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HomeMy WebLinkAbout09-5423IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. V. STANLEY COLBERT, Defendant. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. V. STANLEY COLBERT, Defendant. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, CIVIL ACTION - EQUITY No. oy- Sqz 3 &?:l l ?. Plaintiff, V. STANLEY COLBERT, Defendant. COMPLAINT AND NOW, COMES, GGNSC Camp Hill III LP d/b/a Golden Living Center, Camp Hill ("Plaintiff"), by and through its attorneys, SCHMER BOGAR LLC, and files the within Complaint against Stanley Colbert ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal office located at 46 Erford Road, Camp Hill, Pennsylvania 17011. 2. Defendant, the son of and legal representative for Rose Colbert, is an adult individual who currently resides at 5583 Mercury Road, Harrisburg, Pennsylvania 17109. 3. On or about October 24, 2008, Defendant applied for the admission of his mother, Rose Colbert ("Ms. Colbert"), to Plaintiff's skilled nursing facility. At that time, Plaintiff and Defendant entered into a written Resident Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's mother with skilled nursing services in exchange for Defendant's promise to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. A true and correct copy of the Agreement is attached hereto as Exhibit A. 4. After Defendant's mother became a resident of Plaintiffs skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that he needed to secure Medical Assistance benefits for Ms. Colbert, and an application for Medical Assistance benefits subsequently was filed on or about March 30, 2009. 5. On May 11, 2009, the application for Medical Assistance benefits was denied because Defendant did not provide the information and documentation required by the Cumberland County Assistance Office ("CAO") to establish and maintain Ms. Colbert's eligibility. See the PA-162 attached hereto as Exhibit B. 6. On June 15, 2009, the Plaintiff filed an appeal of this denial. However, if the Defendant fails to provide the CAO with the information necessary to qualify his mother for Medical Assistance benefits, the appeal will necessarily fail, and Ms. Colbert will be precluded from receiving the Medical Assistance benefits that she is entitled to and the Plaintiff will be deprived of payment on Ms. Colbert's account as bargained for at the time of her admission. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 7. The allegations contained in Paragraphs 1 through 6 are incorporated herein by reference as if fully set forth at length. 8. Defendant breached his Agreement with Plaintiff by failing to act in accordance with the terms of the same, as he has failed to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. 9. Because, at all times material hereto, Defendant's mother was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her, 2 Defendant's failure to provide the necessary documentation required by the CAO, to process and approve his mother's application for Medical Assistance benefits, is a critical violation of the terms and conditions of the Agreement. See Exhibit A. 10. Defendant has interfered with Ms. Colbert's right to receive the Medical Assistance benefits she is entitled to, as well as Plaintiff's right to receive payment, via the Medical Assistance benefits process, in accordance with the bargained for Agreement. See Exhibit A. 11. By obstructing the Medical Assistance benefits process, Defendant has irreparably harmed both his mother and the Plaintiff. 12. 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 respectfully requests that this Honorable Court order Defendant to specifically perform his obligations under the Agreement and to produce the information and documents to the Cumberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. COUNT II STATUTORY DUTY OF SUPPORT 13. The allegations contained in Paragraphs 1 through 12 are incorporated herein by reference as if fully set forth at length. 14. Defendant Stanley Colbert is the son of Rose Colbert. 15. Upon information and belief, at all times material hereto, Rose Colbert has been indigent. 16. At all times material hereto, Defendant has had a statutory duty to financially support his mother, Rose Colbert. See 23 Pa. C.S. § 4603(a). 3 17. At all times material hereto, Defendant has failed to financially support his mother. 18. The Defendant's statutory duty to support his mother 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. 19. At all times material hereto, in violation of 23 Pa. C.S. §4603(a), Defendant failed to care for, maintain or financially assist his mother by refusing to provide the information and documents requested by the CAO to determine his mother's eligibility for Medical Assistance benefits. WHEREFORE, Plaintiff respectfully requests that this Honorable Court order Defendant to specifically perform his statutory duty, and to produce the information and documents to the Cumberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. [This section intentionally left blank.] 4 Respectfully submitted, Dated: SCHUTJER BOGAR LLC By: Q-L Livia F. L ngton, Esq. Attorney I.D. No. 91548 (412) 281-3710 Marijane E. Treacy, Esq. Attorney ID No. 84070 (412) 281-3535 600 Grant Street, Ste 3290 Pittsburgh, PA 15219 Fax: (412) 281-0530 Bradley A. Schutjer, Esq. Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff EXHIBIT A WELCOME THANK YOU FOR CHOOSING US FOR YOUR NURSING FACILITY CARE The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. 1. NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. H. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. In addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees and contractors. B. Physician Services - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physicians are not associates or agents of the Facility and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. III. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. IV. ARBITRATION - The Resident acknowledges that disputes under this Agreement may be submitted to arbitration, if the Resident elects to do so, by signing a separate agreement executed 1 between the parties. Agreeing to arbitration is not a condition of admission or continuing care. V. PRIVACY ACT NOTIFICATION STATEMENT - Skilled nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of June 22, 1998, all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the Federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 1819(f), 1919(f), 1819(b)(3)(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or quality of health care services provided in the State; (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Medicare/Medical Assistance nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medical Assistance services. VI. RESIDENT'S PERSONAL PROPERTY A. Safety Of Resident's Personal Property - The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property/valuables, which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility in writing of all personal property upon admission. If, at any time during the Resident's stay, new items of value are brought to or removed from the Resident's possessions in the Facility, the Resident also agrees to so 2 inform the Facility Executive Director or designee. B. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. VII. PERSONAL FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B. Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Resident's, funds shall be credited to the Resident's account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. D. Accounting - The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not - commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. E. Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance Program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance or SSI. F. Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the Facility's Business Office. 3 G. Security of Funds - The Facility shall ensure the security of all personal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance Program Resident's personal funds for any item or service for which payment can be made under the Programs. VIII. THE RESIDENT'S DUTIES A. Facility's Rules And Regulations - The Resident agrees that the Facility may, to maintain orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. It is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. B. Resident Grievances - Residents are urged to bring any grievance concerning the Facility to the attention of the Facility Executive Director or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered anonymously. This number is 1-800-572- 9981. Residents also have the right to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. C. Diet - The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages brought into the Facility for the Resident's benefit. D. Medications - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. All drugs or medications brought into the Facility shall be immediately delivered to the nurses' station. E. Care Of Facility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as is to be expected from ordinary wear and tear. F. Care Of The Resident's Room - The Facility encourages the Resident to have a home-like environment and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must concur with any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. IX. PROHIBITION AGAINST THIRD PARTY GUARANTOR -FEDERAL AND STATE LAWS PROHIBIT A NURSING HOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAYMENT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION OR CONTINUED STAY IN THE FACILITY. HOWEVER, A FACILITY MAY REQUIRE AN INDIVIDUAL WHO HAS LEGAL ACCESS TO THE RESIDENT'S INCOME OR RESOURCES AVAILABLE TO PAY FOR FACILITY CARE TO SIGN A CONTRACT, WITHOUT INCURRING PERSONAL FINANCIAL LIABILITY FOR THE RESIDENT'S COSTS OF CARE, TO PROVIDE FACILITY PAYMENT FROM THE RESIDENT'S INCOME OR RESOURCES. A X. AGENT AND/OR LEGAL REPRESENTATIVE A. Agent - For the purposes of this Agreement, an Agent is a person who manages, uses or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amount of the funds received or held by the Agent for the Resident. The Agent assumes no responsibility to pay for the costs of the Resident's care out of the Agent's personal funds. However, as a necessary party to this Agreement, the Agent is contractually bound by the terms of this Agreement and may become personally liable for failure to perform duties under the Agreement. If the Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these funds for the Resident's welfare. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due and to make prompt payment for care and services provided to the Resident as specified in the terms of this Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESIDENT. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include not only the Resident, but also the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, copies of documents verifying such status must be provided to the Facility at the time of admission. XI. PAYMENT INFORMATION A. Obligation To Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (10th) day of each month or, in the case of a notice of a rate change, within ten (10) days of mailing of the notice. If payment is not received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth under the Transfer and Discharge section of this Agreement. B. Credit Card Charges - The Facility accepts MasterCard and VISA. If the Resident would like the convenience of paying amounts due each month through one of these options, the Resident must provide the needed information and authorization on the Credit Card Authorization form at the back of this Agreement. The Resident recognizes that, unless the Resident has authorized the use of MasterCard or VISA, the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. Fee For Returned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. 5 D. Potential Personal Liability Of Agent - Agent (includes any Legal Representative serving as the Resident's Agent) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's care, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this Agreement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement. XII. PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. In this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer. Non-covered charges may include any coinsurance and/or deductible amounts required by a third party payer. D. Communicating Changes in Assets - It is essential for the Resident to communicate to the Facility any changes in the Resident's assets or resources within ten (10) days of knowledge of the changes in financial status. Upon request by the Facility, the Resident shall provide the required information to the Facility within ten days. If the Resident runs out of private monies, it is important to locate alternative payment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funds are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengthy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of being reduced to an amount that, when combined with the 6 Resident's monthly income, is no longer sufficient to pay for the cost of care and services. If the Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. E. Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. XIII. MEDICAL ASSISTANCE PROGRAM RESIDENT - A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional services/items provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance. A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage. B. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. If the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D. Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits. The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment. E. Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, Private Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis. 7 F. Continuing Payment of Facility Charges Pending Eligibility - When an application for Medical Assistance has been filed, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (10th) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. G. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by the Program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H. Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a Private Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. 1. Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XIV. MEDICARE RESIDENT - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. B. Limited Coverage - Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C. Expiration Of Benefits - When Medicare coverage expires, the Resident may remain in the Facility if private pay or other payment arrangements have been made. If the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission or readmission. If the Resident intends to become private pay when 8 Medicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. D. Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The Facility shall give notice to the Resident and, if known, a family member or Legal Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. In cases where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. B. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVI. BED-HOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed-hold." The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days. If the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for a certain number of bed-hold days. Otherwise, a Private Pay or Medicare Resident requesting a bed-hold must pay the Facility's prorated private monthly rate during the bed-hold period. 9 XVH. RESIDENT'S RIGHTS AND FACILITY POLICY UNDER THE FEDERAL SELF- DETERMINATION ACT A. Right To Make Decisions Regarding Care -The Facility recognizes the right of each Resident to make decisions regarding his or her care. Where a Resident is incompetent, the Facility recognizes the Resident's right to have these decisions made on his/her behalf by a substitute decision maker in accordance with State law. B. Right To Formulate An Advance Directive- The Facility recognizes the right of each Resident to have an advance directive and will honor advance directives developed in accordance with State law and consistent with the level of care the Facility is licensed to provide. An advance directive is a written document that states choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of advance directives. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician and/or attorney. C. An Advance Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to continue to reside in the Facility. However, if the Resident has an advance directive, he or she must make it known to the Executive Director or designee so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at the time of admission, the advance directive information shall be provided to family members or other Resident representatives. However, if the Resident later regains competency, the Facility will provide such information directly to the Resident. XVHI. CHARGES FOR COPIES OF MEDICAL RECORDS -The Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charged in the Facility's community. XIX. SOLE AGREEMENT- This Agreement is the only Admission Agreement between the Facility and the parties. Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid Agreement. XX. ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. XXL INTEGRATION - The Parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, promises, understandings, and agreements between the parties, whether written or oral, and therefore they are of no further force and effect. Because this is a fully integrated agreement, the only discussions, statements, representations, promises, understandings, or agreements that are or will be binding on any of the parties to this Agreement or their employees, affiliates, contractors, agents, or representatives are those expressly set forth in writing in this Agreement, or in other written agreements entered into at the same time as, or subsequent to, this Agreement. in 17177637842 golden living center cam 07:49:01 a.m. 07-15-2009 3122 RESIDENT-SPECIFIC INFORMATION XXH_ Payer So s Facility accepts the following types of payments: }fib. [ ] Private [ [ ] Medical Assistance [ ] Veterans Administration XXIII ACKNOWLEDGEMENTS - By signing the Admission Agreement Signature Page, the Resident/Agent/Legal Representative acknowledges that he or she has been given and has read this Agreement in its entirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not a plicable, write N/A): A list of supplies and services that are included in the Facility's private monthly rate or that will be paid for by the Medical Assistance or Medicare programs and a list of supplies and services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged - Information about the Facility's bed-hold procedures. 3. A written explanation of how to apply for and use Medicare and Medical Assistance benefits and how to receive funds for previous payments covered by these benefits. 4. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuse/theft of resident personal property in the Facility. Copies of the State Resident Rights. A written explanation of the Facility's Rules and Regulations. ?7. Where applicable, if your condition warrants, you may be placed in the Facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the Facility will discuss such a transfer ' h you. Under law, you cannot be discharged from this Facility unless you agree or u ess, following an appeal, it is determined that you may be involuntarily dischar ed or transferred. ?8. I dodo nothave an advance directive. 9. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. 0. I have been given a copy and had an opportunity to review the Facility's Notice of Privacy Practices. XXIV. NOTICES - Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal Representative are responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Agent, and/or Legal Representative. Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident x a c? 0 2 c? W y z 0 I1 17177637842 golden living center cam A. Lega epresentative An Or Agent S Name Home Phone rT liU[l itj [ APE" e[ ][ [ [ ][ l ][ [ ] Street , ity State B. Other Person To Be Notified Name Home Phone[ ][ ][ ][][ ][ ][ ][ ][ ] [ Work Phone[][][][][][][][][][] Street City State 07:49: 18a.m. 07-15-2009 IPC-k 7/69 Zip Zip XXV. MAIL - The Facility is authorized to handle the Resident's mail as follows; (Check one box only.) [ ] mail given directly to the Resident [ Forward all of the Resident's mail to: XXVI. RESID A. NAME: B. SPECIALTY: C. ADDRESS: D. TELEPHONE: 1 1 l _ [ ] All mail read to the Resident ] Give personal mail to the Resident; forward business mail to: 4122 XXVH. RESIDENT TRUST FUND AUTHORIZATION - A Resident Trust Fund is an amount of money held by the Facility for the Resident's personal use. (Examples of use: To allow the resident to pay for room and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on request, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/13/03 White - Business Office Pink -Medical Records Yellow - Resident W) O. c? Z N a c? y Z O 12 17177637842 golden living center cam 07:49:32 a.m. 07-15-2009 5122 shall be authorized by the Resident or his/her Agent or Legal Representative in writing. The following persons may authorize withdrawals on the Resident's behalf: Name of Authorized Person Resident's Signature Witness if Resident Signed with a Mark Legal Representative's Signature (if applicable) Agent's Signature (if applicable) charge the account listed above for monthly charges incurred under this XXVHL CREDIT CARD AUTHORIZATION - Facility accepts MasterCard and VISA. If Resident would lik a convenience of paying amounts due each month through one of these, please provide the needed info ation and authorization: Credit Card Expiration Date I hereby authorize Agreement: Resident or Agent's Signature Date If the Resident is unable to consent or si this provision because of physical disability or mental incompetence or is a minor and this provisi is being signed by an authorized representative, complete the following: Date: Relationship to Signature: Witness: For Facility: Rev. 03/13/03 White - Business Office Date: Account # Name of Authorized Person Date Date Date Date ent: Pink - Medical Records 13 - Resident 7d a Z w z 0 17177637842 golden living center cam Authorized Represent Print Name and Title: 07:49:44 a.m. 07-"5-2099 5/22 x co y a. fD 7 Z W z 0 Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 14 17177637842 golden living center cam s 07:49:53 a.m. 07-15-2009 7/22 ADMISSION AGREEMENT SIGNATURE PAGE XXIX. PARTIES - The parties to this Agreement a . (Name of Facility) (Name of Residen (Name of Resident's Agent) ame of Resid is gal Representative) If the Legal Representative signs the Agreemen check the Type of Legal Repre ntative (below): [ ] Conservator of Person [ ] Guardi Durable Power of Attorne Agent Acting [ ] Conservator of Estate for Health Care (DPAHC) Under General [ ] Other, specify POA If you are signing this Agreement on behalf the i ote your relationship to the Resident: My relationship to the Resi n is On this ay of he ab ies a o be bound by the provisions of t 2?he Resident shall be admitted to his Agreement and agree that on the ay of -Ut this Facility. Resident Address City, State, Zip Witness if Resident Signed Ivith a Mark a Legal Represe Aative Y Legal Representative's ddress Rev. 03/13/03 White - Business Office Date Resident's Social Security Number Resident's Telephone Number Date Date Date Legal Representative's o 1,s7t 7 N0,4 LTelephone Nu er Pink - Medical Records Yellow - Resident x CD y a: z W c? x CD r z 0 15 17177637842 golden living center cam 07:50:06 a.m. 07-15-2009 8/22 r J , Agent Date Age s A dress Agent's Social Security Number Facility Executi Direct or Designee Agent's elepho e N ber Facility Name _ Date --7? IttA Facility Address d t Note: The signatures above refer to the information contained on pages 1 through 16 of the Admission Agreement. co a: z 3 c? z 0 Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 16 W _1'' 1 003 CUMBERLAND CAO MEDICAID iP-O S(IP['?' NOT ELIGIBLE ; ;JEN5TER DRCVE NOTICE SLE ARLr, PA 17013 0539 CAO RETURN ADDRESS CSLD J0026 '01022}22100` ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 Notice ID: 94509621 Co RECORD DIST CAT GG PS 21 012422; 0 PAN 9o WORKER: K WHITTEN TELEPHONE: i800) 269-0173 MAIL DATE: 05;•11/2009 NOT: 042 OPT: D TYPE: N IF YOU 00 NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORXER IAWDIATELY You have been determined not eligible for benefits based on your application dated 03/30/2009. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 04/17/09 . Items: Name: MA51, SSN, BIRTH CERTIFICATE, - ROSE MEDICAL CARDS, POA PAPERWORK, PCA - ACCT, VA FILING, GROSS INCOME, - PROOF OF ALL RESOURCES, UTILITY - - EXPENSES, RETRO BILLS, PG OF APPL T- T NEEDED COMPLETED Citation: 55 Pa. Code 201.1. 201.3 MA Y 1 1 2009 PAGE 1 OI currently receiving benefits and a iair nearing . IT you are your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/24/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94509621 ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 Co RECORD DIST CAT GG PS 21 0124221 0 PAN 80 40 ADDF CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 WORKER: K WHITTEN APPEAL: 05/24/2009 TELEPHONE: (800) 269-0173 MAIL DATE: 05/11/2009 NOT: 042 OPT: D TYPE: N n?w?T?wn ??? i+w? nrv?nn? nr?? If you disagree with our decision. you have rh. VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: 7 t3o I Dq Susan Bertolette, FBOC GGNSC Camp Hill III LP a/b/a Golden Living Center, Camp Hill f. ,.? `?r y k!, y7 X1,:7 rl "'? ?e,,;e dlvll IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, V. STANLEY COLBERT CIVIL ACTION - EQUITY No. Oq - sga3 PETITION FOR PRELIMINARY INJUNCTION Filed on Behalf of Petitioner. GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill Counsel of Record for Petitioner: SCHUTJER BmAR LLC Livia F. Langton Attorney I.D. No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane E. Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4 h Floor Harrisburg, PA 17101 i r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Petitioner, V. STANLEY COLBERT, Respondent. CIVIL ACTION - EQUITY No. o 1- 5 7 013 PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill, ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Petition for Preliminary Injunction against Stanley Colbert ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. On or about August 4, 2009, Petitioner filed its Complaint against Respondent. See the Complaint attached hereto as Exhibit 1. 2. The Complaint sets forth an equitable claim against Respondent relating to his breach of the Resident Admission Agreement ("Agreement") that he signed in conjunction with the admission of his mother, Rose Colbert ("Ms. Colbert"), to Petitioner's skilled nursing facility. The Complaint also sets forth an equitable claim against Respondent for breach of his statutory duty to support Ms. Colbert, his mother, under Pa. 23 Pa. C.S. § 4603(a). See the Agreement attached to the Complaint as Exhibit A. 3. Specifically, the Complaint alleges that Respondent breached the Agreement by failing to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits, i. e. his refusal to provide the necessary verification documentation to the Cumberland County ? t Assistance Office ("CAO") to determine the eligibility of his mother, Ms. Colbert, for Medical Assistance benefits. See Exhibit 1 hereto. 4. Respondent'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 his mother's eligibility for Medical Assistance benefits has resulted in a denial of Ms. Colbert's application for Medical Assistance benefits. See the Notice attached to the Complaint as Exhibit B. 5. Respondent's failure to provide the verification documentation that the CAO required to process and approve his mother's application for Medical Assistance benefits and the resulting denial of said benefits, is in breach of the Agreement and interferes with Ms. Colbert's right to receive Medical Assistance benefits and Petitioner's rights to be compensated, by way of the Medical Assistance benefits, for the services it has provided to Ms. Colbert. See Exhibit A to the Complaint. 6. Additionally, the Complaint alleges that, pursuant to 23 Pa.C.S. §4603(a), Respondent breached his statutory duty of support with respect to Ms. Colbert, which stems from his failure to assist with securing financial support for his mother, through the Medical Assistance benefits system, by providing the necessary financial documentation to the CAO to determine her eligibility for benefits. See Exhibit 1. 7. The Respondent's statutory duty of support includes the duty to not actively work against Medical Assistance benefits approval. 8. The very nature of the Respondent's breach, i.e., the failure of Respondent to produce the information and documents requested by the CAO to determine the eligibility of Ms. Colbert for Medical Assistance benefits, presents an issue of immediate and irreparable harm to Petitioner, as Petitioner cannot realize the benefit of the bargain promised to it under the I t Agreement - specifically, its right to be compensated for the skilled nursing services it has provided to Respondent's mother - unless Respondent provides the CAO with the documentation it needs to process and approve Ms. Colbert's application for Medical Assistance benefits. 9. The requested injunction would restore the parties to the status quo as it existed immediately prior to Respondent's breach of the Agreement and breach of his statutory duty of support. 10. 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's denial of Ms. Colbert's application for Medical Assistance benefits will stand, and Ms. Colbert's right to receive those benefits and Petitioner's ability to receive compensation for the skilled nursing services it has provided under the Agreement will be forever lost. 11. Petitioner's right to relief is clear. See Exhibit A to the Complaint. 12. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Ms. Colbert has been financially unable to fully compensate Petitioner for the services that it has rendered to her. 13. 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 Respondent's specific performance of his contractual and statutory duties. Respectfully submitted, SCHUTJER BoGAR LLC Dated: g By: ivia F. L gton, Esq. Attorney I.D. No. 91548 (412) 281-3710 Marijane E. Treacy, Esq. Attorney ID No. 84070 (412) 281-3535 600 Grant Street, Ste 3290 Pittsburgh, PA 15219 Fax: (412) 281-0530 Bradley A. Schutjer, Esq. Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff Em f 1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP DB/A GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION NO. Q?- 52fa3 TYPE OF PLEADING: COMPLAINT - EQUITY FILED ON BEHALF OF: Attorney I.D. No.: 84070 (412) 281-3535 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Plaintiff COUNSEL OF RECORIOR THIS PARTY: c+ Y LLivia F. Langton, Esq. Attorney I.D. No.: 91548 (412) 281-3710 Marijane E. Treacy Bradley A. Schutjer Attorney I.D. No.: 75954 (717) 909-5921 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION - EQUITY No. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 EN LA CORTE DE ALEGATOS COMLJN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. V. STANLEY COLBERT, Defendant. 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 reclamation 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. V. STANLEY COLBERT, Defendant. COMPLAINT AND NOW, COMES, GGNSC Camp Hill III LP d/b/a Golden Living Center, Camp Hill ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Stanley Colbert ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal office located at 46 Erford Road, Camp Hill, Pennsylvania 17011. 2. Defendant, the son of and legal representative for Rose Colbert, is an adult individual who currently resides at 5583 Mercury Road, Harrisburg, Pennsylvania 17109. 3. On or about October 24, 2008, Defendant applied for the admission of his mother, Rose Colbert ("Ms. Colbert"), to Plaintiff's skilled nursing facility. At that time, Plaintiff and Defendant entered into a written Resident Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's mother with skilled nursing services in exchange for Defendant's promise to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. A true and correct copy of the Agreement is attached hereto as Exhibit A. 4. After Defendant's mother became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that he needed to secure Medical Assistance benefits for Ms. Colbert, and an application for Medical Assistance benefits subsequently was filed on or about March 30, 2009. 5. On May 11, 2009, the application for Medical Assistance benefits was denied because Defendant did not provide the information and documentation required by the Cumberland County Assistance Office ("CAO") to establish and maintain Ms. Colbert's eligibility. Seethe PA-162 attached hereto as Exhibit B. 6. On June 15, 2009, the Plaintiff filed an appeal of this denial. However, if the Defendant fails to provide the CAO with the information necessary to qualify his mother for Medical Assistance benefits, the appeal will necessarily fail, and Ms. Colbert will be precluded from receiving the Medical Assistance benefits that she is entitled to and the Plaintiff will be ,deprived of payment on Ms. Colbert's account as bargained for at the time of her admission. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 7. The allegations contained in Paragraphs 1 through 6 are incorporated herein by reference as if fully set forth at length. 8. Defendant breached his Agreement with Plaintiff by failing to act in accordance with the terms of the same, as he has failed to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. 9. Because, at all times material hereto, Defendant's mother was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her, 2 i Defendant's failure to provide the necessary documentation required by the CAO, to process and approve his mother's application for Medical Assistance benefits, is a critical violation of the terms and conditions of the Agreement. See Exhibit A. 10. Defendant has interfered with Ms. Colbert's right to receive the Medical Assistance benefits she is entitled to, as well as Plaintiff's right to receive payment, via the Medical Assistance benefits process, in accordance with the bargained for Agreement. See Exhibit A. 11. By obstructing the Medical Assistance benefits process, Defendant has irreparably harmed both his mother and the Plaintiff. 12. 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 respectfully requests that this Honorable Court order Defendant to specifically perform his obligations under the Agreement and to produce the information and documents to the Cumberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. COUNT II STATUTORY DUTY OF SUPPORT 13. The allegations contained in Paragraphs 1 through 12 are incorporated herein by reference as if fully set forth at length. 14. Defendant Stanley Colbert is the son of Rose Colbert. 15. Upon information and belief, at all times material hereto, Rose Colbert has been indigent. 16. At all times material hereto, Defendant has had a statutory duty to financially support his mother, Rose Colbert. See 23 Pa. C.S. § 4603(a). 3 17. At all times material hereto, Defendant has failed to financially support his mother. 18. The Defendant's statutory duty to support his mother 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. 19. At all times material hereto, in violation of 23 Pa. C.S. §4603(a), Defendant failed to care for, maintain or financially assist his mother by refusing to provide the information and documents requested by the CAO to determine his mother's eligibility for Medical Assistance benefits. WHEREFORE, Plaintiff respectfully requests that this Honorable Court order Defendant to specifically perform his statutory duty, and to produce the information and documents to the Cumberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. [This section intentionally left blank.] 4 Respectfully submitted, SCHUTJER BOGAR LLC Dated: By: -f Livia F. Li gton, Esq. Attorney I.D. No. 91548 (412) 281-3710 Marijane E. Treacy, Esq. Attorney ID No. 84070 (412) 281-3535 600 Grant Street, Ste 3290 Pittsburgh, PA 15219 Fax: (412) 281-0530 Bradley A. Schutjer, Esq. Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4t' Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unswom falsification to authorities. Dated: -7 f,-)n 10(3 Susan Bertolette, FBOC GGNSC Camp Hill III LP a/b/a Golden Living Center, Camp Hill Ela"ST A WELCOME THANK YOU FOR CHOOSING US FOR YOUR NURSING FACILITY CARE The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. L NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. H. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. In addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees and contractors. B. Physician Services - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physicians are not associates or agents of the Facility and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. III. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. IV. ARBITRATION - The Resident acknowledges that disputes under this Agreement may be submitted to arbitration, if the Resident elects to do so, by signing a separate agreement executed between the parties. Agreeing to arbitration is not a condition of admission or continuing care. V. PRIVACY ACT NOTIFICATION STATEMENT - Skilled nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of June 22, 1998, all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the Federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 1819(f), 1919(f), 1819(b)(3)(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or quality of health care services provided in the State; (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Medicare/Medical Assistance nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care . given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medical Assistance services. VI. RESIDENT'S PERSONAL PROPERTY A. Safety Of Resident's Personal Property - The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property/valuables, which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility in writing of all personal property upon admission. If, at any time during the Resident's stay, new items of value are brought to or removed from the Resident's possessions in the Facility, the Resident also agrees to so 2 inform the Facility Executive Director or designee. B. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. VII. PERSONAL FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B. Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Resident's. funds shall be credited to the Resident's account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. D. Accounting - The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not - commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. E. Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance Program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance or SSI. F. Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the Facility's Business Office. 3 G. Security of Funds - The Facility shall ensure the security of all personal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance Program Resident's personal funds for any item or service for which payment can be made under the Programs. VIII. THE RESIDENT'S DUTIES A. Facility's Rules And Regulations - The Resident agrees that the Facility may, to maintain orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. It is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. B. Resident Grievances - Residents are urged to bring any grievance concerning the Facility to the attention of the Facility Executive Director or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered anonymously. This number is 1-800-572- 9981. Residents also have the right to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. C. Diet - The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages brought into the Facility for the Resident's'benefit. D. Medications - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. All drugs or medications brought into the Facility shall be immediately delivered to the nurses' station. E. Care Of Facility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as is to be expected from ordinary wear and tear. F. Care Of The Resident's Room - The Facility encourages the Resident to have a home-like environment and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must concur with any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. IX. PROHIBITION AGAINST THIRD PARTY GUARANTOR -FEDERAL AND STATE LAWS PROHIBIT A NURSING HOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAYMENT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION OR CONTINUED STAY IN THE FACILITY. HOWEVER, A FACILITY MAY REQUIRE AN INDIVIDUAL WHO HAS LEGAL ACCESS TO THE RESIDENT'S INCOME OR RESOURCES AVAILABLE TO PAY FOR FACHX17Y CARE TO SIGN A CONTRACT, WITHOUT INCURRING PERSONAL FINANCIAL LIABILITY FOR THE RESIDENT'S COSTS OF CARE, TO PROVIDE FACILITY PAYMENT FROM THE RESIDENT'S INCOME OR RESOURCES. n X. ' AGENT AND/OR LEGAL REPRESENTATIVE A. Agent - For the purposes of this Agreement, an Agent is a person who manages, uses or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amount of the funds received or held by the Agent for the Resident. The Agent assumes no responsibility to pay for the costs of the Resident's care out of the Agent's personal funds. However, as a necessary parry to this Agreement, the Agent is contractually bound by the terms of this Agreement and may become personally liable for failure to perform duties under the Agreement. If the Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these funds for the Resident's welfare. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due and to make prompt payment for care and services provided to the Resident as specified in the terms of this Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESIDENT. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include not only the Resident, but also the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, copies of documents verifying such status must be provided to the Facility at the time of admission. XL PAYMENT INFORMATION A. Obligation To Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (10th) day of each month or, in the case of a notice of a rate change, within ten (10) days of mailing of the notice. If payment is not received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth under the Transfer and Discharge section of this Agreement. B. Credit Card Charges - The Facility accepts MasterCard and VISA If the Resident would like the convenience of paying amounts due each month through one of these options, the Resident must provide the needed information and authorization on the Credit Card Authorization form at the back of this Agreement. The Resident recognizes that, unless the Resident has authorized the use of MasterCard or VISA, the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. Fee For Returned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. 5 I ! , D. Potential Personal Liability Of Agent - Agent (includes any Legal Representative serving as the Resident's Agent) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's care, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this Agreement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement. XU. PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. In this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer. Non-covered charges may include any coinsurance and/or deductible amounts required by a third parry payer. D. Communicating Changes in Assets - It is essential for the Resident to communicate to the Facility any changes in the Resident's assets or resources within ten (10) days of knowledge of the changes in financial status. Upon request by the Facility, the Resident shall provide the required information to the Facility within ten days. If the Resident runs out of private monies, it is important to locate alternative payment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funds are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengthy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of being reduced to an amount that, when combined with the 6 Resi'dent's monthly income, is no longer sufficient to pay for the cost of care and services. If the Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. E. Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. XIII. MEDICAL ASSISTANCE PROGRAM RESIDENT - A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional services/items provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance. A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage. B. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. If the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D. Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits. The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment. E. Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, Private Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis. 7 . .11 } F. Continuing Payment of Facility Charges Pending Eligibility - When an application for Medical Assistance has been filed, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (10th) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. G. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by the Program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H. Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a Private Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. I. Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XIV. MEDICARE RESIDENT - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. B. Limited Coverage - Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C. Expiration Of Benefits - When Medicare coverage expires, the Resident may remain in the Facility if private pay or other payment arrangements have been made. If the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission or readmission. If the Resident intends to become private pay when 8 ' l Medicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. D. Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The Facility shall give notice to the Resident and, if known, a family member or Legal Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. In cases where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. B. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVI. BED-HOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed-hold." The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days. If the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for a certain number of bed-hold days. Otherwise, a Private Pay or Medicare Resident requesting a bed-hold must pay the Facility's prorated private monthly rate during the bed-hold period. 9 • r XVIL RESIDENT'S RIGHTS AND FACILITY POLICY UNDER THE FEDERAL SELF- DETERMINATION ACT A. Right To Make Decisions Regarding Care -The Facility recognizes the right of each Resident to make decisions regarding his or her care. Where a Resident is incompetent, the Facility recognizes the Resident's right to have these decisions made on his/her behalf by a substitute decision maker in accordance with State law. B. Right To Formulate An Advance Directive- The Facility recognizes the right of each Resident to have an advance directive and will honor advance directives developed in accordance with State law and consistent with the level of care the Facility is licensed to provide. An advance directive is a written document that states choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of advance directives. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician and/or attorney. C. An Advance Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to continue to reside in the Facility. However, if the Resident has an advance directive, he or she must make it known to the Executive Director or designee so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at the time of admission, the advance directive information shall be provided to family members or other Resident representatives. However, if the Resident later regains competency, the Facility will provide such information directly to the Resident. XVIII. CHARGES FOR COPIES OF MEDICAL RECORDS -The Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charged in the Facility's community. XIX. SOLE AGREEMENT- This Agreement is the only Admission Agreement between the Facility and the parties. Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid Agreement. XX. ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. XXI. INTEGRATION - The Parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, promises, understandings, and agreements between the parties, whether written or oral, and therefore they are of no further force and effect. Because this is a fully integrated agreement, the only discussions, statements, representations, promises, understandings, or agreements that are or will be binding on any of the parties to this Agreement or their employees, affiliates, contractors, agents, or representatives are those expressly set forth in writing in this Agreement, or in other written agreements entered into at the same time as, or subsequent to, this Agreement. in 17177637242 golden Wing center cam 07:49:01 a.m. 07-15-2009 RESIDENT-SPECIFIC INFORMATION XXH. Payer So VEMedicare - This Facility accepts the following types of payments: [ ] Private [ ] Medical Assistance [ ] Veterans Administration XXM ACKNOWLEDGEMENTS - By signing the Admission Agreement Signature Page, the Resident/Agent/Legal Representative acknowledges that he or she has been given and has read this Agreement in its entirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not applicable, write N/A): ffDO W3. 4. A list of supplies and services that are included in the Facility's private monthly rate or that will be paid for by the Medical Assistance or Medicare programs and a list of supplies and services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged Information about the Facility's bed-hold procedures. A written explanation of how to apply for and use Medicare and Medical Assistance benefits and how to receive funds for previous payments covered by these benefits. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuselthef of resident personal property in the Facility. Copies of the State Resident Rights. A written explanation of the Facility's Rules and Regulations. Where applicable, if your condition warrants, you may be placed in the Facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the Facility will discuss such a transfer ' h you. Under law, you cannot be discharged from this Facility unless you agree or ess, following an appeal, it is determined that you may be involuntarily dischar ed or transferred. ?8. I do do not have an advance directive. 9. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. 0. I have been given a copy and had an opportunity to review the Facility's Notice of Privacy Practices. XXIV. NOTICES - Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal Representative are responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Agent, and/or Legal Representative. 3/22 X 0 y a c? 0 2 co 70 CC CA 0 Rev. 03/13/03 White - Business Office Pink -Medical Records Yellow - Resident 11 1717753782 go'den'Ivingcenter cam A. Lega epresentative An &Orgent Name Home Phone rT f jt] ltlt [ [ h[ol V4Wk-PJ=e[ N ][A][ if ][ l[ 1111. 1 G ] Street „--T-ity B. Other Person To Be Notified Name Home Phone[ ][ ][ ][ ][ ][ ][ ][ ][ ] [ ] Work Phone[ ][ ][ ][ ][ ][ ][ l[ ][ 1[ ] Street city 07:49: 18a.m. 07-15-2009 State Zip State Zip XXV. MAIL - The Facility is authorized to handle the Resident's mail as follows: (Check one box only.) [ ] mail given directly to the Resident [ Forward all of the Resident's mail to: v XXVI. RESIDW A. NAME: _ B. SPECIALTY: C. ADDRESS: D. TELEPHONE: [ ] All mail read to the Resident ] Give personal mail to the Resident; forward business mail to: XXVII. RESIDENT TRUST FUND AUTHORIZATION - A Resident Trust Fund is an amount of money held by the Facility for the Resident's personal use. (Examples of use: To allow the resident to pay for room and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on request, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 4/22 c? co c? M Z 3 c? y Z 0 12 71776378'-2 golden I?ving center cam 07:49:32 a.m. 07-15-2009 shall be authorized by the Resident or his/her Agent or Legal Representative in writing. The following persons may authorize withdrawals on the Resident's behalf. Name of Authorized Person Resident's Signature Witness if Resident Signed with a Mark Legal Representative's Signature (if applicable) Agent's Signature (if applicable) Name of Authorized Person Date Date Date Date XXVIR CREDIT CARD AUTHORIZATION - Facility accepts MasterCard and VISA. If Resident would lik a convenience of paying amounts due each month through one of these, please provide the needed info tion and authorization: Credit Card Expiration I hereby authorize Facilit}o charge the account listed above for monthly charges incurred under this Agreement: Resident or Agent's Signature \ If the Resident is unable to consent or incompetence or is a minor and this pr the following: Account # Date this provision because of physical disability or mental is being signed by an authorized representative, complete Date: Relationship to Signature: Witness: For Facility: Rev. 03/13/03 White - Business Office Pink - Medical Records 13 Date: - Resident 5/22 co H M co 0 Z P 3 c? :n z 0 1111 /b3/t5az 0 f • goiaer wing center cant 0/:49:44 a.M. U/-15-2UU9 Authorized Represent Print Name and Title: b /22 M ro a: c? Z 0 Z 0 Rev. 03/13/03 White - Business Office Pints - Medics! Records Yellow - Resident 14 17177637842 golden 11ving center cam +4 . 07:49:53a.m. 07-15-2009 7/22 ADMISSION AGREEMENT SIGNATURE PAGE XXIX. PARTIES - The parties to this Agreement . L K7 & - 0 bldfi9ff- (Name of Facility) (Name of Residen Lj::d r ub (Name of Resident's Agent) ame of Resid is gal Representative) If the Legal Representative signs the Agreemen check the Type of Legal Repre tative (below): [ ] Conservator of Person [ ] Guardi Durable Power of Attorne Agent Acting [ ] Conservator of Estate for Health Care (DPAHC) Under General [ ] Other, specify POA If you are signing this Agreement on behalf the i ote your relationship to the Resident: My relationship to the Resi is On this A?. ay of a ab es a 8b be bound by the provisions of this Agreement and agree that on the y of he Resident shall be admitted to this Facility. Resident Date 7d c? y r, z d a c? Address Resident's Social Security Number City, State, Zip Resident's Telephone Number Witness if Resident Signed th a Mark Date H 0 11 h k ? z a ,lLegal Represent tive L 51 Q--> e. ,gA L r Legal Representative's dress Date a--2-q, 0 Date Legal Representative's o ' Se Leg Representative's Telephone Nu er Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 15 '71775379,'.2 golden Pving center cam 07:50:06 a.m. ^'7-15-2009 8/22 r y Agent ----,% Date Agent's Social Security Number Facility Executi Direct or Designee Agent's elepho a ber 0,-j i v a d Facility Name Date Facility Address 1 I Note: The signatures above refer to the information contained on pages 1 through 16 of the Admission Agreement. y z 0 ' Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 16 i rq ,. E HIRIT B NOT ELIGIBLE 3? :JES'!'?1[NSTER DRIVE NOTICE ARLISLE PA 17013 0599 4 CAO RETURN ADDRESS CSLD 0026 •01022422100* ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 -V1146 1u. 94509621 CO RECORD DIST CAT GG PS 21 0124221 0 PAN 90 WORKER: K WHITTEN TELEPHONE. ;8001 269-0173 MAIL DATE: 05/11/2009 NOT: 042 OPT. D TYPE: N IF YOV DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR Ai10RKER IAWDIATELY. You have been determined not eligible for benefits based on your application dated 03/30/2009. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 04/17/09 /Items: Name: J MA51, SSN. BIRTH CERTIFICATE, - ROSE MEDICAL CARDS, POA PAPERWORK, PCA - ACCT. VA FILING, GROSS INCOME, - PROOF OF ALL RESOURCES, UTILITY - - EXPENSES, RETRO BILLS, PG OF APPL T- T NEEDED COMPLETED MAY Citation: 55 Pa. Code 201.1. 201.3 1 1 Zp?g PAGE 1 O If you disagree with our decision, you have the right to appeal. 1v1 cvlnvlv?e onwa?wuun yi Your riant to appeal ana IO a Talr nearina it you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/24/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 94509621 ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 CAO ADDRESS CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 CO RECORD DIST CAT GO PS 21 0124221 0 PAN 80 WORKER: K WHIT EN APPEAL: 05/24/2009 TELEPHONE: (800) 259-0173 MAIL DATE. 05/11/2009 NOT: 092 OPT: D TYPE: N CAO. nnw"TIall Ir-r% ^0L4 nrvrne%r r•Ir%r .i `LS CERTIFICATE OF SERVICE I hereby certify that, on this date, a true and correct copy of the foregoing Petition for Preliminary Injunction was provided to Shinkowsky Investigations for personal service upon the following: Stanley Colbert 5583 Mercury Road Harrisburg, PA 17109 Date: t D .G??GQ?'`? Linda Scisciani, paralegal I V - ?(? jj?ygF.?4'?/?"dry}! , ?$?'??' III 7 ? E PRO 1ONOTARY, 2009 AUG 17 PM 12: 2 6 Ci: 3::; ` CQTY PENNSA..V; A r 0, AUG 19 2009q( I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Petitioner, V. STANLEY COLBERT, Respondent. CIVIL ACTION - EQUITY No. Of- 571/ A.3 PRELEMI NARY ORDER AND NOW, this Z, ut , day of , 2009, a hearing in the above- captioned matter on Petitioner's Petition for the Preliminary Injunction is scheduled for 2009, at o'clock m. in Court Room No. , Cumberland County Courthouse. BY THE COURT: RLEU v; f ;E OF THE PPO w"NOTARY 2009 AUG 2 I F'n' 2.4 J CUM r., DiES GII &4? k . /.-" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendants. CIVIL ACTION - EQUITY No. 09-5423 MOTION TO CONTINUE HEARING DATE AND NOW, COMES, Plaintiff, GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill, by and through its attorneys, SCHUDER BOGAR LLC, and files the following Motion to Continue Hearing Date, stating in support as follows: 1. On or about August 5, 2009, Plaintiff filed its Complaint against Defendant. 2. Pursuant to Pa. R.C.P. 402, Plaintiff immediately retained Shinkowsky Investigators to personally serve the Complaint upon the Defendant. 3. On or about August 17, 2009, Plaintiff filed its Petition for Preliminary Injunction and Brief in Support of the Petition for Preliminary Injunction against Defendant. 4. Plaintiff provided copies of the Petition for Preliminary Injunction and Brief in Support to Shinkowsky Investigators for service upon the Defendant, along with the Complaint. 5. On or about August 21, 2009, this Court scheduled a hearing for September 14, 2009 on the Plaintiff's Petition for Preliminary Injunction. 6. On or about August 27, 2009, Plaintiff provided service, by U.S. Mail First Class and Certified Mail, to Defendant's residence, of both the Petition for Preliminary Injunction and this Court's Order of August 21, 2009. . 7. Plaintiff did not receive any indication that the August 27, 2009 service was defective or that the Defendant's address was incorrect, i. e. there was no notice of unclaimed mail nor a return to sender from the U.S. postal service. 8. Plaintiff, despite retaining an additional process server and the sheriff's department, each making multiple service attempts, has been unable to perfect personal service of the Complaint, upon the Defendant. 9. On or about September 4, 2009, the thirty day deadline ran for service of the Complaint upon the Defendant. 10. On or about September 10, 2009, contemporaneously herewith, Plaintiff filed its Praecipe to Reinstate the Complaint. 11. Due to Defendant's evasiveness and the resultant inability to timely serve him with the Complaint, Plaintiff requests that the Court continue the September 14, 2009 hearing on the Petition for Preliminary Injunction. 12. A continuation of the September 14, 2009 hearing on the Petition for Preliminary Injunction will provide additional time to serve the reinstated Complaint upon the Defendant. 13. Assuming that Plaintiff is able to arrange for successful personal or alternate service upon the Defendant in the coming weeks, Plaintiff requests that the Court then reschedule the hearing on the Petition for Preliminary Injunction. WHEREFORE, Petitioner requests that this Honorable Court grant this Praecipe to Continue Hearing Date and upon confirmation of service of the Complaint upon the Defendant reschedule the hearing on the Petition for Preliminary Injunction. Respectfully submitted, Dated: q/10 Igool ScmiTJER BoGAR LLC By: Livia F. L on Attorney . No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4'' Floor Harrisburg, PA 17101 Attorneys for Petitioner CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Motion to Continue Hearing Date was served U.S. Postal Service, First Class mail, upon the following: Stanley E. Colbert, Jr. 5583 Mercury Road Harrisburg, PA 17109 Dated: /©a 13' Linda L. Scisciani, Paralegal FlLG 43 °riGE OF THE PFROTHil-11'N)OTARY 2009 SEP 1 1 AM 11: 19 tP P1tiYb?AN IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendants. CIVIL ACTION - EQUITY No. 09-5423 PRAECIPE TO REINSTATE COMPLAINT TO THE PROTHONOTARY: Kindly reinstate the Complaint in the above-captioned matter which was originalj? filed on August 5, 2009. Respectfully Submitted, SCHUTJER BoGAR LLC Dated: 4 l a ZlaO By: Livia F. L gton Attorney I. . No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane E. Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Plaintiff FILED- ILF(CE OF THE FIRC) RONOTARY 2009 SER I I AM 11: 19 CU,r lutI?`f i'EP INSYNI NI A l e.c? tg4s Sheriffs Office of Cumberland County R Thomas Kline Pt 1-111, `_;y ` ^r Sheri Ronny R Anderson ?tr of ??tinbrt fn OF T° i ?)TiY Chief Deputy Jody S Smith Civil Process Sergeant OFFICE C,r rP- $hERIFF Edward L Schorpp " " t?°• Solicitor GGNSC Camp Hill III LP d/b/a Golden Living Center-Camp Hill Case Number vs. Stanley Colbert 2009-5423 SHERIFF'S RETURN OF SERVICE 08/28/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and inquiry for the within named defendant, to wit: Stanley Colbert, but was unable to locate him in his bailiwick. He therefore deputized the Sheriff of Dauphin County, PA to serve the within Preliminary Order, Complaint in Equity and Petition for Preliminary Injunction according to law. 09/04/2009 Dauphin County Return: And now, September 4, 2009 I, Jack Lotwick, Sheriff of Dauphin County, Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for Stanley Colbert the defendant named in the within Complaint and that I am unable to find her in the County of Dauphin and therefore return same NOT FOUND. SHERIFF COST: $42.44 September 11, 2009 sEP 14 Zoo9y i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendants. CIVIL ACTION - EQUITY No. 09-5423 ORDER AND NOW, this _, day of September, 2009, upon the Plaintiff's Motion to Continue Hearing Date, it is ORDERED that the hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction, originally scheduled for Monday, September 14, 2009 at 1:30 p.m., is continued a y l Q l iS L U sc 0S i LtC ?L1 o L 1X37 1 C TJ UtJ ` 21 BY THE COURT: FILL- ,??F CF THE' P^E 5 ! .l ?? ?,?aF?Y 2099 SEP 15 AM 11: 2:i PEI' 911 s(vq - eo?,;as- .l? rte(, -L 0. 0,40L4- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 09-5423 GGNSC Camp Hill III LP DB/A Golden Living Center, Camp Hill VS. Stanley Colbert Commonwealth of Pennsylvania County of Dauphin as. AFFIDAVIT OF SERVICE I, Erin Johnson, a competent adult, being duly sworn according to law, depose and say that at 9:17 PM on 08/26/2009,1 non-served Stanley Colbert at 5583 Mercury Road, Harrisburg, PA 17109 in the manner described below: a true and correct copy of Complaint - Equity; Notice to Defend; Complaint; Petition for Preliminary Injunction; Brief in Support of Petition for Preliminary Injunction issued in the above captioned matter. Comments/Prev. Attempts: 08/11/2009 7:16 PM - No answer. 08/13/2009 5:39 PM - No answer. A brown package was on the door step. A white female, 64 years of age, 5' 0611, and 140 pounds, residing at 5582 Mercury Road stated she rarely sees the subject and does not know when he is usually home. 08/15/2009 08:31 AM - A black male, bald, 33 years of age, 6' 0211, and 175 pounds stated he was a ca-resident and the subject was not home. He refused to accept service and closed the door on the Process Server. 08/21/200911:19 AM - No answer. 08/26/2009 9:17 PM - No answer. No lights were observed illuminating inside of the residence. A bag; containing the Yellow Pages was laying at the bottom of the driveway. on this 2 00?. x Erin Jo son Shinkow ky Investigations 316 Fawn Ridge North Harrisburg, PA 17110 (800) 276-0202 Atty File#: glc-ch-001 - Our File#'8349 Law Firm: Schutjer Bogar, LLC - Pittsburgh Address: 600 Grant Street, Suite 3290, Pittsburgh, PA, 15219 Telephone: (412) 281-0965 COMMONWEALTH OF PENNSYLVANIA Notarial Seal John F. Shinkowsky, Notary Public Susquehanna Twp., Dauphin County My Commission Expires Sept. 28, 2010 Member, Pennsylvania Association of Notaries OF THE PPOI?'ONJOTARY 2009 SEP 18 PM 2.00 r'' It ZYLVA AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania County of Cumberland Common Pleas Court Case Number: 09-5423 Petitioner. GGNSC Camp Hill III LP dfb/a Golden Living Center-Camp Hill vs. Defendant: Stanley Colbert For: Schutjer Bogar LLC Received by Pennsylvania Professional Process Svc. to be served on Stanley Colbert, 5583 Mercury Rd., 7tr Harrisburg, PA 17103. I, .lo lio T, k?Et#A-_K,K being duly swom, depose and say that on the, _ day of SepT6M6eR 20G aW :_ Q.m., executed service by delivering a true copy of the Preliminary Order, Complaint, Petition for Preliminary Injunction in accordance with state statutes in the manner marked below: () INDIVIDUAL SERVICE: Served the within-named person. O SUBSTITUTE SERVICE: By serving _ as NON-SERVICE: For the reason detailed in the Comments Below () OTHER COMMENTS: q 13) o 3 1(63 N .16TH ST r N# gKj 50v t6 & - No ANS W f R , gNar Desk 6W n.o rug, (?+++?ie S i r.35 /i,n. c( (3/p3 Cr 1,"y 5.93 "+6Qcvfv 09, (A,4 ,*5e, , A4 APs-M. M c.ACs fi ftu 5i?R[, FfS Q fficf C: ftO e Q 5N;0 wI a"> t9 P 5• 14 R ST Cok6 T &V S CI/Li 04 D it -4W Vik 0-6- jVVIkV Pip Reswfwg NT Du0>o . DI FFPSf-- 4^$&& ST+c kNR oa W)wpOv+? nO, eN5L 61%LIC54- * 05'4 tPl AIJ% Of"' w?a0pw. SvA'34(-CT +M11`1 wot..K AT 06fT• bF. oi:+ rSt', P&w -WdPgd.q.D' e1q, I certify that I have no interest in the above action, am of legal age and have proper authority in the jurisdiction in which this service was made. Jay PR CESS SERVER # Appointed in accordance with State Statutes Pennsylvania Professional Process Svc. 48 W. High St. P.O. Box 1148 Carlisle PA 17013 COMMONWEALTH OF PENNSYLVANIA () 863-2341 f?Y Public M. MIchWN OuytdlNUY sa, Nom y Job Serial Number. 2009000454 CWUW 9M. CumbWWW C 20 2 W (;gtNMlb oopydght O 1892-20o5 DoWme s.rww, tr,c. - Proem servers Tooftx VS.& [MOMW n d" RLED-4,','H rfCE OF THE PROD-ILDINOTAPY 2009 SEA' 18 P 2= Q 0 CUM Fr ^,iW Y VAN! A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION - EQUITY No. 09-5423 MOTION FOR SPECIAL ORDER FOR ALTERNATE SERVICE PURSUANT TO Pa.R.C.P. 430 AND NOW, COMES, Plaintiff, GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill, by and through its counsel, Schutjer Bogar LLC, and files this Motion for Special Order for Alternate Service Pursuant to Pa.R.C.P. 430, as follows: 1. Plaintiff operates a skilled nursing facility, located at 46 Erford Road, Camp Hill, Pennsylvania 17011. 2. Rose Colbert is a resident at Plaintiffs skilled nursing facility, located at 46 Erford Road, Camp Hill, Pennsylvania 17011. 3. Rose Colbert's son and agent through power of attorney is the Defendant, Stanley Colbert, whose residential address and mailing address is 5583 Mercury Road, Harrisburg, Pennsylvania 17109. 4. On or about August 5, 2009, Plaintiff filed its Complaint against the Defendant. 5. In accordance with Pa. R.C.P. 402, Plaintiff, by and through Erin Johnson, of Shinkowsky Investigators, attempted to make personal service of the Complaint upon the Defendant at his place of residence. See Affidavit of Erin Johnson attached hereto as Exhibit A. 6. In accordance with Pa. R.C.P. 402, Plaintiff, by and through John T. Kranchick, Jr., of Pennsylvania Professional Process Svc., again attempted to make personal service of the Complaint upon the Defendant at all then known physical addresses, including the 5583 Mercury Road address as well as 1103 N. 16'' Street, both in Harrisburg, Pennsylvania. See Affidavit of John T. Kranchick, Jr. attached hereto as Exhibit B. 7. Plaintiff made another attempt to comply with Pa. R.C.P. 402, by engaging the Cumberland County Sheriff, who deputized the Dauphin County Sheriff, to attempt t6 make personal service upon the Defendant at all known physical addresses. 8. The Dauphin County Sheriff was unable to perfect service upon the Defendant. See Sheriff's Return for Dauphin County and Sheriffs Return for Cumberland County attached hereto as Exhibits C and D, respectively. 9. Personal service was also attempted at Defendant's place of employment, the Defense Distribution Center; however, Defendant refused to come to the security gate to accept service of the Complaint. See Affidavit of Service of Jack Kranchick, attached hereto as Exhibit E. 10. All personal service attempts upon Defendant, regardless of location, have been unsuccessful. See Exhibits A, B, C, D and E. 11. Attempts to provide service of other legal documents and correspondence via Certified Mail - Return Receipt Requested have similarly been unsuccessful, due to Defendant's failure and/or refusal to claim the same. See the August 27, 2009 letter and envelope from an attempt to contact Defendant via Certified Mail, attached hereto as Exhibit F. 12. However, the U.S. Mail has been used successfully for communicating with the Defendant, as correspondence sent to his residence in this fashion has not been returned to sender, nor has any indication of non-receipt been provided. See the July 29, 2009 letter to Defendant, attached hereto as Exhibit G. 2 13. Pursuant to Pa. R.C.P. 430, where service cannot be made under the applicable Rule, i.e. Pa. R.C.P. 402, a Special Order may be issued allowing for alternate service. 14. The U.S. Mail First Class is the only known way to communicate with Defendant, as he refuses to receive or return telephone calls and personal service cannot be made. 15. Service of the Complaint, Petition for Preliminary Injunction and Brief in Support, via U.S. Mail First Class, would provide adequate notice to Defendant of the proceedings filed against him, which the Court has the authority to permit by special order. WHEREFORE, Plaintiff requests that the Court enter a Special Order permitting Alternate Service of the Complaint, Petition for Preliminary Injunction and Brief in Support upon Stanley Colbert via U.S. Mail First Class, as well as all future pleadings, Court Orders or otherwise. Dated: Respectfully submitted, SCHUTJER BOG LLC By: Livia F. L gton PA. I.D. #91548 (412) 281-3710 Marijane E. Treacy PA. I.D. #84070 (412) 281-3535 U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer PA. I.D. #75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Plaintiff 3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC Camp Hill III LP D/B/A Golden Living Center, Camp Hill AFFIDAVIT OF SERVICE CASE NO.: 09-5423 VS. Stanley Colbert n ? ) y Commonwealth of Pennsylvania County of Dauphin ss. I, Erin Johnson, a competent adult, being duly sworn according to law, depose and say that at 9 08/26/2009,1 non-served Stanley Colbert at 5583 Mercury Road, Harrisburg, PA 17109 in below: a true and correct copy of Complaint - Equity; Notice to Defend; Complaint; Petition for Pr Injunction; Brief in Support of Petition for Preliminary Injunction issued in the above captii Comments/Prev. Attempts: 08/11/2009 7:16 PM - No answer. 08/13/2009 5:39 PM - No answer. A brown package was on the door step. A white female, 64 years'df age, 5' 06and 140 pounds, residing at 5582 Mercury Road stated she rarely sees the subject and does not,know when he is usually home. 08/15/2009 08:31 AM - A black male, bald, 33 years of age, 6' 0211, and 175 pounds stated he was a co-resident and the subject was not home. He refused to accept service and closed the door on the Process Server. 08/21/200911:19 AM - No answer. 08/26/2009 9:17 PM - No answer. No lights were observed illuminating inside of the residence. A bag containing the Yellow Pages was laying at the bottom of the driveway. and sub 'bed b fore me on this Erin Jo son day of ; , 2007. Shinkow ky Investigations 316 Fawn Ridge North I-- -y -!?? Harrisburg, PA 17110 (800) 276-0202 UBLIC Atty File#: glc-ch-001 - Our File# 8349 Law Firm: Schutjer Bogar, LLC - Pittsburgh Address: 600 Grant Street, Suite 3290, Pittsburgh, PA, 15219 Telephone: (412) 281-0965 COMMONWEALTH OF PENNSYLVANIA Notarial Seal John F. Shinkowsky, Notary Public Susquehanna Twp., Dauphin County My Commission E>pires Sept 28, 2010 Member, Pennsylvania Assoclation of Notaries AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania County of Cumberland Common Pleas Court Case Number: 09-5423 Petitioner. GGNSC Camp Hill III LP d/b/a Golden Living Center-Camp Hill vs. Defendant: Stanley Colbert For. Schutjer Bogar LLC N C7 C) Received by Pennsylvania Professional Process Svc. to be served on Stanley Colbert , 5583 Mezu, Gn Harrisburg, PA 17103. I, . c T, k,?A l ry ?? day of S tPTt: ?+n,be 2p ,? at i , being duly swom, depose and say tit on t T Complaint, Petition for Prelim n unction in ccordance wthlstate statutes in the mari Pn i nina rde'?. nneark?belowc O INDIVIDUAL SERVICE: Served the within-named person. •' () SUBSTITUTE SERVICE: By serving C;) as -- -4 NON-SERVICE: For the reason detailed in the Comments Below (} OTHER COMMENTS: IL31 3 I003N•/V H Si HAe,SgvrtC fR N;,&V4WEQ, 5 ??l@3 Ii',N S7L?3 ?hreco Kv Ud ?oA ( ner-L A.C ?s- De•o?. ??LL rt.C Nk-i6N?.S IP.3S/9+s'1. 3.? nom P 5 A ST asL M2 cfti A(? Si QitFf7 0FAI LAX0 n05 Via fgc-ft ?S? ?? &Ao,.? 1K S??Cj4.fL It OSJ iZ`l f}1aG Cr-'wir0p?v..uC ? Ni`I- t4 'u c'k d w OLN •i? '--2Ni Sv?3?ti?t dniv-1 KKK AT 0E?1• aF. Sri En?S? , P6- c_v416C-Ri.,4..0 , e1q I certify that I have no interest in the above action, am of legal age and have proper authority in the jurisdiction in which this service was made. on the lay PR CESS SERVER # Appointed in accordance with State Statutes Pennsylvania Professional Process Svc. 48 W. High St. P.O. Box 1148 COMMONWEALTH OF PENNSYLVANIA Carlisle, PA 17013 Notariatseat.._ _ . (1ko_o)_663-2341 _ M. Micheft S Dayton, Notary Public Our Job Serial Number: 2009000454 Cariisle k eoro, Qum<xsrlatind County My Cwwn ft Ex 1.2012 Copyright o 1992-2005 ASS" Morn or, 1% t o a of atadn Dambase Services, inc. - Process Servers Toolbox W& E IT C x (Ott ft Jane Sn " der Charles E. Sheaffer .Dep uy Beat Estat •;?.+ Chief Deputy Willi cT Tully t W. _ ant 'y '& h 'hart Dauphin County Harrisburg Pennsylvania 17101 pb: (717) 780-6590 fax. (71.7),255-2389 Jack Lotwick Sheriff Commonwealth of Pennsylvania GGNSC CAMP HILL III LP ET;` AL VS County of. Dauphin STANLEY COLBERT Sheriff s .Return No. 2009-T-2342 OTHER COUNTY NO. 095423 I, Jack Lotwick, Sheriff of the County of Dauphin, State of Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for STANLEY COLBERT the DEFENDANT named in the within . COMPLAINT and that I alp unable.to_ find him/her in the County of Dauphin, and therefore return same NOT FOUND, SEPTEMBER 4, 2009. SEVERAL ATTEMPTS WERE MADE WITH NO RESPONSE . Sworn and subscribed to before me this I OTH day of September, 2009 "?Al NoTARlAl. SEAL RY JANE SNYDER, Nutary Publ' High9ire, Daiiphin C&nly LMY Conuniniou res S " 1; 2010 So Answers, y el%4 ?- B Y Depu heriff Deputy: W CONWAY Sheriffs Costs: $47.25 8/3112009 E IT D Sheriffs Office of Cumberland County R Thomas Kline Sheriff Ronny R Anderson Chief Deputy Jody S Smith Civil Process Sergeant office Edward L Schorpp Solicitor GGNSC Camp Hill III LP d/b/a Golden Living Center-Camp Hill Case Number vs. Stanley Colbert 2009-543 SHERIFF'S RETURN OF SERVICE 08/26/2009 R. Thomas Kline, Sheriff who being duly sworn according to law states that he made a diligent search and inquiry for the within named defendant, to wit: Stanley Colbert, but was unable to locate him in his bailiwick. He therefore deputized the Sheriff of Dauphin County, PA to serve the within Preliminary Order, Complaint in Equity and Petition for Preliminary Injunction according to law. 09/04/2009 Dauphin County Return: And now, September 4, 2009 I, Jack Lotwick, Sheriff of Dauphin County, Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for Stanley Colbert the defendant named in the within Complaint and that I am unable to find her in the County of Dauphin and therefore return same NOT FOUND. SHERIFF COST: $42.44 September 11, 2009 1 CI*A.I1 10110 AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania Case Number: 09-5423 County of Cumberland Petitioner GGNSC Camp Hill 111 LP dro/a Golden Living Center-Camp Hill VS. Defendant: Stanley Colbert For: Schutjer Bogar LLC U.S. Steel Tower 600 Grant St., Suite 3290 Pittsburgh, PA 15219 Common Pleas Court Received by Pennsylvania Professional Process Svc. to be served on Stanley Colbert 0 POE DOD, 2001 Mission Drive, New Cumberland, PA 17070. I, Jack Kranchick, being duly swom, depose and say that on the 17th day of September, 2009 at 10:45 pmo I: NON-SERVED: After due search, careful inquiry and diligent attempts I was unable to serve the Complaint, Petition for Preliminary Injunction, Praeeipe to Reinstate Complaint for the reason that I failed to find refused or information to allow further search. Additional Information pertaining to this Service: 9/21/2009 10:52 am On Sept. 15, '09 at 10:45 PM, server spoke with Captain Christopher Klein, watch commander who spoke with Stanley Colbert about Legal Paperwork for Colbert. Colbert refused to meet with server to accept papers as referenced above. Also no one else willing to accept - Commander advised that becasue these were civil docs this would be voluntary for anyone working there as to whether they opted to accept or not - Stanley was also advised that this was not going to go away - we would continue to persue service at home as well. 9/21/2009 11:02 am A follow up by server on 09/17/09 10:45 PM did not result in any different outcome - Captain Klein advised that he had done all that he could & all that he was going to do - they do not wish to get involved in these civil matters - would not provide server with Stanley Colbert's Supervisor's name or title nor would he provide server with Stanley Colbert's position / job status with the Defense Distribution Center. Advised that any further contact on the Federal Property regarding this matter would have to be cleared by the Legal Dept. - Perhaps the attorney wants to contact the JAG to advise how to go about assitiing in Stanley Colbert being served. I certify that I am over the age of 18, have no interest in the above action, and am a Certified Process Server, in good standing, in the judicial circuit in which the process was served. COMMONWEALTH OF PENNSYLVANIA tlotI W sad M. Mid?eYaGuylon, Notary Public carlsle Bono, Cunbstand county My commission Eon July 1, 2012 Member, Pennsylvania Aasodatbn of Notaries c ra ick Jay of Process Server Ilennsyhrania Professional Process Svc. 48 W. High St. P.O. Box 1148 Carlisle, PA 17013 (800) 863-2341 Our Job Serial Number: 2009000465 Ref: Colbert CopyrWC 4992.2005 Databsse Services, Inc. - Process Server's Toolbox V5.5i i *?OR III BS WAR LLC Email: IlangtonQschuljerbogar.com Direct Dial: (412) 281-3710 August 27, 2009 Via U. S. First-Class Certified Mail Stanley Colbert 5583 Mercury Road Harrisburg, PA 17109 Re: GGNSC Camp Hill LU LP dIVa Golden Living Center - Camp Hill v. Stanley Colbert Cumberland County Civil Action No. 09-5423 Dear Mr. Colbert: L LC _ :29D 'A 1' 219 Fax (412) 281-0530 www.schutjerbogar.com Enclosed are courtesy copies of the Complaint which was filed against you on August 5, 2009 and the Petition for Preliminary Injunction which was filed on August 17, 2009. Additionally, enclosed is a copy of the Preliminary Order signed by the Honorable Judge J. Wesley Oler scheduling a hearing on the Petition. Non-compliance with the court documents may result in a Judgment against you. Please note that the hearing before Judge Oler is scheduled for 1:30 p.m. on September 14, 2009 in Court Room No. 1. Very truly yours, SCHUTJER BOGAR LLC Livia F. L on enclosure s _ E •:_; ?i f : 1 ?. :, c ` 0 N , N J ?? S .1 _.. (? A _: ;... I f .. T ,:, pl ... ? , ;; I...... , ' 1.: I ft 1 v m ni N 1 ru ` -co r zr d r-I O 61 4C > 0 C3 O -0 rq 0r O O N ?.i V I \ {Y t ? i. Cf F. i rya i ' tL3 ' ???yy r? r ? 1 ' ?{ 1 EXIiIBIT G A SGAR E Email: ]langton@schutjerbogar.com Direct Dial: (412) 281-3710 July 29, 2009 Stanley Colbert Agent and Legal Representative for Rose Colbert 5583 Mercury Road Harrisburg, PA 17109 Re: Medical Assistance Benefits for Rose Colbert Dear Mr. Colbert: Schutje>r Boga LLI. U.S. Steel Tower 600 Grant Street 32" Floor, Suite 3290 PiTtsburcjh. PA 1,5219 Fax (412) 281-0530 www.schutjerbogar.com Our law firm serves as counsel for GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill ("Golden Living Center"). As a condition of your mother's admission to our client's skilled nursing facility, you contractually agreed, as Agent and Legal Representative for your mother, with respect to Medical Assistance benefits/coverage, to "act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited, to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all step necessary to ensure that the Resident's assets are appropriately spent down and maintained with the allowable limits." Therefore, we are now requesting the cooperation you agreed to provide pursuant to the Resident Admission Agreement. An application for Medical Assistance ("Medicaid") benefits was filed on your mother's behalf on March 30, 2009. On May 11, 2009, the application was denied because' certain information was not timely provided to the County Assistance Office. A copy of the denial notice is enclosed for your reference. An appeal of that denial is currently pending. However, as you may be aware, your mother's application for benefits requires the production of certain information necessary to determine whether or not she is eligible for benefits. While I understand that the process can be time-consuming and difficult, it is essential that benefits be secured. To facilitate our obtaining the information needed by the County Assistance Office, I have enclosed herewith an Authorization Statement for your signature. Please sign and return the Authorization Statement in the enclosed self-addressed stamped envelope. Additionally, please contact me to discuss the required documentation and when that documentation will be available, including a copy of your mother's Power of Attorney document. Golden Living Center wishes to assist you with the application process and to avoid dispute. Therefore, they have retained our firm to assist in getting your mother qualified for benefits. Once qualified, your mother's care will be almost completely paid by the Commonwealth of Pennsylvania - a situation which clearly benefits both parties. Please understand that if you refuse to assist with the Medicaid process, we will have no alternative but to pursue any and all legal remedies available, including, but not limited to, commencing a lawsuit against you and/or Ms. Colbert to compel cooperation. If I do not hear F. `? L:. r .. G F. 1 _. f E H. t= 1 1 . P t: t_ r'' ASWAJTRJ E S n,Jtj(-r Bogar LLC _S, SC@ei Tower 00') Grant Street ;2- Floor. Suite 3290 Pittsburgh, PA 1519 Fax (412) 281-0530 www.schutierbogar.com from you by Friday, August 7`h, I will assume you will not be cooperative and will act accordingly. Sincerely, SCHUTJER BOGAR LLC Livia F. Langton Enclosures P 1, , L .. r; ... L. F , . P .. F . ....E , ., r! i' ? ? ;. E: t .. CERTIFICATE OF SERVICE I hereby certify that on this date a true and correct copy of the foregoing Motion for Special Order for Alternate Service Pursuant to Pa. R. C.P. 430 was served via first-class, United States mail, postage prepaid, upon the following: Stanley Colbert Agent for Rose Colbert 5583 Mercury Road Harrisburg, PA 17109 Date: qzco/??p By 12,4 1 Linda Scisciani, Paralegal 5 FIL> D r-?'; = Cip ?TAPY 2009 SFP 24 AM 11: 23 AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania Case Number: 09-5423 County of Cumberland Petitioner: GGNSC Camp Hill III LP d/b/a Golden Living Center-Camp Hill VS. Defendant: Stanley Colbert For: Schutjer Bogar LLC U.S. Steel Tower 600 Grant St., Suite 3290 Pittsburgh, PA 15219 Common Pleas Court Received by Pennsylvania Professional Process Svc. to be served on Stanley Colbert @ POE DOD, 2001 Mission Drive, New Cumberland, PA 17070. I, Jack Kranchick, being duly swom, depose and say that on the 17th day of September, 2009 at 10:45 pm, I: NON-SERVED: After due search, careful inquiry and diligent attempts I was unable to serve the Complaint, Petition for Preliminary Injunction, Praecipe to Reinstate Complaint for the reason that I failed to find refused or information to allow further search. Additional Information pertaining to this Service: 9/21/2009 10:52 am On Sept. 15, '09 at 10:45 PM, server spoke with Captain Christopher Klein, watch commander who spoke with Stanley Colbert about Legal Paperwork for Colbert. Colbert refused to meet with server to accept papers as referenced above. Also no one else willing to accept - Commander advised that becasue these were civil docs this would be voluntary for anyone working there as to whether they opted to accept or not - Stanley was also advised that this was not going to go away - we would continue to per-sue service at home as well. 9/21/2009 11:02 am A follow up by server on 09/17/0910:45 PM did not result in any different outcome - Captain Klein advised that he had done all that he could & all that he was going to do - they do not wish to get involved in these civil matters - would not provide server with Stanley Colbert's Supervisor's name or title nor would he provide server with Stanley Colbert's position / job status with the Defense Distribution Center. Advised that any further contact on the Federal Property regarding this matter would have to be cleared by the Legal Dept. - Perhaps the attorney wants to contact the JAG to advise how to go about assiting in Stanley Colbert being served. I certify that I am over the age of 18, have no interest in the above action, and am a Certified Process Server, in good standing, in the judicial circuit in which the process was served. worn before me o t X-1 day of by t affiant who ' o y PU COMMONWEALTH OF PENNSYLVANIA Notarial Seal M. Michelle Guyton, Notary Public Carlisle Boro, Cumberland County My Commission Expires July 1, 2012 Member, Pennsylvania Association of Notaries Pennsylvania Professional Process Svc. 48 W. High St. P.O. Box 1148 Carlisle, PA 17013 (800) 863-2341 Our Job Serial Number: 2009000465 Ref: Colbert Copyright ®1992-2005 Database Services, Inc. - Process Server's Toolbox V5.5i RIL-. OF THE 2009 ISHP 2 :z w.:U IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. 09-5423 V. STANLEY COLBERT, Defendant. SPECIAL ORDER AND NOW, this day of L , 2009, upon review of the record and GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill's Motion for Special Order for Alternate Service Pursuant to Pa.R.C.P. 430, it is hereby ORDERED, DECREED and GRANTED that service of the Complaint, Petition for Preliminary Injunction and Brief in Support, and/or future pleadings and Court Orders, be served upon Stanley Colbert by U.S. Mail First Class. J. a 4 FILED-OF iCE OF THE PROTHONOTARY 2009 OCT -5 PM 2: 4 8 CUPS ,. "UNTY -?,rtir ; n; r P --iN10 SYLVANIA r, 161 s/D'- cer ES rr? 1.? R-P ? L. k"40AJ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP DB/A GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, : Defendant. CIVIL ACTION NO. 09-5423 TYPE OF PLEADING: AFFIDAVIT OF SERVICE FILED ON BEHALF OF: Plaintiff COUNSEL OF RECORD FOR THIS PARTY: Livia F. Langton, Esq. Attorney I.D. No.: 91548 (412) 281-3710 Marijane E. Treacy Attorney I.D. No.: 84070 (412) 281-3535 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No.: 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Petitioner, V. STANLEY COLBERT, Respondent. CIVIL ACTION - EQUITY No. 09-5423 CERTIFICATE OF SERVICE I hereby certify that, by Special Order of the Court, on this date, a true and correct copy of the foregoing Complaint, Petition for Preliminary Injunction, and Brief in Support of Preliminary Injunction was served via United States, first-class mail, postage prepaid from Pittsburgh, PA upon the following: Stanley Colbert 5583 Mercury Road Harrisburg, PA 17109 Dates woj Linda Scisciani, Paralegal FLED /?. ,tr l?r Ia n t ?:`??('ZT? i G i ,, f 2069 OCT 12 A (C: 2 S t1{b'. ti ? ?`d IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL CIVIL ACTION - EQUITY No. 09-5423 V. STANLEY COLBERT MOTION FOR HEARING ON PETITION FOR PRELIMINARY INJUNCTION Filed on Behalf of Plaintiff: GGNSC Camp Hill III LP d/b/a Golding Living Center - Camp Hill Counsel of Record for Plaintiff: SCHUTJER BmAR LLC Livia F. Langton Attorney I.D. No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 14 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. 09-5423 V. STANLEY COLBERT, Defendant. MOTION FOR HEARING ON PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following Motion for Hearing on Petition for Preliminary Injunction against Stanley Colbert ("Defendant") pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. On or about August 5, 2009, the Plaintiff filed its Complaint against Defendant. A copy of the Complaint is attached hereto as Exhibit A. 2. On or about October 2, 2009, the Court executed a Special Order Allowing Alternate Service of the Complaint, upon the Defendant, by First Class Mail. A copy of the Order is attached hereto as Exhibit B. 3. On or about October 7, 2009, the Complaint was served upon the Defendant. A copy of the Certificate of Service for the Complaint is attached hereto as Exhibit C. 4. On or about August 17, 2009, the Petitioner filed its Petition for Preliminary Injunction ("Petition") in this matter. A copy of the Petition for Preliminary Injunction is attached hereto as Exhibit D. 2 5. On or about August 21, 2009, the Court scheduled the Petition for hearing on September 14, 2009. 6. On or about September 15, 2009, due to the inability to perfect personal service upon the Defendant, the Court granted Plaintiff's request for continuance of the hearing on the Petition. 7. On or about October 7, 2009, following the issuance of the aforementioned Court Order permitting service upon the Defendant via first class mail, the Petition for Preliminary Injunction was served upon the Defendant. See Exhibit C. 8. Plaintiff now wishes to reschedule the argument on its Petition. 9. Because of service issues and the related pending Medical Assistance benefits application and appeal, as discussed in the Complaint and the Petition, resolution of this matter is urgent and Plaintiff respectfully requests a hearing on its Petition as soon as practicable and convenient for the Court WHEREFORE, Petitioner respectfully requests a hearing on Petition for Preliminary Injunction against Stanley Colbert pursuant to Pa. R.C.P. § 1531. Respectfully submitted, Dated: 0 'l0 SCE' R LLC By: ivia F. L on Attorney I. . No. 91548 (412) 281-3710 Ilangton@schutjerbogar.com Marijane Treacy Attorney I.D. No. 84070 (412) 281-3535 mjtreacy@schutjerbogar.com U.S. Steel Tower, 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 3 A E IT A IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA, GGNSC CAMP HILL III LP DB/A GOLDEN LIVING CENTER, CAMP HILL, STANLEY COLBERT, Plaintiff, V. Defendant. CIVIL ACTION NO. TYPE OF PLEADING: COMPLAINT - EQUITY FILED ON BEHALF OF: Plaintiff "2 ? COUNSEL OF RECORTY'FOR" 'n THIS PARTY: Livia F. Langton, Esq. Attorney I.D. No.: 91548 (412) 281-3710 Marijane E. Treacy Attorney I.D. No.: 84070 (412) 281-3535 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No.: 75954 (717) 909-5921 417 Walnut Street, 4`h Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Plaintiff' A ?+ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION - EQUITY No. 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 +'. ' 1 EN LA CORTE DE ALEGATOS COMON DEL CONDADO DE CUMBERLAND, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION - EQUITY No. 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 action dentro de los proximos veiente (20) dias despues de la notification de esta Demanda y Aviso radicando personalmente o par media de un abogado una comparecencia escrita y radicando en la Corte par escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar action como se describe anteriormente, el caso puede proceder sin usted y un fallo par cualquier suma de dinero reclamada en la demanda a cualquier otra reclamation o remedio solicitado par el demandante puede ser dictado en contra suya par 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 RiNfEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 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 BA70 COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Tel: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER, CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant. CIVIL ACTION - EQUITY No. COMPLAINT AND NOW, COMES, GGNSC Camp Hill III LP d/b/a Golden Living Center, Camp Hill ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Stanley Colbert ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal office located at 46 Erford Road, Camp Hill, Pennsylvania 17011. 2. Defendant, the son of and legal representative for Rose Colbert, is an adult individual who currently resides at 5583 Mercury Road, Harrisburg, Pennsylvania 17109. 3. On or about October 24, 2008, Defendant applied for the admission of his mother, Rose Colbert ("Ms. Colbert"), to Plaintiff's skilled nursing facility. At that time, Plaintiff and Defendant entered into a written Resident Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's mother with skilled nursing services in exchange for Defendant's promise to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. A true and correct copy of the Agreement ? . +, E is attached hereto as Exhibit A. 4. After Defendant's mother became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that he needed to secure Medical Assistance benefits for Ms. Colbert, and an application for Medical Assistance benefits subsequently was filed on or about March 30, 2009. 5. On May 11, 2009, the application for Medical Assistance benefits was denied because Defendant did not provide the information and documentation required by the Cumberland County Assistance Office ("CAO") to establish and maintain Ms. Colbert's eligibility. See the PA-162 attached hereto as Exhibit B. 6. On June 15, 2009, the Plaintiff filed an appeal of this denial. However, if the Defendant fails to provide the CAO with the information necessary to qualify his mother for Medical Assistance benefits, the appeal will necessarily fail, and Ms. Colbert will be precluded from receiving the Medical Assistance benefits that she is entitled to and the Plaintiff will be deprived of payment on Ms. Colbert's account as bargained for at the time of her admission. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 7. The allegations contained in Paragraphs I through 6 are incorporated herein by reference as if fully set forth at length. 8. Defendant breached his Agreement with Plaintiff by failing to act in accordance with the terms of the same, as he has failed to use Ms. Colbert's income and assets for her welfare, to make prompt payment for the care and services provided to Ms. Colbert, and to establish and maintain Ms. Colbert's eligibility for Medical Assistance benefits. 9. Because, at all times material hereto, Defendant's mother was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her, 2 r ?. Defendant's failure to provide the necessary documentation required by the CAO, to process and approve his mother's application for Medical Assistance benefits, is a critical violation of the terms and conditions of the Agreement. See Exhibit A. 10. Defendant has interfered with Ms. Colbert's right to receive the Medical Assistance benefits she is entitled to, as well as Plaintiff's right to receive payment, via the Medical Assistance benefits process, in accordance with the bargained for Agreement. See Exhibit A. 11. By obstructing the Medical Assistance benefits process, Defendant has irreparably harmed both his mother and the Plaintiff. 12. 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 respectfully requests that this Honorable Court order Defendant to specifically perform his obligations under the Agreement and to produce the information and documents to the Cumberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. COUNT H STATUTORY DUTY OF SUPPORT 13. The allegations contained in Paragraphs I through 12 are incorporated herein by reference as if fully set forth at length. 14. Defendant Stanley Colbert is the son of Rose Colbert. 15. Upon information and belief, at all times material hereto, Rose Colbert has been indigent. 16. At all times material hereto, Defendant has had a statutory duty to financially support his mother, Rose Colbert. See 23 Pa. C.S. § 4603(a). 3 J. 17. At all times material hereto, Defendant has failed to financially support his mother. 18. The Defendant's statutory duty to support his mother 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. 19. At all times material hereto, in violation of 23 Pa. C.S. §4603(a), Defendant failed to care for, maintain or financially assist his mother by refusing to provide the information and documents requested by the CAO to determine his mother's eligibility for Medical Assistance benefits. WHEREFORE, Plaintiff respectfully requests that this Honorable Court order Defendant to specifically perform his statutory duty, and to produce the information and documents to the Camberland County Assistance Office required to establish and maintain the eligibility of his mother, Rose Colbert, for Medical Assistance benefits. [This section intentionally left blank.] 4 ( ._... WELCOME THANK YOU FOR CHOOSING US FOR YOUR NURSING FACILITY CARE The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. L NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. II. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. In addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees and contractors. B. Physician Services - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. Ify however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physicians are not-associates or agents of the Facility and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. M. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. IV. ARBITRATION - The Resident acknowledges that disputes under this Agreement may be submitted to arbitration, if the Resident elects to do so, by signing a separate agreement executed t.. t between the parties. Agreeing to arbitration is not a condition of admission or continuing care. V. PRIVACY ACT NOTIFICATION STATEMENT - Skilled nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of June 22, 1998, all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the Federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 1819(f), 1919(f), 1819(b)(3)(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Lang-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or quality of health care services provided in the State; (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVM functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Medicare/Medical Assistance nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medical Assistance services. Vt. RESIDENT'S PERSONAL PROPERTY A. Safety Of Resident's Personal Property - The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property/valuables, which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility in writing of all personal property upon admission. If, at any time during the Resident's stay, new items of value are brought to or removed from the Resident's possessions in the Facility, the Resident also agrees to so inform the Facility Executive Director or designee. B. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. VII. PERSONAL FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B. Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Residenfs.funds shall be credited to the Resident's account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to maintain alI Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. D. Accounting - The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. E. Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance Program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance or SSI. F. Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the Facility's Business Office. 3 1. . X. AGENT AND/OR LEGAL REPRESENTATIVE A. Agent - For the purposes of this Agreement, an Agent is a person who manages, uses or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amount of the funds received or held by the Agent for the Resident. The Agent assumes no responsibility to pay for the costs of the Resident's care out of the Agent's personal funds. However, as a necessary party to this Agreement, the Agent is contractually bound by the terms of this Agreement and may become personally liable for failure to perform duties under the Agreement. If the Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these funds for the Resident's welfare. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due and to make prompt payment for care and services provided to the Resident as specified in the terms of this Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO DISTRIBUTE TO THE FACILPIY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESIDENT. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident:" shall be construed to include not only the Resident, but also the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, copies of documents verifying such status must be provided to the Facility at the time of admission. XI. PAYMENT INFORMATION A. Obligation To Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (10th) day of each month or, in the case of a notice of a rate change, within ten (10) days of mailing of the notice. If payment is not received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth under the Transfer and Discharge section of this Agreement. B. Credit Card Charges - The Facility accepts MasterCard and VISA. If the Resident would like the convenience of paying amounts due each month through one of these options, the Resident must provide the needed information and authorization on the Credit Card Authorization form at the back of this Agreement. The Resident recognizes that, unless the Resident has authorized the use of MasterCard or VISA, the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. Fee For Returned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. D. Potential Personal Liability Of Agent - Agent (includes any Legal Representative serving as the Resident's Agent) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's care, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this Agreement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement. XK PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. In this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer. Non-covered charges may include any coinsurance and/or deductible amounts required by a third party payer. D. Communicating Changes in Assets - It is essential for the Resident to communicate to the Facility any changes in the Resident's assets or resources within ten (10) days of knowledge of the changes in financial status. Upon request by the Facility, the Resident shall provide the required information to the Facility within ten days. If the Resident runs out of private monies, it is important to locate alternative payment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funds are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengthy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of being reduced to an amount that, when combined with the Resident's monthly income, is no longer sufficient to pay for the cost of care and services. If the Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. E. Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. XU1 MEDICAL ASSISTANCE PROGRAM RESIDENT - A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional services/items provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance. A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage. B. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. If the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D. Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits. The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment. E. Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, Private Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis. 7 F. Continuing Payment of Facility Charges Pending Eligibility - When an application for Medical Assistance has been filed, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (10th) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. G. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by the Program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H. Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a Private Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. L Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XIV. MEDICARE RESIDENT - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. B. Limited Coverage - Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period), If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C. Expiration Of Benerits - When Medicare coverage expires, the Resident may remain in the Facility if private pay or other payment arrangements have been made. If the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission or readmission. If the Resident intends to become private pay when i Medicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. D. Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The Facility shall give notice to the Resident and, if known, a family member or Legal Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Residents transfer or discharge. Incases where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. B. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVL BED-HOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed-hold." The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days. If the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for a certain number of bed-hold days. Otherwise, a Private Pay or Medicare Resident requesting a bed-hold must pay the Facility's prorated private monthly rate during the bed-hold period. 9 XVII. RESIDENT'S RIGHTS AND FACILITY POLICY UNDER THE FEDERAL SELF- DETERMINATION ACT A. Right To Make Decisions Regarding Care --The Facility recognizes the right of each Resident to make decisions regarding his or her care. Where a Resident is incompetent, the Facility recognizes the Resident's right to have these decisions made on his/her behalf by a substitute decision maker in accordance with State law. B. Blight To Formulate An Advance Directive- The Facility recognizes the right of each Resident to have an advance directive and will honor advance directives developed in accordance with State law and consistent with the level of care the Facility is licensed to provide. An advance directive is a written document that states choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of advance directives. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician and/or attorney. C. An Advance Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to continue to reside in the Facility. However, if the Resident has an advance directive, he or she must make it known to the Executive Director or designee so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at the time of admission, the advance directive information shall be provided to family members or other Resident representatives. However, if the Resident later regains competency, the Facility will provide such information directly to the Resident. XVIII. CHARGES FOR COPIES OF MEDICAL RECORDS The Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charged in the Facility's community. XIX. SOLE AGREEMENT- This Agreement is the only Admission Agreement between the Facility and the parties. Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid Agreement. XX. ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. XXL INTEGRATION - The Parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, promises, understandings, and agreements between the parties, whether written or oral, and therefore they are of no further force and effect. Because this is a fully integrated agreement, the only discussions, statements, representations, promises, understandings, or agreements that are or will be binding on any of the parties to this Agreement or their employees, affiliates, contractors, agents, or representatives are those expressly set forth in writing in this Agreement, or in other written agreements entered into at the same time as, or subsequent to, this Agreement. ,1717755`;'842 golden living center cam RESIDENT-SPECIFIC INFORMATION XXH. Payer Soure - This Facility accepts the following types of payments: -tab [ ) Private VEMedicare [) Medical Assistance [ ] Veterans Administration XXLQ ACKNOWLEDGEMENTS - By signing the Adnussion Agreement Signature Page, the Resident/Agent/Legal Representative acknowledges that he or she has been given and has read this Agreement in its entirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not a plicable, write N/A): A list of supplies and services that are included in the Facility's private monthly rate or that will be aid f b +1k M d' al A Med' 2. 3. 4. p or y e etc sststanCe or scare programs and a USE of supplies and services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged Information about the Facility's bed-hold procedures. A written explanation of how to apply for and use Medicare and Medical Assistance benefits and how to receive funds for previous payments covered by these benefits. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuse/theft of resident personal property in the Facility. Copies of the State Resident Rights. A written explanation of the Facility's Rules and Regulations. Where applicable, if your condition warrants, you may be placed in the Facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the Facility will discuss such a transfer . h you. Under law, you cannot be discharged from this Facility unless you agree or u ss, following an appeal, it is determined that you may be 1 ari! d' h ed 07:49:01 a.m. 07-15-2009 3122 i /f tnvo unt y tse ar or transferred. 2c8. I do do not have an advance directive. 9. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. 0. I have been given a copy and had an opportunity to review the Facility's Notice of Privacy Practices. XXIV. NOTICES - Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal Representative are responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Agent, and/or Legal Representative. Rev. 03113/03 White -Business Office Pink -Medical Records Yellow - Resident P Ct `c R R x a II 1. 1717737842 golden living center cam 07:49:18 a.m. 07-15-2009 A. Lega epresentative An Or Agent Name Home Phone rijj,?[6 [ f jr e[ ][ [ [ ][ ] ] y (Wry, X10 Street y State Zip B. Other Person To Be Notified Name Home Phone[ ][ ][ )[ ][ ][ ][ ][ ][ ] [ ] Work Phone[ ][ ][ ][ ][ ][ ][ ][ ][ ][ ] Street City State Zip XXV. MAIL - The Facility is authorized to handle the Resident's mad as follows: (Check one box only.) [ ] mail given directly to the Resident j Forward all of the Resident's mail to: X.X'VI. RESIDE A. NAME: B. SPECIALTY: C. ADDRESS: [ ] All mail read to the Resident [ ] Give personal mail to the Resident; forward business mail to: D. TELEPHONE: _111- 01--11 S I XXV11L RESIDENT TRUST FUND AUTHORIZATION - A Resident Trust Fund is an amount of money held by the Facility for the Resident's personal use. (Examples of use: To allow the resident to pay for room and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on request, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/13/03 White - Business Office Pink - Medical Records 12 Yellow - Resident 4122 x a cc a to ns M n, Z a 1 ' 1717767842 golden living center cam f 07:49:32a.m. 07-15-2009 5122 shall be authorized by the Resident or his/her Agent or Legal Representative in writing. The following persons may authorize withdrawals on the Resident's behalf: Name of Authorized Person Resident's Signature Name of Authorized Person Date Witness if Resident Signed with a Mark Date Legal Representative's Signature (if applicable) Agent's Signature (if applicable) Date Date XXVDL CREDIT CARD AUTHORIZATION - Facility accepts MasterCard and VISA. If Resident would likl e convenience of paying amounts due each month through one of these, please provide the needed info ation and authorization: Credit Card \ Account # Expiration I hereby authorize Facifit o charge the account listed above for monthly charges incurred under this Agreement: Resident or Agent's Signature Date If the Resident is unable to consent or sig this provision because of physical disability or mental incompetence or is a minor and this provisi is being signed by an authorized representative, complete the following: Date: Relationship to sident: Signature: Authorized Representative Witness: For Facility: Rev. 03/13103 White - Business Office Pink - Medical Records 13 Date: - Resident 9 c? n: c? Z PA c? z 0 17177637842 golden living center cam Authorized Represea Print Name and Title: 07:49:44 a.m. 07-15-2009 6122 x CD y Q CO Z CD Rev. 03/13/03 White - Business office Pink: - Medical Records Yellow - Resident CD 47 z Q 14 M7760842 golden living center cam 07:49:53 a.m. 07-15-2009 7122 1.. ADMISSION AGREEMENT SIGNATURE PAGE XXEX. PARTIES - The parties to this Agreement L', & ?,a noa- L,Er (Flame of Facility) (Name of Residen (Name of Resident's Agent) arne of Resid is gal Representative) If the Legal Representative signs the Agreemen check the Type of Legal Repre ntative (below): [ ] Conservator of Person [ ] Guardi Durable Power of Attorney Agent Acting [ ] Conservator of Estate for Health Care (DPAHC) Under General [ ] Other, specify POA If you are signing this Agreement on behalf the lUq i ote your relationship to the Resident: My relationship to the Resi taf is On this A kA_ay___0f he a tes a81he , o be bound by the provisions of this Agreement and agree that on the ay of Resident shall be admitted to this Facility. Resident Address City, State, Zip Witness if Resident Signed Legal Legal Representative's Rev. 03/13/03 a Mark White - Business Office Date Resident's Social Security Number Resident's Telephone Number Date Date ._2.q, p Date Legal Representative's o ' Se 17-1 ?-7 7 Leg Representative's Telephone Nu er Pink -Medical Records Yellow - Resident A a u. i= n a P x c? y d 15 17177637842 golden living center cam Agent _ s 07:50:06 a.m. 07-15-2009 i Date Agent's Social Security Number Facility Executi Direct or Designee Agent's elepho e N ber Facility Name Date N44 Facility Address Note: The signatures above refer to the information contained on pages I through 16 of the Admission Agreement. Rev. 03/13/03 8122 cQ z to H z 0 White - Business Office Pink - Medical Records Yellow - Resident 16 ?.•,...,,..,?,? ?Itw MEDICAID 4 'e"°• VQK 599 NOT ELIGIBLE e ? :JESTA ENSTER DR EVE NOTICE _ARLISLE PA 17013-05{. CAO RETURN ADDRESS CSLD aa2e •01022422100' ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 Notice ID: 94509621 CO RECORD DIST CAT GO PS 21 0123221 0 PAN 80 WORKER: K WRITTEN TELEPHONE: (800) 269-0173 MAIL DATE: 0511112009 NOT: 042 OPT: D TYPE: N IF YOU DO NOT UNDERSTAND AUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. You have been determined not eligible for benefits based on your application dated 03/30/2009. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 04/17/09 lItems: Name: J MA51, SSN, BIRTH CERTIFICATE, - ROSE MEDICAL CARDS, POA PAPERWORK, PCA - ACCT, VA FILING, GROSS INCOME, - PROOF OF ALL RESOURCES, UTILITY - - EXPENSES, RETRO BILLS, PG OF APPL T- T NEEDED COMPLETED MAY I 1 I} ZUUJ dog Citation: 55 Pa. Code 201.1. 201.3 PAGE 1 It you disagree with our decision, you have the right to appeal. In a cGNrlu?sfle r? ?anui?cri 91 vow none [o appeal ano ip a ralr nearing, IT you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/24/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. tPPLICANT NAME AND ADDRESS ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 •• ADDRESS CUMBERLAND CAD P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 LEGAL HELP IS AVAILABLE AT MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 1717) 243-9400 Notice ID: 94509621 E CO RECORD DIST CAT GCS PS I 21 0124221 0 PAN 80 WORKER: K WHITTEN APPEAL: 05/24/2009 TELEPHONE (800) 259.0271 MAIL DATE 0511112009 NOT- 042 OPT: D TYPE: N VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unworn falsification to authorities. Dated: -7 k5o I C Susan Bertolette, FBOC GGNSC Camp Hill III LP a/b/a Golden Living Center, Camp Hill EXHIBIT B IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, V. STANLEY COLBERT, Defendant- CIVIL ACTION - EQUITY No. 09-5423 SPECIAL ORDER AND NOW, this atc-day of 2009, upon review of the record and GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill's Motion for Special Order for Alternate Service Pursuant to Pa.R.C.P. 430, it is hereby ORDERED, DECREED and GRANTED that service of the Complaint, Petition for Preliminary Injunction and Brief in Support, and/or future pleadings and Court Orders, be served upon Stanley Colbert by U.S. Mail First Class. TRIM: and in T?3-4' 1'n and tl?e sea! 6 52-a J Coup at ??i. Jal+ Pa. This ... day .t 4 otaryy EXHIBIT C IN TEE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Petitioner, V. STANLEY COLBERT, Respondent. CIVIL ACTION - EQUITY No. 09-5423 CERTIFICATE OF SERVICE I hereby certify that, by Special Order of the Court, on this date, a true and correct copy of the foregoing Complaint, Petition for Preliminary Injunction, and Brief in Support of Preliminary Injunction was served via United States, first-class mail, postage prepaid from Pittsburgh, PA upon the following: Stanley Colbert 5583 Mercury Road Harrisburg, PA 17109 Date: Linda Scisciani, Paralegal EDIT D IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, V. CIVIL ACTION - EQUITY No. Qe' - 5ga3 STANLEY COLBERT PETITION FOR PRELIMINARY INJUNCTION Filed on Behalf of Petitioner: GGNSC Camp Hill III LP d/b/a Golden Living Center - Camp Hill Counsel of Record for Petitioner: SCEIMER BMAR LLC Livia F. Langton Attorney I.D. No. 91548 (412) 281-3710 llangton@schut erbogar.com Marijane E. Treacy Attorney I.D. No. 84070 (412) 281-3535 mitreacy@schutjerbogar.com U.S. Steel Tower 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax (412) 281-0530 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4 h Floor Harrisburg, PA 17101 a? Respectfully submitted, SCHUTJER BOGAR LLC Dated: By: Livia F. L gton, Esq. Attorney I.D. No. 91548 (412) 281-3710 Marijane E. Treacy, Esq. Attorney ID No. 84070 (412) 281-3535 600 Grant Street, Ste 3290 Pittsburgh, PA 15219 Fax: (412) 281-0530 Bradley A. Schutjer, Esq. Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4' Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plain tiff WELCOME THANK YOU F(j-t CHOOSING US FOR YOUR NURSzjdG FACXLITY CARE The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. L NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. II. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. In addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees and contractors. B. Physician Services - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the Facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident, including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physicians are not associates or agents of the Facility and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refuse treatment and to revoke consent for treatment. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. M. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape for purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. IV. ARBITRATION - The Resident acknowledges that disputes under this Agreement may be submitted to arbitration, if the Resident elects to do so, by signing a separate agreement executed 1 ? between the parties. Agreeing to arbitration is not a condition of admission or continuing care. V. PRIMACY ACT NOTIFICATION STATEMENT - Skilled nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of June 22, 1998, all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the Federal Central Office Minimum Data Set (MDS) repository of the Centers for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 1819(f), 1919(1), 18 1 9(b)(3)(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose. The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or quality of health care services provided in the State; (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVM functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Medicare/Medical Assistance nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care , given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any Medicare/Medical Assistance services. V1. RESIDENT'S PERSONAL PROPERTY A. Safety Of Resident's Personal Property - The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property/valuables, which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility in writing of all personal property upon admission. If, at any time during the Resident's stay, new items of value are brought to or removed from the Resident's possessions in the Facility, the Resident also agrees to so j inform the Facility Executive Director or designee. B. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however,'shall not be liable for any damage to or loss of the Resident's property. The Facility may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law. VII. PERSONAL FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B. Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Resident's.funds shall be credited to the Resident's account. The Facility shall have the option of depositing funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility's policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience. D. Accounting - The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not - commingled with the Facility's funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident. E. Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance Program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance or SSI. F. Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the Facility's Business Office.- 3 G. Security of Funds - The Facility shall ensure the security of all personal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance Program Resident's personal funds for any item or service for which payment can be made under the Programs. VIII. gHE RESIDENT'S DUTIES A. Facility's Rules And Regulations - The Resident agrees that the Facility may, to maintain orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. It is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. B. Resident Grievances - Residents are urged to bring any grievance concerning the Facility to the attention of the Facility Executive Director or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered anonymously. This number is 1-800-572- 9981. Residents also have the right to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. C. Diet - The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages brought into the Facility for the Resident's *benefit. D. Medications - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. All drugs or medications brought into the Facility shall be immediately delivered to the nurses' station. E. Care Of Facility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as is to be expected from ordinary wear and tear. F. Care Of The Resident's Room - The Facility encourages the Resident to have a home-like environment and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must concur with any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. IX. PROHIBITION AGAINST TRXRD PARTY GUARANTOR -FEDERAL AND STATE LAWS PROHIBIT A NURSING HOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAYMENT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION OR CONTINUED STAY IN THE FACILITY. HOWEVER, A FACILITY MAY REQUIRE AN INDIVIDUAL WHO HAS LEGAL ACCESS TO THE RESIDENT'S INCOME OR RESOURCES AVAILABLE TO PAY FOR FACILITY CARE TO SIGN A CONTRACT, WITHOUT INCURRING PERSONAL FINANCIAL LIABILITY FOR THE RESIDENT'S COSTS OF CARE, TO PROVIDE FACILITY PAYMENT FROM THE RESIDENT'S INCOME OR RESOURCES. X. AGENT AND/OR LEGA .. REPRESENTATIVE A. Agent - For the purposes of this Agreement, an Agent is a person who manages, uses or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the Resident. The Agent's financial obligations are limited to the amount of the funds received or held by the Agent for the Resident- The Agent assumes no responsibility to pay for the costs of the Resident's care out of the Agent's personal funds. However, as a necessary party to this Agreement, the Agent is contractually bound by the terms of this Agreement and may become personally liable for failure to perform duties under the Agreement. If the Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these funds for the Resident's welfare. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due and to make prompt payment for care and services provided to the Resident as specified in the terms of this Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESIDENT. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include not only the Resident, but also the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, copies of documents verifying such status must be provided to the Facility at the time of admission. XL PAYMENT INFORMATION A. Obligation To Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (10th) day of each month or, in the case of a notice of a rate change, within ten (10) days of mailing of the notice. If payment is not received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth under the Transfer and Discharge section of this Agreement. B. Credit Card Charges - The Facility accepts MasterCard and VISA If the Resident would like the convenience of paying amounts due each month through one of these options, the Resident must provide the needed information and authorization on the Credit Card Authorization form at the back of this Agreement. The Resident recognizes that, unless the Resident has authorized the use of MasterCard or VISA, the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. Fee For Returned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. 5 D. Potential Personal Liability Of Agent - Agent (includes any Legal Representative serving as the Resident's Agent) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's care, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this Agreement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement. XIL PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unused advance payment shall be refunded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. In this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (I0) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer. Non-covered charges may include any coinsurance and/or deductible amounts required by a third party payer. D. Communicating Changes in Assets - It is essential for the Resident to communicate to the Facility any changes in the Resident's assets or resources within ten (10) days of knowledge of the changes in financial status. Upon request by the Facility, the Resident shall provide the required information to the Facility within ten days. If the Resident runs out of private monies, it is important to locate alternative payment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funds are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengthy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of being reduced to an amount that, when combined with the Resident's monthly income, is nab -. Ager sufficient to pay for the cost of cap _ and services. If the Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. K Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. X111. MEDICAL ASSISTANCE PROGRAM RESIDENT - A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional services/items provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance- A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage. B. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. If the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets.provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D. Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits. The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment. E. Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, Private Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis. 7 F. Continuing Payment of Facility Charges Pending Eligibility - When an application for Medical Assistance has been fled, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (IOth) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. C. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by theProgram for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H. Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a Private Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. L Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XIV. MEDICARE RESIDENT - A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business office and is available for review during normal business hours. B. Limited Coverage - Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C. Expiration of Benefits - When Medicare coverage expires, the Resident may remain in the Facility if private pay or other payment arrangements have been made. If the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission or readmission. If the Resident intends to become private pay when t Medicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. D. Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The Facility shall give notice to the Resident and, if known, a family member or Legal Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. In cases where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. B. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility. The Resident may be transferred/discharged because the Facility ceases to operate. XVI. BED-HOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed-hold." The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days. If the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for a certain number of bed-hold days. Otherwise, a Private Pay or Medicare Resident requesting a bed-hold must pay the Facility's prorated private monthly rate during the bed-hold period, 9 .'1717747E42 golden Ung center cam 07:49:01 a.m. 07-15-2009 RESIDENT-SPECIFIC INFORMATION XXII_ Payer So VEMedicare - This Facility accepts the following types of payments: M [) Private [ ] Medical Assistance [ ] Veterans Administration XXM ACKNOWLEDGEMENTS - By signing the Admission Agreement Signature Page, the Resident/Agent/Legal Representative acknowledges that he or she has been given and has read this Agreement in its entirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not applicable, write N/A): A list of supplies and services that are included in the Facility's private monthly rate or that will be paid for by the Medical Assistance or Medicare programs and a list of supplies and services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged P 3 2. Information about the Facility's bed-hold procedures. . A written explanation of how to apply for and use Medicare and Medical Assistance benefits and how to receive funds for previous payments covered by these benefits. LAP, 4. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuse/thett of resident personal property in the Facility. #6. . Copies of the State Resident Rights. A written explanation of the Facility's Rules and Regulations. 7. Where applicable, if your condition warrants, you may be placed in the Facility's Medicare-Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate for you. In that case, the Facility will discuss such a tr71er you. Under law, you cannot be discharged from this Facility unless you agrefollowing an appeal, it is de termined that you may be involuntarily distransferred. 8. I dodo not n advance directive. 9. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. 0. I have been given a copy and had an opportunity to review the Facility's Notice of Privacy Practices. XXIV. NOTICES - Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal Representative are responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Agent, and/or Legal Representative. Rev. 03/13/03 White - Business Office Pink -Medical Records Yellow - Resident 3/22 i i r f i U 0 11 ' 17177842 golden Ungcenter cam A. Legs epr Name Horne Phone [?[ J] Street 1 B. Other Person To Be Notified Name Home Phone[ J[ J[ ][ J[ ][ I[ ][ ][ ] [ ] Work Phone[ ][ ][ J[ ][ ][ J[ ][ ][ ][ ] Street 07:49:19 a.m. 07-15-2009 Agent S M) lam" City '1? State State ) 0,7/69 Zip Zip XXV. MAIL - The Facility is authorized to handle the Resident's mail as follows: (Check one box only.) [ ] mail given directly to the Resident [ ] All mail read to the Resident [ Forward all of the Resident's mail to: [ ] Give personal mail to the Resident XXVI. RESIDEI A NAME: B. SPECIALTY: C. ADDRESS: D. TELEPHONE: , forward business mail to: XXVII. RESIDENT TRUST FUND AUTHORIZATION - A Resident Trust Fund is an amount of money held by the Facility for the Resident's personal use. (Examples of use: To allow the resident to pay for roost and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on request, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03113/03 4122 7 CT c R t 0. y P White - Business Office Pink - Medical Records Yellow - Resident 12 17177fi37942 golden Ung center cam 07:49:32 a.m. 07-15-2009 5122 shall be authorized by the Resident or his/her Agent or Legal Representative in writing. The following persons may authorize withdrawals on the Resident's behalf: Name of Authorized Person Resident's Signature Witness if Resident Signed with a Mark Legal Representative's Signature (if applicable) Agent's Signature (if applicable) Name of Authorized Person Date Date Date Date XXVIl1. CREDIT CARD AUTHORIZATION - Facility accepts MasterCard and VISA If Resident would lik te convenience of paying amounts due each month through one of these, please provide the needed infation and authorization: Credit Card Expiration Date I hereby authorize FaciIit}O charge the account listed above for monthly charges incurred under this Agreement: or Agent's Date If the Resident is unable to consent or si this provision because of physical disability or mental incompetence or is a minor and this provisi is being signed by an authorized representative, complete the following: Date: Relationship to Signature: Witness: For Facility: Rev. 03/13/03 White - Business Office Account # Pink - Medical Records 13 Date: - Resident x c? CL 9 2 H ?v ?C CD z 0 • 1 J9 /A4164G gonen nving center am u/:49:44 a.m. W-15-200 b /22 Authorized Represeni Print Name and Title: 7 R v_ C R t F R PC [D y 0 Rev. 03/13/03 White - Business Office Pink: - Medical Records Yellow - Resident 14 j 7tf77rj37S42 golden living center cam 07:49:53 a.m. 07-15-2009 7122 r ADMISSION AGREEMENT SIGNATURE PAGE XXIX. PARTIES ? - The parties to this Agreement L, (Name of Facility) (Name of Resident (Name of Resident's Agent) ame of Resid is gal Representative) If the Legal Representative signs the Agreemen check the Type of Legal Rep re tative (below): [ j Conservator of Person [ ] Guardi Durable Power of Attome Agent Acting [ ] Conservator ofEstate for Health Care (DPAHC) Under General [ ] Other, specify POA If you are signing this Agreement on behalf the Rapi Wote your relationship to the Resident: My relationship to the Resi n is On this ay of U + - .2 &'ie agr be bound by the provisions of this Agreement and agree that on the ay of 1 20 a Resident shall be admitted to this Facility. Resident Address City, State, Zip Witness if Resident Signed Legal Legal Representative's a Mark Date Resident's Social Security Number Resident's Telephone Number Date Date Y_ateq?'_ Legal Representative's o i Se Leg Representative's Telephone Nu er Rev. 03/13/03 White - Business Office Pink -Medical Records Yellow - Resident 15 U Q 17W77I N842 golden Ilving centercam 07:50:06 a.m. 07-15-2009 8122 r Agent ___-I% Date Ag s A V?/ Agent's Social Security Number Facility Execu . Direct or Designee Agent's elepho e N ber 0,-I ?- I d FacilityName Date z !??!( Facility Address 1 Note: The signatures above refer to the information contained on pages 1 through 16 of the Admission Agreement. y z P Rev. 03/13/03 White -Business Office Pink - Medical Records Yellow - Resident 16 E IT B LCAO ?,?,31 77 NOT ELIGIBLE , 4 tsS 1k INSTER DRIVE NOTICE •.ARLISLE PA 17013-Ok CSLD 00=6 •01022422100• ROSE E COLBERT GOLDEN LIVING CENTER CH 46 ERFORD ROAD CAMP HILL PA 17011 You have been determined not eligible for benefits based on your application dated 03/30/2009. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 04/17/09 /Items: Name: J MA51, SSN. BIRTH CERTIFICATE, - ROSE MEDICAL CARDS. PDA PAPERWORK, PCA - ACCT, VA FILING, GROSS INCOME, - PROOF OF ALL RESOURCES, UTILITY - - EXPENSES, RETRO BILLS, PG OF APPL T- T NEEDED COMPLETED MAY 2009 Citation: 55 Pa. Code 201.1, 201.3 HI tJ .V.Ioc ,u. 94509621 CO :CORD DIST CAT GO PS 21 0121221 U PAN 90 WORKER: K WHITTEN TELEPHONE: 1800) 269-0173 MAIL DATE: 05/11/2009 NOT: 042 OPT: D TYPE N IF yW DO Wr UNDEMAW OUR DECISION OR HAVE ANr OVE57IONlS, PV_4W COUXI` YOUR Wf7RKER IMNEDIArELY. PAGE ] APPEAL AND FAIR HEARING LEGAL HELP IS AVAILABLE A' If you disagree with our decision, you have the right to appeal. See attached form MIDPENN LEGAL SERVICES for a complete explanation of your right to appeal and to. a fair hearing, if you are 401-405 LOUTHER STREET currently receiving benefits and your oral request for a hearing is received in the CARLISLE PA 17013 County Assistance Office or your written request is postmarked or received on or (717) 243-9404 before 05/24/2009 your assistance will continue pending the hearing decision. except when the change is due to State or Federal law. PPLICANT NAME AND ADDRESS 30SE E COLBERT !OLDEN LIVING CENTER CH 16 ERF'ORD ROAD 'AMP HILL PA 17011 CAD ADDRESS CLWISERLAND CAO P.O. BOX 599 33 WESTNENSTER DRIVE CARLISLE PA 17013-0599 Notice ID: 94509621 CO RECORD DIST CAT GO P5 21 0124221 0 PAN 80 WORKER: K WRITTEN APPEAL 05/24/2009 TELEPHONE: (800) 269-0173 MAIL DATE 05/11/2009 NOT. 042 OPT: D TYPE: N "IN .?i CERTIFICATE OF SERVICE I hereby certify that, on this date, a true and correct copy of the foregoing Petition for Preliminary Injunction was provided to Shinkowsky Investigations for personal service upon the following: Stanley Colbert 5583 Mercury Road Harrisburg, PA 17109 Date: $ O &Z406v Linda Scisciani, paralegal FILC= , ;C F° 12; 2000 QCT 21 0 v'' r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GGNSC CAMP HILL III LP d/b/a GOLDEN LIVING CENTER - CAMP HILL, Plaintiff, CIVIL ACTION - EQUITY No. 09-5423 V. STANLEY COLBERT, Defendant. ORDER AND NOW, to wit, this day of O d_, 2009, a hearing in the above captioned matter regarding the Petition for Preliminary Injunction is hereby scheduled for the day of ?(; , 2009 atf % 3Ll a.m. in Courtroom of the Cumberland County Courthouse. CDG/yI h1 BY THE COURT: FILED-4OFFICE OF THE PROF ;rA1ryTARx 2004 OCT 28 PM 3: 48 CUIMI-?, ; ti }?