5' 08" - Weight: 150
X
Sw rn to and sub cribed before me on this Tinothy Hoot
_ day of 200q. Shinkowsky Investigations
316 Fawn Ridge North
Harrisburg, PA 17110
(800) 276-0202
NOTARY UBLIC
Atty File#: - Our File# 8232
Law Firm: Schutjer Bogar LLC
Address: 417 Walnut Street, 4th Floor, Harrisburg, PA, 17102
Telephone: (717) 909-5925
COMMONWEALTH OF PENNSYLVANIA
NOTARLAL SEAL
Erin A Johnson, Notary Public
Lower Paxton 't'ownship, Dauphin County
M commission cxir--s November 18, 2012
ORIGINAL
FILE,- C, r i E
OF I ... ,. y
2009 AUG -7 PI-I 2. 13
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No. 09-4845
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants. :
AFFIDAVIT OF SERVICE
I, William Keslar, being duly sworn according to law, depose and say that
I served Defendant G. Lucille Luce with the attached Order dated August 3,
2009, in the above-captioned matter, via UPS Overnight Delivery to her residence
at Forest Park Care Center, 700 Walnut Bottom Road, Carlisle, PA 17013 on the
41h day of August, 2009. A copy of the UPS Delivery Notification is attached
hereto as Exhibit "A."
Dated: 43 ]to G
William Keslar, Paralegal
Sworn to and Subscribed before me
this 10 day of August, 2009.
Notary Public
My Commission Expires:
COMMONWLMM OF PENNSYLVANIA
NOTARIAL, SEAL
BRTTPMlY A. SHHARER, NOTARY PUBLIC
SWID'ARA TOWNSHIP, DAUPM COUNTY
L!Y COMMUSSION EXPOW M.23, 2DI1
ORIGINAL
s
BS ??AR ER LLC
Email: wkeslar@schutjerbogar-com
Direct Dial: (717) 909-8985
August 4, 2009
Via Overnight DeHEM
G. Lucille Luce
Forest Park Care Center
700 Walnut Bottom Road
Carlisle, PA 17013
Schutier Bogar LLC
417 Walnut Street
4th Floor
Harrisburg, PA 17101
Fax (717) 909-5925
www.schutjerbogar.com
Re: Guardian Elder Care at Carlisle, LLC d/b/a Forest Park Health Center v.
G. Lucille Luce and Gordon Luce; Docket No. 09-4845
Dear Mrs. Luce:
Enclosed please find an Order dated August 3, 2009, granting a continuance of
the preliminary injunction hearing to September 14, 2009 at 2:00 p.m. in Court Room
No. 3, Cumberland County Courthouse, Carlisle, Pennsylvania.
If you should have any questions, please do not hesitate to contact Brandon S.
Williams at (717) 909-5922. Thank you.
Sincerely,
\P??
William Keslar
Paralegal
Enclosure
HARRISBURG, PA - PHILADELPHIA, PA • PITTSBURGH, PA BERWYN, PA
COLUMBUS, OH - PRINCETON, NJ BALTIMORE, MD - ARLINGTON. VA . DALLAS, TX
AUG 0 3 2009 2
\J
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
t
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff, No. 09-4845
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
• Defendants.
ORDER
d
AND NOW this 3 day of A-4-?- 2009, it is hereby
ORDERED that Petitioner's Motion for Continuance is GRANTED and the
Hearing on Petitioner's Petition for Preliminary Injunction is hereby continued
'a':00 p.wi,
J?
• The hearing is continued to MONDAY, SEPTEMBER 14, 2009, at 2:00 p.m. in
Courtroom # 3.
A?
.
U-4 Me at Caf pa,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
V.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
No. 09-4845;-,'
CIVIL ACTION - EQUITY
MOTION FOR CONTINUANCE
AND NOW, COMES, Petitioner, Guardian Elder Care at Carlisle, LLC
d/b/a Forest Park Health Center ("Petitioner'), by and through its attorneys,
SCHUTJER BOGAR LLC, and moves for a continuance of the hearing on the
Petitioner's Petition for the issuance of a Preliminary Injunction, and in support
thereof states:
1. On July 20, 2009, a Complaint, Petition for Preliminary Injunction,
and Brief in Support of Petition for Preliminary Injunction was filed in the above-
captioned matter.
2. On July 24, 2009, this Honorable Court entered an Order
scheduling a hearing on Petitioner's Petition for Preliminary Injunction for
August 7, 2009, at 9:30 a.m.
3. Due to an error on the part of the Court Administration,
timestamped copies of the pleadings were not returned to Petitioner until July
29, 2009. Promptly upon receipt, the Complaint, Petition, Brief, and Order were
forwarded to a Process Server, however, to date, service of the documents has
yet to be effectuated.
4. Petitioner's counsel was previously scheduled to present a Petition
to Make Rule Absolute before The Honorable William J. Ober in the
Westmoreland County Court of Common Pleas on August 7, 2009 at 9:00 a.m.,
conflicting with the hearing on Petitioner's Petition for Preliminary Injunction
scheduled with this Honorable Court.
WHEREFORE, Petitioner respectfully requests a brief continuance so that
service on Defendants G. Lucille Luce and Gordon Luce may be effectuated, and
additionally, so that Petitioner's counsel may attend the hearing and present the
Petitioner's Petition for Preliminary Injunction.
Respectfully submitted,
Dated: 7 ` F d` . 2009
SCHUTJER BOGAR LLC
By:
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schutjerbo ar.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Petitioner
2
x
CERTIFICATE OF SERVICE
I hereby certify that on this date a true and correct copy of the foregoing
Motion for Continuance was served via first-class, United States mail, postage
prepaid, upon the following:
G. Lucille Luce
c/o Forest Park Care Center
700 Walnut Bottom Road
Carlisle, PA 17013
and
Gordon Luce
1 West Penn Street
Carlisle, PA 17013
Dated:
B
Y:
William Keslar, Paralegal
EXHIBIT "A"
(TO AFFIDAVIT OF SERVICE)
Page 1 of 2
William Keslar
From: UPS Quantum View [auto-notify@ups.com]
Sent: Thursday, August 06, 2009 9:40 AM
To: William Keslar
Subject: UPS Delivery Notification, Tracking Number 1ZY99V530195461806
***Do not reply to this e-mail. UPS and Schutjer Bogar LLC will not receive your reply.
At the request of Schutjer Bogar LLC, this notice alerts you that the shipment listed
below has been delivered.
Important Delivery Information
Delivery Date / Time: 06-August-2009 / 9:11 AM
Delivery Location: FRONT DESK
Signed by: FETTER
Shipment Detail
Ship To:
G. Lucille Luce
Forest Park Health Center
700 WALNUT BOTTOM RD
CARLISLE
PA
17013
US
UPS Service: NEXT DAY AIR
Shipment Type: Letter
Tracking Number: 1ZY99V530195461806
Reference Number 1: ge-fp-008
2rr2rr298hb1 KT52@E_gzxEWrDgR@zYhSgz-WhO
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8/7/2009
F1Li;
.. THE?_
[', i' 9',Uv 12 i i'1 L
?i
S,; I
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
V.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
No. 09-4845
CIVIL ACTION - EQUITY
AFFIDAVIT OF SERVICE
I, William Keslar, being duly sworn according to law, depose and say that
I served Defendant Gordon Luce with the attached Order dated August 3, 2009,
in the above-captioned matter, via UPS Overnight Delivery to his residence at 1
West Penn Street, Apt. 408, Carlisle, PA 17013 on the 4th day of August, 2009. A
copy of the UPS Delivery Notification is attached hereto as Exhibit "A."
Dated:.
William Keslar, Paralegal
Sworn to and Subscribed before me
this 10 0" day of August, 2009.
otary Publ c
My Commission Expires:
of PENNSYLVANIA
NOTARIAL SLAT
BRITTANY A. SH AR>Rt, NOTARY PUBLIC
SWATARA TOWNSHF. DAUFM OOUMT
MY COIMQSSION WGUM R L 23, 2011
ORIGINAL
UTJER
AR LLC
Email: wkeslar@schugerbogar.com
Direct Dial: (717) 909-8985
August 4, 2009
Via Overnight Deliver
Gordon Luce
1 West Penn Street, Apt. 408
Carlisle, PA 17013
Schutjer Bogar LLC
417 Walnut Street
4th Floor
Harrisburg, PA 17101
Fax(717)909-5925
www.schutjerbogar.com
Re: Guardian Elder Care at Carlisle, LLC d/b/a Forest Park Health Center v.
G. Lucille Luce and Gordon Luce; Docket No. 09-4845
Dear Mr. Luce:
Enclosed please find an Order dated August 3, 2009, granting a continuance of
the preliminary injunction hearing to September 14, 2009 at 2:00 p.m. in Court Room
No. 3, Cumberland County Courthouse, Carlisle, Pennsylvania.
If you should have any questions, please do not hesitate to contact Brandon S.
Williams at (717) 909-5922. Thank you.
Sincerely,
William Keslar
Paralegal
Enclosure
HARRISBURG. PA PHILADELPHIA, PA PITTSBURGH, PA BERWYN, PA
COLUMBUS, OH PRINCETON, NJ BALTIMORE, MD . ARLINGTON. VA DALLAS, TX
AUG 0 3 2009 z
\J
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
V.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
ORDER
No. 09-4845
CIVIL ACTION - EQUITY
d
AND NOW this 3 day of 2009, it is hereby
ORDERED that Petitioner's Motion for Continuance is GRANTED and the
Hearing on Petitioner's Petition for Preliminary Injunction is hereby continued
I?" ' a'.oo P.M.
J.
• The hearing is continued to MONDAY, SEPTEMBER 14, 2009, at 2:00 p.m., in
Courtroom # 3.
,? I ti z> ° , t ,1 ? . 0 wit Vii'. ?
-o Id Said N" id Car", Pa
1?V
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER, c....
Plaintiff, No. 09-4845
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants.
MOTION FOR CONTINUANCE
AND NOW, COMES, Petitioner, Guardian Elder Care at Carlisle, LLC
d/b/a Forest Park Health Center ("Petitioner'), by and through its attorneys,
.SCHUTJER BOGAR LLC, and moves for a continuance of the hearing on the
Petitioner's Petition for the issuance of a Preliminary Injunction, and in support
thereof states:
1. On July 20, 2009, a Complaint, Petition for Preliminary Injunction,
and Brief in Support of Petition for Preliminary Injunction was filed in the above-
captioned matter.
2. On July 24, 2009, this Honorable Court entered an Order
scheduling a hearing on Petitioner's Petition for Preliminary Injunction for
August 7, 2009, at 9:30 a.m.
3. Due to an error on the part of the Court Administration,
timestamped copies of the pleadings were not returned to Petitioner until July
29, 2009. Promptly upon receipt, the Complaint, Petition, Brief, and Order were
forwarded to a Process Server, however, to date, service of the documents has
yet to be effectuated.
4. Petitioner's counsel was previously scheduled to present a Petition
to Make Rule Absolute before The Honorable William J. Ober in the
Westmoreland County Court of Common Pleas on August 7, 2009 at 9:00 a.m.,
conflicting with the hearing on Petitioner's Petition for Preliminary Injunction
scheduled with this Honorable Court.
WHEREFORE, Petitioner respectfully requests a brief continuance so that
service on Defendants G. Lucille Luce and Gordon Luce may be effectuated, and
additionally, so that Petitioner's counsel may attend the hearing and present the
Petitioner's Petition for Preliminary Injunction.
Respectfully submitted,
Dated: 7 ` - , 2009
SCHUTJER BOGAR LLC
By:
Brandon S. Williams
Attorney I.D. No. 200713
(717) 909-5922
bwilliams@schut erbo ag r.com
Chadwick O. Bogar
Attorney I.D. No. 83755
(717) 909-5920
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Fax No. (717) 909-5925
Attorneys for Petitioner
2
CERTIFICATE OF SERVICE
I hereby certify that on this date a true and correct copy of the foregoing
Motion for Continuance was served via first-class, United States mail, postage
prepaid, upon the following:
G. Lucille Luce
c/o Forest Park Care Center
700 Walnut Bottom Road
Carlisle, PA 17013
and
Gordon Luce
1 West Penn Street
Carlisle, PA 17013
Dated: -r,.
-
By. ' -1 't
William Keslar, Paralegal
EXHIBIT "A"
(TO AFFIDAVIT OF SERVICE)
Pagel of 2
William Keslar
From: UPS Quantum View [auto-notify@ups.com]
Sent: Thursday, August 06, 2009 10:10 AM
To: William Keslar
Subject: UPS Delivery Notification, Tracking Number 1 ZY99V530195965218
***Do not reply to this e-mail. UPS and Schutjer Bogar LLC will not receive your reply.
At the request of Schutjer Bogar LLC, this notice alerts you that the shipment listed
below has been delivered.
Important Delivery Information
Delivery Date / Time: 06-August-2009 / 9:41 AM
Delivery Location Left At: OFFICE
Signed by: CHRISTOPHR
Shipment Detail
Ship To:
Gordon Luce
1 W PENN ST
ROOM 408
CARLISLE
PA
17013
US
UPS Service: NEXT DAY AIR
Shipment Type: Letter
Tracking Number: 1ZY99V530195965218
Reference Number 1: ge-fp-008
2rr2rr2p8a.dtbr4NCTKmyC_gS@cNm-axKmp_aD
Discover more about UPS:
Visit www.ups.com
Sign Up For Additional E-Mail From UPS
Read Compass Online
8/7/2009
RE ??
T !,- 11Y
Eµ {
L?'09 A l 12 PH i : G i
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/b/a FOREST
PARK HEALTH CENTER,
Plaintiff,
V.
G. LUCILLE LUCE and
GORDON LUCE,
Defendants.
No. 09-4845
CIVIL ACTION - EQUITY
PRAECIPE TO WITHDRAW
TO THE PROTHONOTARY:
Kindly withdraw the Petition for a Preliminary Injunction and Brief in Support of
Petition for a Preliminary Injunction filed on July 20, 2009.
Dated: 4 • 4 , 2009 By:
Attorney I.D. No. 77851
(717) 909-8160
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
Respectfully submitted,
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to
Withdraw Petition for Preliminary Injunction and Brief in Support of Petition for
Preliminary Injunction was served Priority-Class, United States mail, postage prepaid,
upon the following:
Gordon Luce
1 West Penn Street, Apt. 408
Carlisle, PA 17013
And
G. Lucille Luce
Forest Park Care Center
700 Walnut Bottom Road
Carlisle, PA 17013
Dated: y t
By:
U-__-
William Keslar, Paralegal
RH)--D:FtCE
OF THE PRO OT r)NOTARY
2009 SEP -8 PM 1: 2 7
PE- NSYLkj*p,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIAN ELDER CARE AT
CARLISLE, LLC d/ b/ a FOREST
PARK HEALTH CENTER,
Plaintiff, No. 09-4845
V.
G. LUCILLE LUCE and
GORDON LUCE, CIVIL ACTION - EQUITY
Defendants.
PRAECIPE TO WITHDRAW, DISCONTINUE, AND END
TO THE PROTHONOTARY:
Kindly mark the above-captioned action withdrawn, discontinued, and ended.
Dated: J- Z43 - a? , 2009 By:
SCHUTJER BOGAR LLC
Kirk S. Sohonage `---
Attorney I.D. No. 77851
(717) 909-8160
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
Respectfully submitted,
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw,
Discontinue and End was served via first-class, United States mail, postage prepaid, upon
the following:
Gordon Luce
1 West Penn Street, Apt. 408
Carlisle, PA 17013
And
G. Lucille Luce
1 West Penn Street, Apt. 408
Carlisle, PA 17013
Dated:
By:
William Keslar, Paralegal
oc 4%w.ow
209 SEP 30 PSI 1: 09