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HomeMy WebLinkAbout09-24-09IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVAI~TIA ORPHAN'S COURT DIVISION IN RE: WALTER PATTERSON O.C. No. 2009-00553 PETITION TO MAKE RULE ABSOLUTE AND TO FILE AN ACCOUNTING AND TURN OVER OF BENEFITS Filed on Behalf of: Perini Services/Southampton Manor Limited d/b/a Shippensburg Health Care Center Counsel of Record: Livia F. Langton Attorney I.D. No. 91548 (412) 281-3710 Marij ane E. Treacy Attorney I.D. No. 84070 (412) 281-3535 600 Grant Street, Suite 3290 Pittsburgh, PA 15219 Fax: (412) 281-0530 Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorneys for Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION ~~ ~_ ~ _, ,-,-n IN RE: WALTER PATTERSON O.C. No. 2009-00553 ~ `~'~? J , ~ `~' ._J ` ~ ~ ~, ~ . ~.. + U =a PETITION TO MAKE RULE ABSOLUTE AND TO FILE "' ~ Y ' AN ACCOUNTING AND TURN OVER OF BENFITS . ~` Petitioner, Perini Services/Southampton Manor Limited d/b/a Shippensburg Health Care Center ("Shippensburg"), is a creditor of Walter Patterson and Eddie L. Collins, and hereby respectfully requests that the Court make its Rule absolute and order Respondent Eddie L. Collins to file an Accounting and turn over benefits, stating in support thereof as follows: 1. Petitioner filed its Petition for Accounting and Turn Over of Benefits on June 22, 2009. A true and correct copy of the Petition is attached hereto as Exhibit A. 2. Eddie L. Collins, the Agent through Power of Attorney for Walter Patterson, is the Respondent in this matter. 3. The Preliminary Decree was signed by Judge Bayley on June 23, 2009, which directed Eddie L. Collins "to show cause, if any there be, why an Order should not be entered requiring him to file a full and complete accounting of all transactions undertaken by him with respect to Walter Patterson's resources and income from June 29, 2007 to the present" and indicating the Citation was returnable 15 days from the date of service. A true and correct copy of the Preliminary Decree is attached hereto as Exhibit B. 4. The Preliminary Decree was served upon Eddie L. Collins on August 18, 2009, following the Court's granting of Petitioner's Motion for Special Order for Alternate Service. A true and correct copy of the Affidavit of Service of the Preliminary Decree is attached hereto as Exhibit C. 5. To date, Eddie L. Collins has not responded to the Preliminary Decree. WHEREFORE, Petitioner requests that this Honorable Court deem the Rule absolute and grant the Final Decree, ordering and directing Eddie L. Collins to file a full and complete Accounting of all transactions undertaken by him with respect to Walter Patterson's resources and income from June 29, 2007 to the present, directing him to turn over to Shippensburg all resources and income of Walter Patterson's that comprise Walter Patterson's patient pay obligation and satisfy Walter Patterson's obligations to Shippensburg. Respectfully submitted, SCHVTJER BOGAR LLC Dated: September ~, 2009 By: Livia F. Langto Attorney I.D. o. 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 Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 417 Walnut Street, 4~' Floor Harrisburg, PA 17101 Attorneys for Petitioner IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: WALTER PATTERSON O.C. No. G~1 a~ ~ a05s3 PETITION FOR ACCOUNTING AND TURN OVER OF BENEFITS Petitioner, Perini Services/Southampton Manor Limited d/b/a Shippensburg Health Care Center ("Shippensburg HCC"), is a creditor of Walter Patterson ("Mr. Patterson"), and hereby respectfully represents that: c ~ ~' ~ -~ ~. ~~ 1. Mr. Patterson was admitted to Shippensburg HCC, a skilled r far~i ity, F ~ 3' _ ~,-; ~ - _, --, ; -- located at 121 Walnut Bottom Road, Shippensburg, Pennsylvania 17257, on or~`,'u~'k~bnxa~ 3, `~-; ~f c ~ <:~: -- 2007. A copy of the Admission Agreement is attached hereto as Exhibit A. ~ --~ `~~ t, , '-~ ~ -fi 2. Subsequent to his admission, Mr. Patterson's friend, Eddie L. Collins ("Mr. Collins"), claimed the role of agent through Power-of-Attorney for Mr. Patterson. A copy of the Power-of-Attorney document is attached hereto as Exhibit B. 3. Upon information and belief, at all times relevant hereto, Mr. Collins, as agent-in- fact for Mr. Patterson, has exercised control over Mr. Patterson's resources, including the proceeds from the sale of Mr. Patterson's home, the funds in Mr. Patterson's bank account and Mr. Patterson's monthly income. 4. Upon information and belief, Mr. Collins has received and/or used Mr. Patterson's resources for purposes other than paying for services provided to Mr. Patterson by Shippensburg HCC. See the PA-162 attached hereto as Exhibit C, which references the improper transfer(s) of Mr. Patterson's resources in the amount of $69,000. Respectfully submitted, SCHUTJER BOGAR LLC Dated: (pj15 ~200q _ 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 Chadwick O. Bogar PA. I.D. #83755 (717) 909-5920 417 Walnut Street, 4~` Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Petitioner ~~ - _ . IIEALTFI CARE CB33TER IZ2 WalnutBottomRoad ~hippenstTurg, Pennsylvania FA.~ {7X7) 5 4-8304 1'1257-90D5 TTY1-S00-6545984 ADNIYSSI4N,A.GREEM'~ NT reement' etweeu Sluppeusburg Healffi Care Center (the "Facility" or "`we" and} . 'i7~u~~~''?~ ~1 (the "Resider' or "you") and, if you. or the court have designated an individual to aot oa b , or there is another ixxdividnal to act on your behalf, ar operation oflaw, ~~~ ~"~fat~ `pour xepresentativ~'), A checklist of the rights and responsibilities applicable to your representafiive is listed in Exhibit l and is incorporated irrto tfiis Agreement. PayingiorYour Care If you are applying to this facility as a privatetpay resident, yon must provide all financial info=rnation requested by us, If we later find that the infor~utativn you or your representative provided was incomplete or inacciuate; we will consider that as a breach of this Agreement which dives us the right to pursae: all legal remedies against you or your representative. ; Who Can Be Reuufred #a Pay far Yoevr Care ' Only you and pour insnt~ can be t~equired to pay for your care. No other nersart, (Le. a family member, friend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care, although he yr she may knowingly and valuYrtaridy agree to guarantee payment for the cost of your care. We require the person responsible for mating payments on yourbehalf to gay for pour care under the teens of this contract in a timely manner, If you are a beneficiary of Medicare, Medicaid or any ofiher third party payment plarf, your representative agrees to make all necessary payments from pour fiends. Your representative could face a civil penalty for intentionally failing to pay required amounts firom your fiends and - could face a criminal penalty far abusing your fiends. ~rrvate Pav Resicien.ts ThG i#eans and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for itetus and services that are included in $ie daily rate is payable cane month in advance and due an the first of each nnonth. Items and services included in your daily rate are lusted in Exla'bit Z.A. Yea wp1 be charged separately for additional. items and sexvitces not included in our daily rates such as special nursing ~ special equipment, pharmacy charges, laboratory charges, medical tramspoetation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers. Items and services far which you will be charged are listed in 13~chibit Z.B. Payment for these additional items and services are due after you have requested thenv and; you havereceived and have been billed for them. Within 30 days of receiving an item or seeviee, you have the right to ask us for an itemized financial statement that briefly but clearly describes each item and the amount charged for it. Yon will be given an updated listing of services and • related charges, incltxling any charges for services not covered under Medic~ixxe or by the facilities basicper diem charges, annually on or about 7anuary 1 of esclt year. Medicare Res~idenfs We participate in the Medicare I'xogrann. Medicare may pay for some or all of your nursing hvrae care, For is-£oimatian on Medicarq see Exhibit 3. If you are eligibly for Medicare, you have the right to have olaims fioz your nursing harne care submitted to Medicare. I~Iedicald Residents We participate in the Medicaid program. For information on Medicaid, see)~ibit 3. You are not: xegaired to give up any of your rights to Medicaid benefits to be admitted or to stay here. if your private fiords are used up during your stay here and you a7re eligible for Medicaidt; we will accept Medicaid payments although Medicaid may require yvu to pay some amount in addition to what Medicaid pays for your care. If you are planning on applying to Medical Assistance later, you may want bo ford out now if your are "m~edieally eligible" for nursing home paytttent by Medicaid. Youare responsible for applying far and obtaining Medicaid bexefits and we will assist you.. We may not charge, ask fob accept ox receive any gift; money, donation or consideaafion ocher ihsn Medicaid xeimbursement as a condition of your admission. ox eontuxaed stay here except that Medicaid may require you tv pay certain amounts from your prorate funds. If you receive ~VSedicaid, most of your nursing home charges such as raain, board, and general nursing case are covered. Far a fist of services covered by ildedicaid, see Exhifiit 4.A. The local B oard of Assistance will tell you whether you have to pay part of the charge for your care and, if so, how much. Same of the items and services that we offer are not covered by Medicaid. I£you want arxy items ar services, which are not covered by Medicaid, you ox your xepresentative will have to pay fox them. A list of Cite items and services not covered by Medicaid and the charges fox tkean are in $xhibit 4d3. Payment for items and services that are not covered by Medicaid is due eflex you have requested them, and; have received and have been billed far there. Witiun 30 clays of receiving 'the item or seaviee, you have the right to ask us for an itemized statement that briefly but clearly describes each item and the amaunt charged for it. Increases in Chaxges and Fees ,Any time we increase a fee or charge far item oz service•or add a nevv item or service we will pmvlde you and your representative with 3 0 days advance written notice. Penalties • ~Te may eat charge you intez~est if you pay your bill in tune. Your payment as an time if if is made within 45 days of the date the bill is post marked, or 30 days after the end of the billing period, whichever is later. T?4e penalty we charge is S% of the axaonnt due, calculated on a per day basis, Tf you or your representative do n,ot pay the money you owe us and we hire a collection agency - or attorney, you agree to be liable £or their fees aad corns costs. Pnavafe Dut~v Nurses Getriafric Aides Tf yon want a private duty nurse ar a private ~ geriatric aide, you are ~~esponsible far selecting a person licensed and/or certif ed according fo Pennsylvania laws and regulations, You are also responsible £or paying him or her and far letiing us kiww that you have hired one. The person ya~z hire is not an employee or agent of the facility, but be or she must meet our standards and follow otar policies and procedures. Employees of the Facdliiy may not serge as pziva#e duty nurses or pnivate-duty geriatric aides. - . FioIdiug Your Bed ffYon Leave the Facility _ Tf you are hospitalized or on leave from the Facility, die will hold your bed £ox you as follows: ,A. Tf you are private~pay resident, or axe receiving inpatient care xeunbursed under Medicare Pragraan (gad yov. ate Aot covered undex ~llledicaid), unless you notify us athenvise, v~ will hold your bed far as long a's you pay for rt at the daily rate yon are cvrrent[y being charged, B_ Y£ Medicaid paps for part or all o£ your nursing home care and you need to he hospitalized, we will hold your bed for up to the maximiwu; nmmber of days required by this state, cun~ntly l5 days. I£yoa Leave for any other xeason, we ~avill hold your bed £or up to the maximum number of days required by ffi.is state, cuaeutly l $ days. You have a right to be readmitted to the ;facslity to the $rst availa131e appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for vvIzich you are liable as determined. by the Medicaid Program. C, If you have applied far Medlcaid, your b ed ~1 he reserved in a ccordanee with Paragraph B. However, if you are found to be ineligible for Medieaid,thenyou ors requiredto pay for the bed as a private pay resident as described in Pazagraph A. D . Other thn~l party payers may or Wray not have a bed hold poliey_ We will discuss this if it applies to you, Your Righ# to lYlake Comp~ts and Suggest Chsn~es in~'olicies and Services As a nursing home resident, you have many xights according to State and Federal law These are described in detail inBxhibit 6, which is attached and is part o~fhis Conhaet Yon may make complaints about your care in the Facility and you may also suggest changes in the policies and servit;es of the Facility. 'You will not be harassed or discriminated against for snaking a complaint or suggesting a change in a poliey or service. You utay present your complaints to the &cility, management company or to one ofthe following State agencies: Lin `>'iexsob, NHA 1-idministra~tor ShippensburgHealth Care Center l 2l walnut Bottom Road . ~uppensburg, PA 17257 717-530-8300 Ombudsman Office of Aging 16 West High Street Carlisle, PA 1?013 71? 240-6110 717-532?286 Ext. 6110 Mr. John Perini x'resident irlagaolia Management, lnc. 1710 Underpass ~47ay, Suite 201 Hagerstown, ~ 21740 301745-8700 Department of Healtfi. 100 North Cameron Street 2~ Floor Harrisburg, PA 17101 717-783-37911 roux l~ht to MakeDecisians Yau have the right to make your own medical decisions and to manage your personal affairs. If you become disabled, ix may be necessary for someone else to make decisions for you. For this reason, we recommend that volt have a living will and/or advance directive for medical deci~%ons and a financial Power of Attorney, but you aL~e not required to do so. See h~hzbit 7 for a deseriptiot- of your legal rights to decide abo~ your fiiture meclicaL treatment. ' Transfer, Relocation attcl Discharse Yan have the right to remain here, and you may not be transferred, relocated or discharged agaznst your will, except for $ie following reasons: (1) A medical reason (i.e. flee facility caAnot provide the kind of care that you need, your condition has improved so that you no longer need the care we provide, or a medical emerge~tcy arises; (2) Your welfare or the welfare of other residents or staff; (3) Nonpayment fnr a stay, or (4) the Facility ceases to operate. If we decide that you should be transferred or discharged, we will notify you, and an inuuediate family member or legal representative, by letter 30 days in advance. If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter will also tell you how you can appeal our decasiorx to transferor discharge you. If you are discharged involuntarily, we ~vs-il1 attempt to make other appropriate arrangemeaats for your care. However, ifothex arrangements are not avin~able, yourrepresentativeagrees to accept you into his ox her custody if it is rnedicaliy appropriate. Yonr Right to En.cl This Contract If you deeid~e to end this Contract and leave the Facility, you must pay your bill before you leave. You must give us five (5) days written notice to terminate this contract. Tf you leave before the . end of that time, you must still pay for each day of the required notice. r . ~zt$e event you die wh~,e ~ zesideret oi'~~ac~y, 37our representa~.ive is responsible £armahing t~ funeral a~atigemeots. We -will xzotify your repre~e ~~- ewe are uua~ble to - reach your repress we w~l ~ont~t the fiiheral home a£ your choice to, ar~getuents. ..~:dt3ifianaIDocamienfs = . xt is not posss~le to coves everyf,~ag ffiat i~ important to your sEay in our Fa~ity ~a ttia bo ~Y o~ Cot~rarx. Therefor we hive ~.eturyad ad&ttonal iZnpoirtan~t doevmexcEs as These • - are pant o£ t#us .eont~act. Please veri.~t {hat you xeeei~ved the ~ aad that the s o~ t~ Baits wire explained fio Y~ by placing-pour•iiu~ais on-~e hae~ne~ to the ' destxr a~'eachFt. :~l~u~it I. 12iglZts and Obllgxfians ofReXsxese~atives. " ~L~ibiC2. 1~c~rPu~ta#ePayR.esidex~: ~a} Zte~ns and sezvice~ eavexed by damp rate. - - ' (b} Items and's~ces not cwexed by daffy ram. P~'6it3. Hawto Apply For andU~elvTedieare and>yledicaidBepe,6is. •~l3x~it4, (a) Xtazns and Services Cov~red.byMeslic~d. i - (c)Ii~sa~xdServicesl~ot+Ca~recibyMedicaid. ~Ex1u`6it 5, Phpsiciaa~s Who a at the Ra:ci~ty. • •, I~n~bit 6. ~egalRigh#s oi;~'eausylvania to DecadeFu~:ure Medical Treatnasnt ~zE?. Policaes andl?rocetlures Coi~seaxing'St'our~'ersonalFuitds and'~gur . • Persanal~'roP~-Y . • ,P.xhibit 8. Services Pzovidedby OutaidelTBatfh CacePxoviders. G~~tn~es iu law . _ Auggrovision of this Coniractthat is found to ba zn~valid oz'vnea3forceable as aresalt of ~. el~w,ge ' is~. Spa or FedecaL ta~v wtT(not invalidate fire temaini;ag provi~,ons of this Ooniract, ffthera ate sarc-ices wa bave a,~reed to provide that are lam found to b a imposs~~e fi~ render as~.re~lt of a cbxage iu Stets or Federal lsw, it is agreed that to the exterxi po~ih1~, tbs Bey and •the Fact~i~q will coatauue to futfll owr respective obligations undzr this Contrast cc~t~aith tha law - r t~~~ - 7N S W~tEOF, the patties have executed this Cantraet on this ~~~, day o£ ~Y= wire w. tt M,~rray, Adnai~ustrtttar - s'hippepsburg health Saxe Ceflter _ - Witness Resident I~~e xesident bas been adjudicated disabled ox the Resident's ddctnr deteirnin;es tl~t the Resident is incapable of understanding or exercising his ox her rights end respansibiiities, the facility ~y requure rth~e srgrnatwre of atia8~ea person onthis oonixact. the other pe~soxi may be: (13 A:n appbimted healthcare agent ender and advance directive i'or ~aiedical care; (2) A guardian ox rower of Atfomey of the person; (3) A surrogate or #~aily member. i~ - . ty -- w~ --- - ---- -------_ ..__._.. - - - _ -- _ Res~onsibleParty (Nanne)M- _ - ...__.- - _--.-- _ _ _~__. TTxtle: Indicate w ether yon are (1), (2) or (3) x~x~rr x R1GIfiTS AND 08LYGATIONS Ob' REPRESb~.tiTATIVE The Representative shall have the right to be nofifted by the Facility of .any event or occurrence involving the Resident; which directly affects any obligation of the Representative under thus Agreement. Represenf~ati~oe agrees to assume independently, under ties Agreement; the follovging obligations and is entitled to the foIlowing rights, as indicated by Representative's initials accompanying any ofthe ~ollowingprovisions: R.epresenfative agrees to be responsible for ensuring fat any payment from. the resident t+r~ ~arhich the Facility is entitled prnsuant to ties Agreement shall be paid to the Facility in a , . timely manner. In the event the Resident is a beneficiary of Aifedieare, Medicaid or any other fiord-party payment plan, Representative agrees to ea~sure fitakall eo-payments, co-ansuranice ar charges and fees fosnon-covered items and services, together with any late fees as descried under this Agreement; shall be paid from the Resideent's funds. Representative is snbj ect to a civil penalty fox ~illfizl violation o£the agreement to distribute tha Resident's funds to the fa~eility. • (Unless the Representative voluntarily agrees to act as guarantor}, Representative shall be t~sponsible fox any payments regndred under this Agreement only to the extent of the Resident's fends. Resident is applying for admission on private pay basis, and Repzeseve agrees to assist the Resident in grovlding all financial information rewired by the Facility to detem~ute the extent of the Resident's resources. If it is ever determined tbeRepreseni$tive participated in the disclosure of incomplete or it~aecurate infarrnation, the incowplete ar inaccurate disclosure shad be deemed a material breach of this Agreement and the Facr~i[ty reserves the right to pursue all available legal. remedies against the Representative, including bet no# limited to an action for breach o£contxact. Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or gnardzan appointed by a cow.t A copy of all supporting documentation for this representation is atfafxched ip this Agr~nent. Representative is signng this Agreement on Resident's b ehalf, based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not p ossess the capability to understand his or her rights and responsibilities. Representative agrees that in the event of the Resident's death, Representative shall take xesponsi`Ii~lity o£all burial arrangepaents for the Resident a_ nd for xernoval of all persanai property fromtheFacIlity. (E~hihit 1, Continued) • 7f it is the desire of the Resident o~ Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, Representative agrees to ba responsible for arranging independently for (hose services, ' includ3ngensuxinganypaymerrt. _ Representative agrees that inthe evesitthe Resident's private fluids are exhausted during the Resident's stay and the Resident is eligible to apply for ben;el'tts under the Medicaid Program, the Representative shall assist the Resident and the Facility with any application for i~tedicaidbeaiefits. Represezt~kive farther agrees to act, ou Gehalf of the Resident, to facilitate any Ivtedicare, Veterans Admim~istration or other third party h enefits w2~ieh may be available to coves the cost of Resident's care at the Facility. • Iuthe eveutthe resident seeks~bo terminatethisAgreeinerrt,the Representative agrees~to ensure that all notices required under thus Ag~reemertt are provided to fhe Facility. In the eveIIt of an involuntary termination of this Agreement, if other anaugements acceptable to the Resident cannot be x~aade, ~e Repres~ttative agrees to accept ~ Resident into t$e Representative's custody, if medically appiapriate. Representative has the right tcs oopies of the following doctnments and any amen~nent to them. Representative further acknotivledges receipt afthe fallowing documents,which may be amended from fi~ne"to-dine. 1_ A copy of this Admission Agreement. ~. A list of the Facility's rates, subj ect to amendment on thirty-(3 a) days notice, and a description of charges for services not included. 3. A list o~hsalth care providers offering sen~icas at the facility. • Representative acknowledges the Facility's rim to oily legal remedies available under law for Repceseutative'sbreach of ilzis Agreement. EXEIIBXT 2.A. Private Pfrv Residents AAILY RO OiV.[ RATFS Total Daily Room Rates Effective 7anuary 1, 2a 07 Priva#eltooius ........................ $200.00 Semi-Private Rooms ................. 5190.00 T~ripl~elQuatl Rooms .................. $1.85.00 A. The daily zate incIndes the following services: Special Corte Program 5204.00 $199.00 $Y89.00 Rooom • Board • Social Services . ~ l~tnsing Care, iincluding: • - o The administration of prescribed medications, treat[aents and diets v The provision of care to prevent slcinE breakdown, bedsores, and defomnities. o The provision of care necessary to encourage fbe resident from acc~ldent, injury and infection o The provisions of Gaze necessary to encourage, assist sad train the =esident in self-care and group activities. The daffy rate does IriOT include the following itemslservices: • Physician Services • Medications • Specialized and/or specially ordered medical supplies/seiviees/equipmeut ' • Prescribed dietary sapplement~ . • Cable ($?.00 per month) . • Telephone and telephone services • Beaz~tylBarber Shop Services • DisposableDiapers . Items listed onAncillary Charge Sheet • Personal Laundry Payment Payment is due in full and an the first day of each month. ' Hill is done on a. monthly basis. Bach mont3ily payment shall also include any additions[ fees and charges incurred in the proceeding month. ~x»oaarr a.B ITEMS AND SII2'YICES NOT COVERED BY TII~ DAIIfY RATE The following iteans and services are nat covered by the Faca'lity's basic daily rate: item or Service Physiesan Services ~~I.edicatious l?rescn'bed Dietary Supplements PersonalDry Cleaniu~ Personal Linens Telephone Television Service BeautylBexber Shop Services Clotlung- SundryPharmaceutical Ambulance Service, l~Cedical Transporta#ioa ~ IV Therapy X Ray Services Medica~Nursi~ag Supplies . Denfal, Podiatrist and Ophthalmology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized audlar specially orderedmedical serviceslequipment Guest meals • (Exhibit 2.B, Continned~ t ltt'11+ MS ANn sl'1RVIC~ YoT cov~RED BX T~ DAILY RATS (refer to the Ancillary Charge List for additional costs) Item C ~e Telephone Direct bill from telephone company Television/Cableper maxrth $ 7.00 p er month Beauty/Barber Shap Services: • Peunauent $35.00 Haircuts and Blow dry $10.25 Hart Sets $ 8.25 Cut On[y $ 8~5 Color $30,00 Personal Laundry $ 45.00 per montlx Persona! Dry Cleaning Sams as killed by cleauex Physical Therapy Service Detex7uinsd by level of care required ( OccupatiozxaUSpeech Therapy Determined by level of care required 1V Therapy Charge list will be provided by contract pharmacy prior to delivery of services Aerosol Therapy Determined by level of care required Sluppensburg Health Care Ceater cordially invites famiIp members, guests and frie~uds to join our Resident's of ~oaeal times. The prices for guest hays, effective July 1, 2001 are as follows: Breakfast A $4.00 w111 be served at 7:00 AM Breakfast B $4,00 ($3,77 + .23 state tax) served at 7:30 AM L-unchA $4.00 w;u be served at 12:00 PM - Luneh B $4.00 t;$3.77 + .23 state tax) served at 12:30 PM Dinner A $4,00 will be sewed at 5:04 PM " Dinner B $4.00 ($3.77+ .23 state tax} served at 5:30 PM The Resident's will b e assigned their meal tunes upon admission. Meals can b e paid for at the Receptionists' desk, In order to prepare suSicient quantifies vve require a 2 hour notice to prepare guest tray, E~~ 3 Thy following suimnatizes the lvtedicare and 1Vlediraid programs.. It also tell§ you who to call for more detailed information. Xfyou Dave questions, our staffwill also help you. VQIia•E's Covered-Medicare 1. Care in a hospital 2. 100 days of slrilled care in anursing home. Medicare provides fall coverage for the first 20 days. You mnstmake a eo-payment aitex that. The following services aze examples of skilled care: a. Injections 8t feedings given through an IjT b. Tube feedings c. Application of a dressing that involved preseaription.medication d. Treatment of stage 3 or 4 bedsores 3. Medically necessary doctor's services. 't'4haE's Coverred-Medxeaid Medicaid is a comprehensive program. that wilt cover most of the casts of a nursing home stay. See Exhibit 4 for information about.covered and non-covered items. Your Contribution-Medicare Medicate dOE3 not pay I Oo'~ of the cost of covered services. Xou w711 be required to pay pact of the charges. '~owr payment may be Balled a "co-payment ;"deductible" or "premium", depending on fltetppe of Bate provided. Ifyou reeeivelrledic~id,lVledicaid will pay for arty payntentthatyou are zesponsible forunder Medicare. Yowr Conir~ufion-Medicaid Depending on your income and assets, you may be required to make a contribution toward the coat of your case, The amount of any contribution will be decided by the local B said of Assistance. . 'S1Vltds Eligible-1V><edicare People 65 years old or olderwho are eli~gibleto collect old-agebenefits under Social Seetvaty are eligible. Persons who receive Social ~ecaritp disability benefits for at least 24 months, or have been found eligible for Medicare by the S octal Secwrity Admirustxation because they have end stage renal disease recluirimg regular dialysis or kidney transplant are also eligible. ~Flio's Eligible---il~edicatd Eligibility depends on wha~ier your income and assets are below certain levels; 1, c me: You should consult the local Board of Assistance to find nut whether your income makes you eligible, That phone number is listed on the next page. If you qua]ify, $3Q per innnth of your income is protected for your personal use vrhile in the Facility. 2. Assets: The Camherland Co~eznty Board of Assistance will also be able to evaluate your assets and fell you whether you qualify. The following are examples of things nol counted as assets. a, Your house if your spouse lives there. b, T3ousehold goods. c. A certain amount of cash. d. Personal PzoperEy in your possession in the Nttirsing home. e. A certain amount of money for burial. arrangecnenfs. I_ ~Or~v to Apn1Y-Medfcare Cotatact ~e local Social Secaxity Office atthe fallowing address: Social Security Office 401 E. Lauther Street Carlisle, PA 17oi3 (800) 772-1213 (717) 243-0085 . Hm~v #o Apps-MedEcaid Corafact the local County Board of Assistance at the following address: Board ofAssistance 3~ wes~iinistear Dave Carlisle, PA 17013 (800) 259-0173 (717) 249-2929 W ham to Conte ct if you have $ Ouestlon ox Pr ablem -Metlicare if Medicate denies a claim, youhave the right to aplseal the denial 'You may appeal by wxiti~ to: Aetaia Medicare CIaun Administration 5010ffaee Center Building Fazt Washington, PA 19034 (215) 643 7200 Whom to ContacE ~ you have a Question or i'roblezn - ~Iedicafd 1f pour application for Medicaid is denied, your coverage is teraninated, or a service is not eovexed, you may appeal in waiting to County Board ofAssistarce Office 33 31Vestmiaii.~r Drive P.O. Bax 599 Carlisle, PA 17013 (717J 249 2929 (800) 269-0173 (.E~ibit 3, Continued}. ~G'hom (n Contact iaf von have Incurred lrredical L~x~s eases trriox to vour M_A_._ Effective Date Medicare-Tot applicable '~vm to Coma ct zf you have Incurred Medical Exn eases vrior to vaur MA Effective D ate -Medicaid Medical bills that you received in the 3 months priox to receiving Medicaid may he coveted by Medicaid. Contact: - . County Bomrd of Assistance OfFzee 33 Westminister Dxive - ls.O.Box 599 Carlisle, PA 17013 (7I7) 249 2929 (800) 269-0173 r~ R~XT 4.A A.. Z#ems and Se~-v}ees Covered by the Medicaid Per been Rate • R,egu~ar room, dietary services, social services and other services required to meet certification standards, medical and surgical supplies, and th$ use of egnipsuent and facilities. • General nursing servlces, inchuding but not limited to, administration of oxygen and related medications, hazed feeding, incontinency care, tray service and enemas. • 13asis B eautyiBarber Services. The faer~ity mustpzovida shampooing and hair cane which is considered necessary for hygiene. The facility mast inform the resident of the types and frequency of the services provided, • Items fuamished ro utinely and relatively uniforaniy fo alI residents, such as water pitchers, basins, and bedpans. • Items flunished, distributed, or used individually in small quantities such as alcohol, applicators, cotton balls, band-aids, antacids, aspirin (and other nan legend chugs ordinarily kept on hand), suppositories, and tongue depressors. • Items used by individual residents, but wliicla are reusable and expected to be available such as ice bags, bed rails, canes, clutches, ~aIlaers, wheelchairs, traction equipment, anal other durable medical equipment. • Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even irf written as a prescrirption item by a physician. • Laemdxy services for other than pexsonal clathin~ + ATan emergency medical transportation services. Other special medical services of a xehabiIitative; restorative, or maintenance nature, designed to zestoza or sustain the resident's physical and social capacities, • Personal care items including a patient gown, shampoo, skin lotion, comb, brush, toothpaste, toothbrush, and denture exeam. f' EXBISXI' 4.E B. Xteto0.s attd Services Not Covered by the Medicairi Per Diem Rate Medical expenses such as, but not limited to: • Heal#h lnsuranCe prer~]lu1uS. . • Visits by a no3rparticipating physician other than approved by the nursing care facility. • Emergency ambulance services, if the ambulance company does not acceZrt MA. • 4vex the-counter medications, which are a p articular brand not supplied by fine nursing facility. For example, the nursing facility mast provide aspirin, bnt the patient mayxequest and buy a specificbrand ofpainaeliever, such as Excedrin PM, or Tylenol Hearing aids and batteries. • Sp.eciaiized.BeautylBarber Shop services. ~ • Ditapexs, if the resided wants a style or hxand ~rhich is notprovided by the ' musis~ ca~.e ;Facility. + Personal case items of the resident's choice if preferred instead of the items provided by the nursing came facility. This inelndes items such as brushes, combs, toothbrushes, cosmetics, eta . ~IBiT ~ PHI'~ICIAJYS WHO PRACTICE AT THE FAC~ITY Dr. Yogincira S. Balbara, M.D, Dr. Paul Orange, M1~. Dr. Baxter Drew Wellmon, II, D.O., P.C, 751 Fi$h Avenue Chambersburg, PA 1?201 (717} 26I 2583 4225 I;incaln'4Vay Bast Fayettevt~11e,1~A 1722'L (717) 352~3b16 127 Vlalnut Bottom Road Shippeostourg, PA 17257 (717) 532-3211 EXHIBIT 6 LEGAL RIGHTS OF PEI~INSYLVANIAN;; TO DECIDE,~A.EOUTHEALTH CAItL~ 3tou btave the R~iatit to D eef de About Your Health.Care Adults generally have the right to decide if they want m~dieal-heafinent, unless they ate not competent This rightincludes decisions abou#trea6ments that extend Iife,life-s~upportmachines, or feeding tubes. Sometimes, atR accident or illness takes away a person's ability to make health cane choices. Bu# the decisions still must be made. If you are unable to make them, others will. They will decide based on your wishes or your hest interests if your wishes aze unlmown, Pennsylvania law gives you thezight to rs~.alce many healthcare decisions in advance, are way bo da this is by using a writfien advance direotiva to rains an ag~ntto make your healthcare decisions if you camnot. A written advance du~ective can also state your treatment pre~ces, especially about life sustaining procedures, lYanaine a. Healttlt Care Agent You cam name anyone to be your health care agent. The onfy exception is that, m general, someone who works where you are receiving your care oannot be your agent. Your agent can be a family member or afriend. You rho ose when your agent can decide for you- right avray, if Soo want; or only after two doctors agree that you are not able to decide for yourself. You also choose the kinds of declsions pour agent can make for yon. For example, if you vraut; you can give your agent very broad power to decide about fife-sustaining treatment. Pick our health eaxe agent very eai~efully. ilrlaloe sure your agentkuows what you want. Your agent will then fo]Iow yoiu wishes, even if your friends o~fatnity disagree, IIsf~n~ Advance Directives Thexe are many ways to use an adverse directive..A living wilt is a type of written advance directive that states your wishes onlife-sustaining -h~eatmenfs. Ii usually comes into affect vtirhen a person will die very soon from an incurable condition, It can also be used when a person is permanently unconscious (in a vegetative state}. You can make a bxnadez written advance directive fox other health Date issues too. For example, you can decide whether yon want life.-sustaining treatment if you are in anend-stage condition. .A.n end-stage condition is an advanced, progressive, and incurable condition resulting itn complete dependeaxcy, What Happens If You f3o No# Make an Advance Directive? No one can dewy you health care because you do not have an advance directive. $ut you should -know vQhat happens Legally if you do not. ~Ifi 7 POLICIES AND FROCEII'ORl/S'CONCLRi~IING YOUR PERSONALTIIL~TDS A1~tD'YOIIR PZRSON,~L PROPERTY A.. Your Rights: 1. You have the right to keep and use yourpersonal properEy, including some furnishings and clothing, so long as there is enough space and other residents are not inconvenienced, Xou also have the 17ght to seeudtp far your personal possessions. 2. -You have the right to manage your financial af6ixs unless a court fleterniines that you are incapacitated. or the Social Security Adnuuiistradon selects a representative to receive Social Security fundsfor youruse and benefit. 3. We cannot require you to deposit your personal fiends aZth us. Yonmay, however, choose any p erson to mai~ge your funds, including the Facility, 4. ~ you decide to have us manage your personal funds, you may withdraw your money that we keep in the Facility during the Facility's business hours. If we have deposited any of your funds in a bank, you cnay obtain those funds within thine banking days, provided the funds have cleared. 5. If you need help to p erfonn your banking transactions, you may give the administrator of our Facility legal authority to access pour account. This authority is called `4~eptesentative payee' To give the administrator this authority, you will need to complete a special form. 6. You and your personal representative have the right, during normal bu,sin;ess hours, to inspect our zvi7tteu records that eoncein your personal funds. 7. You and your personal representative have a right to file a complaint if either of you beliaew..s that your funds, valaables or other assets have been stolen or damaged. The agenoies to contact in order to make a eornplaint are listed below: a. The Cumberland Cou~ity Office of Aging Atlu: Ombudsman; Human Services Building 16 West High Street - Carlisle, PA 17013 (717) 53~-7286 Bxt. di 10 (71'7 240-617 0 (Bxbibit 7, Continued) i~ • U.' Cumberland County Board of Assistance 33 Westminster Drive ' P.O, Box S99 Carlisle, PA 171313 (717) 249 2929 (840) 269-01'73 c. The D epartment of Healilt. Division of Nursing Care Facilities ' 100 Narth Cameron Stree# 2"~ Floor . I~arrisbwrg, PA 17141 ('717}'7$3 3794 _ B. OurResponsibt~'es: 1. We v~al1 provide a reasonable amount of secure space for you to keep your clothing aad other personal. property. We mustinvestigate any damageto or loss of yom personal property. 2. If you want as to manage $ 5©.0 0 or less of your personal fends, we will deposit this mmaeyirra~n-interest bearing accotmt or a petty cash fund. 3. If you wantus to manage more than $50,40 of your personal fizuds, we will deposit ibis money in an interest bearing account that is insured by the federal govemmeut. This account will be separate from the accounL~ we useto operate the factl~t' y. rit addition, we wi11 erect you unth all inbexest emrned on your money. 4. We will maintain a full, comglete and separate acco-untiug of yovx personal funds. We will also provide you with a quarterly statement of the activity of your accour-t. 5. If you receive Medicaid benefits,1ve will notify you if your account balance becomes too high. Xf you are to remain eligible for Medicaid, your account balance must loe under a certain dollar limit that is established by the Federal gavemmant amd changes periodically. 6. We may not use your personal funds to pay for an item or service tT~t Medicare or Medicaid covexs. 7. We will maintain2 adequate ftte and theft coverage to protect your funds and pe~.~sonal property that are kept at the Facility. ~7e steal l also obtain a surety bond or otbeiwise assure the security of yourpersonal fiu;ds mat are deposited witlxthe Facility. {.F~rhibif ?, Continued) • $. 7f you ~ e discharged, there are several things we must dot a. We will ensure the return of your personal funds in aurpossession. Ifwe have deposited your personal fonds in a bank account, s~ will ensure that this money is made available to you or your authorized representative within 30 days. b. Zf we are your zepxrsentative payee for Social Secuxity benefits, we v~'ll promptly ask the Social Secarrity Administration to nabdte a new • representative payee and we will transfer your money to thatperson. 9. In the event .of your deatby #here are several things rve must do: a. We will convey your personal Funds and a final accounting of moose funds to the person in charge of adininistemng your estate within 30 days. tie will, i~runedrateZy notify anygovernrnentogencythat paid for all or part of your care in owr Facility. That agency shall have the right to assert us in' determining what to da with your property. b. Yf a government agency did not pay for your care, we zarill immedia#ely aro#ify your representative or next of loin to determine what to do wiith your pmp~Y- ~~ - c, if we have your fiw.ds, valuables or ot}aer assets %n our possession, eve will hold them until the appointed personal representative of yacur estate presents a colry of the ceatx:6" red Letters o£Admiiustration to us. All conveyance of personal fiords wi[1 be by check made payable `moo the Estate of...". d. We will make ze~sonable attempts to to cage your personal representative and your heirs. If no alarm is made on your fiords, valuables or other assets in our possession within sip weeks of your death, we wdl wxite the State Office of the Comptroller for direction. 10. If w8 are in possession of your farads, valuaables or other assets for more than one year from the date of your transfer or discharge, we wsIl transfer your funds, any interest on your frzjzds, and pour valuables or other assets to the State 0#~ice of the Carnptroller's Office of any account(s) in your name of ~,vhieh we have lmowledge. E30•lIB1T 8 SERVICES PROVIDED BY OUTSIDE HEALTH CARE PROVIDERS Some of the services available in the Facilt'ty, such as pharmacy services, are provided by outside health care praviders. These services, and information about th® providers, appear beiovir. You are free to pick your own provider or to use one of those listed below: Whether we have • Provides Name, a financial Address and interest in Tvpe of Service Teleahone Number the arovider Physician Dr. Yogit~dra Balhara 761 Fifth Avenue No Chambersburg, PA 17201 (717} 2646185 X-Ray Services Mobil ?~ Ray Setvlces The Chambersburg Hospital No ' 112 N. Seventh Street Chambersburg, PA 17201 (717) 267 7153 I_ah Sarvlces Health Network Labs 1200 Walnut bottom Road No _ Carlisle, PA 17013 (87?} 402-4221 Pharmaceutical Millennium Pharmacy Systems, inc. 12450 Perry Highway, Suite 20D No UVexford, PA 1590 (866) 4607779 Podiatrist Dr. Pinker and D. Golec 47 Broo[cwood Avenue Na Carlisle, PA 17013 {717} 243 2236 Hospital Chambersbarg Hospital No inpatient or Carlisle Hospital No Ernergertcy F'utlon Co, Medical Center No Roam Hershey Medlca! Center No Waynesboro Hospital No .a.: - .. _ . .. - .. is - _ _ .. _ . 1~~ a"i _ ;i S .~ r y~ i sF ~ .i -r~ _ ~-C K } E~ ... sr r .. } Y Y,. _ . KNOW ALL MEN BY THESE :PRESENTS, that I, WALTER M. PATTERSON III, currently residing at 50? Muench Street, Harrisburg, County of Dauphin, Pennsylvania, hereby revoke any general power of attorney that I. have heretcsfore given to any person and do hereby appoint EDDIE L. COLLINS of 2234 Penn Street, Harrisburg, County of Dauphin, Pennsylvania, (hereinafter "my Agent") my true and lawful Agent for me and on my behalf to perform all such acts as my Agent in my Agent's absolute discretion may deem advisable, as fully as I could do if personally present. - This Power of Attorney shall not be affected by my subsequent disability or incapacity. My Agent is hereby given the fullest possible powers to act on my behalf: to transact business, make,.execute and acknowledge all agreements, contracts, orders, deeds, writings, assurances, and instruments for any matter, with the same powers and for all purposes with the same validity as I could, if personally present. ~, i~ ~ z: -C jt - .r - _ {i -_,xr ~r~'+_i:~+r ~~~vc'~i'~r ,~: °fr~~~:...~w S?l~y.t"F~ 4~E~.vz7 ~3r ,a,:.~-zg5.~ta~+.~. _ .. - " }. - -_ SPECIFIC POWERS INCLIIDED IN GENERAL POWER- Without limiting the general powers hereby already conferred, my Agent shall have the following specific powers which are included ~in the foregoing general powers: (1) To create a trust for my benefit. (2) To make additions to an existing trust for my benefit. (3) To claim an elective share of the estate of my deceased spouse. (4) To disclaim any interest in property. (5) To renounce fiduciary positions. (6) To withdraw and receive the income or corpus of a trust. ('~ To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care. (8) To authorize medical and surgical procedures. (9) To engage in real property transactions. (10) To engage in tangible personal property transactions: (11) To engage in stock, bond and other securities transactions. (12) To engage in commodity and option transactions. (13) To engage in banking and financial transactions, including checking and savings account(sj, certificates of deposit, and savings bonds transactions. (14) To borrow money. (15j Ta enter safe deposit boxes. (16) To engage in insurance transactions. (17) To engage in retu-ement p~ ~sactions. (18) To handle interests in estate and trusts. _ (19j To pursue cleans and litigation. (20) To receive government benefits. _ , (21) To pursue tax matters. 1. This Power of Attorney shall mat expire by reason of lapse of time. 2. Thereby ratify and confirm all that each Agent acting hereunder s hall do or cause to be done under this General Power of Attorney. I s ecfi P tally direct that such Agent shall not be subject to liability for such A ent's g decisions, acts or failures to act. ~ .~'S"aT~-"34 rpm" 9R: ~w~ :`~h: ~ is i-`* .ti<s ~': _.'_'-- .._ _' v~ '~_ '~ ': ... _ 7 i _._ _ _'.:: ~ . -..,.:.: :;-.. .,.,.. -. ' . :a~tzng liereurider. written~notificatibn of~the~revocatton,~'Wtiich -notice shall nat be considered binding .unless actually received. HIPPA RELEASE AU1`~iORIT'Y I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any . information governed b3' the Health Insurance Portability and Accountability Act of 1966 (aka HIPPA}, 42 USC 1320d and 45 CFR 160-164. I authorize: (a) any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider any insurance company and the Medical Information Bureau Inc., or other health care clearingXiouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services; (b) to give, disclose and release to my agent, without restriction all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HN/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse. of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. IN WITNESS WHEREOF, and intending to be legally bound, I have hereunto set my hand and seal this ~ day of 2007. Signed, sealed, and delivered in the presence of ~ ~'i~.~° WALTER M. PATTERSON III COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the ~ day of 2007, before me, A Notary Public, personally-appeared WALTER M. PATTERSON III, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. T PUBLIC COMMONWEALTH OF PENIVSYLVANtA Notarial Ssa~ fGelly P. f~berb, Notary Pic p Boro, Dam ~tY ~ ~ cxplres,lat~. 27.2009 Member, Pennsykvanta AssociatEon of Notartea - may have., made with my health care :providers to restrict access to -or cnsciose NOTICE THE PURPOSE OF THiS POWER OF ATTORNEY iS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT'S BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUISE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED; YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GNEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FU~iDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTIPtG PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE E~LAINED MORE FULLY IN 20 Pa.C.S. Ch. 56. ~. ~" .7.~Y 4 aL 5z ~.'. : < _-5-7 --es' . ~:.~f _ ~:,. ~'~.. . ~.'.~ t _-9cta..,.. q. 3" '~-~t `~,~'.t .2Fr.r~+ .~.. ° 7s`'";~ ~4 ".~..,.+v +uxL. 4 y ~ `4C~ ._ . .:..... .. _ t ,` '~ IF THERE IS ANyTHINC~ °ABOUT THIS`FORM T~•T YOU DO_N~.~.... . UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I EVE READ OR HAD EX'pLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. -^ _ '_-t' ~,J~ ~ `a WALTER IVI. PA'T'I'ERSON III PRINCIPAL AGENT'S ACKNO'WLEZ-GEMENT I, EDDIE L. COLLINS, have xead the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specif c provision to the contrary in the power of attorney ar in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. - AGENT DATE ,E x~~.S- COMMONWEAI:TH OF PENNSYL~TANIA COUNTY OF DAUPHIN On this, the .~ day of 2007, before me, A. Notary Public, personally appeared EDDIE L. COLLINS, known to me (or satisfactorily proven) to lie the person whose name is subscribed to the foregoing instrument; and acknowledged that he ea~ecuted it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and~official seal. Member. Pennsy!vanla Aesociatlort of Notaries P.O. BOX 599 33 >WESTMINSTER DRIITS CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 *01080000000* SHCC ATTN: DOROTHY ABBOTT 1710 UNDERPASS WAY STE 201 HAGERSTOWN 1!RD 217 4 0 T.EUCIBLE PALS 1. oP 1 ricE - s._ .. 21 0116611 0 TJN 00 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE 12/15/zoos NOT: 985 OPT; J TYPE: N `>Tf=f'OtlDD NOT°lINAERSTAMD'OUR:DECISIOM AR7IAYE ANY OUF5710N5, PLEASE COWrACT YOUA NOIkXER 11f1ED1At•ELY. You have been determined not eligible for benefits based on your application dated 12/11/2008_ You disposed of a total of $ 69000.00 in assets without receiving fair market va]ue. This transfer results in a period of ineligibility for payment of Medicaid/Services in a Long Tern Care (LTC) facility. You are not elfgible for payment towards the cost of Medicaid/Services in an LTC facility beginning on 05/01/08 and endtng on 02/27/09 During thfs period, you will be responsible to pay the LTC~fac"itity-"foN the LTC services you receiv®. You are eligible for alt other Medicaid benefits: You can request an undue. hardship waiver if the denial of payment of'Medicatd/Services in an LTC facility would deprive you of medical care whfch would endanger your health or life or if the denial of payment of Mediczttd/Services in an LTC facility would deprive you of food. clothing. shelter, or other necessities of life. Citations: Pub. L. 109-171. 6011 and 601678.104 (d) Pub. L. 3i, Ato. 21 41.5 and 55 Pa. Code 178.104 (d) If you disagree with our decision. you have the right to appeal. See attaches form for a complete explanation of your right to appeal and to a fair:-hearing. if-:you are currently receiving benefits and your oral request for a hearing ~s received in the County Assistance Office or your written request is postmarked or received on or before 1z/ze/2ooe your assistance will continue pending the hearing decision, except when the change is due to State or Federal taw • •~~~ i9ALTER M PATTERSON SHIPPSNSBIIRG HEALTH CTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG PA 17257 .~ .~~~ ~Fnr.aun CAp P.O. BOR 599 _ 33 WESTMINSTER DRIVE CARLISLE PA 1'7013-0599 MIDPENN LEGAL SERVICES 401-405 LOIITHBR STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 89539711 - .. ~ 21 0116611 WORKER: s PEZPER - APPEAL 12/28/2008 TELEPHONE:: - ,leoo) 269-0173 MAIL DATE: 12/15/2ooe NOT: 98S "OPT: J TYPE N .~-'~°~{'~~~`-`~4'ta~~~~1~.3~~~~~,~,~^'-~~Ok~.i+~..~~°~~-.~n~i,`~~'A~~:.1~~'~~~~"~r~t37 <A7~~~'~1~R~ ~ ~~~ +~p ~aul~ ~°~,~~~'~ - PAnnntazA CONT{NUED ON REVER~F StnF -••--• --- 71-53~-8304 Shippenshurg Heath Car STATEMENT 09:56;56 Z1-05-2009 5131 SHtPPENSBURG HEALTH CARE CTR Facility Phone: 797-530-8300 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Resident: WALTER Ivl PATTERSON - Statement Date: 05/05/09 Ed Collins P.O. Box 2905 Harrisburg, PA 17105 Date Service Through Qty Description Amount Sub Total as of 03/31!09 97,536.68 Total Amount Due 57,556.68 Payment due within 15 days_ We accept Visa and Mastercard. Page 1 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: (01 j~1 t~~ Stephen Coetzee, Represe ative for Perini Services/Southampton Manor Limited dlb/a Shippensburg Health Care Center IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: WALTER PATTERSON O.C. No. PRELIMINARY DECREE AND NOW, this day of 2009, upon consideration of the annexed petition, a Citation is issued and directed to Eddie L. Collins to show cause, if any there be, why an Order should not be entered requiring him to file a full and complete accounting of all transactions undertaken by him with respect to Walter Patterson's resources and income from June 29, 2007 to the present. A copy of the petition shall be served with the citation. Citation returnable days from the date of service. BY THE COURT: J. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: WALTER PATTERSON O.C. No. FINAL DECREE AND NOW, this day of , 2009, Eddie L. Collins is hereby ORDERED and DIRECTED to file a full and complete accounting of all transactions undertaken by him with respect to Mr. Patterson's resources, including the proceeds from the sale of Mr. Patterson's home, the disposition of the funds in Mr. Patterson's bank account and Mr. Patterson's monthly income from the time Mr. Collins was made Agent through Power-of- Attorney on or about June 29, 2007 to the present, and directing Eddie L. Collins to turn over to Shippensburg HCC said resources and income. BY THE COURT: J. JUN 2L 2009 (~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: WALTER PATTERSON O.C. No. ~ ~ Q ~ (j`~~ 3 PRELIMINARY DECREE AND NOW, this °~y day of ~ ~ ~--- , 2009, upon consideration of the annexed petition, a Citation is issued and directed to Eddie L. Collins to show cause, if any there be, why an Order should not be entered requiring him to file a full and complete accounting of all transactions undertaken by him with respect to Walter Patterson's resources and income from June 29, 2007 to the present. A copy of the petition shall be served with the citation. Citation returnable 1 ~ days from the date of service. J. y ~ ~-- -=~~ ` --, •.O --p n ~ r~ `y..~~ 7nQ 'V ~ ` r~ ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: WALTER PATTERSON CUMBERLAND COUNTY : PENNSYLVANIA N0.21-09-0553 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 6/23/09 JUDGE'S INITIALS: EBB TIME STAMP DATE: 06-23-09 IN RE: PRELIMINARY DECREE SERVICE TO: EDDIE L COLLINS LARRY PATTERSON WALTER PATTERSON GLORIA PATTERSON METHOD OF MAILING: ® USPS ^ RRR ^ HAND DELIVERED ^ OTHER MAILED: 6/24/2009 ENVELOPES PROVIDED BY: ® PETITIONER ^ JUDGE ^ CLERK OF ORPHANS COURT SERVICE TO: METHOD OF MAILING: ^ USPS ^ RRR ^ HAND DELIVERED ^ OTHER MAILED: ENVELOPES PROVIDED BY: ® PETITIONER ^ JUDGE ^ CLERK OF ORPHANS COURT l~`t~~~ Deputy Clerk of Orphans' Court IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: Walter Patterson O.C. No. 2009-00553 AFFIDAVTT OF SERVICE I, Livia F. Langton, being duly sworn according to law, depose and say that on August 19, 2009, I caused Eddie "Ed" Collins to be served, at his Post Office Box, via certified mail return receipt requested, pursuant to the Court Order of 3uly 20, 2009, with the Petition for Accounting and Turn Over of Benefits; and the Preliminary Decree. The original executed green certified mail card, reflecting the service noted above, is attached hereto as Exhibit A. Dated: , 2009 Swo~rn~o and Sub ribed before me thisJ! day of _ , 2009. Notary Public My Commission Expire : 3//~j ~~ co nn ~~ s.a+ u~ t. saa~t, -~,.r n~uc Ccir of Pimburyh, AN~gMnr ~Y t My Commission ExpirN Jan. 31, tot 1 Mvnba, Mnrylvodws AocbNaw NstarNs S~ afore ~o :~~ ~, -D ~ ~ te- ~, ~ c~ r -~~ -~cr;~ w - - - `` ,~ _~ ,-; ,-, ~ -~ --~ ~• w : ; ' , C..) O `~T ^ Complete Reins 1, 2. and 3. Also complete item 4 if Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the maitpiece, or on the front if space permits. 1. Article Addressed to: ~~~ t~ ~8 ~ ~ t~ f'.o ~e~ ~ ~ °~' ~-q IZ,~ZtS~E?~ , ~v~ !~I ©~ A. Signature X ~ ~ ~~ ^ Addressee B,,,~eceive¢by (Prj(#ed Name) C. Date of Delivery D. is delivery a~diff8~rojn item 1? O Yes If YES, -pryt,'yeloyr. D No 4-`' ~~;. \~ ~~ 3. Service Type F``f . ` ~'' ed Mali ~~ press Mail /^ Registered ~;rr~ Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Deliver~R (E~cba Fee} ^ Yes 2. Article Number 7dd9 ~82~ QD[]x 7079 X449 (transfer fmm service label) PS Form 3811, February 2004 Domestic Return Receipt to25ss-o2•M-t5~w CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing PETITION TO 1KASE RULEABSOLUTEAND TO FILEANACCOUNTINGAND TURN OVER OFBENEFITS was served via first-class, United States mail, postage prepaid, on the 1~,~ day of September, 2009 upon the following: Eddie L. Collins P.O. Box 2105 Harrisburg, PA 17105 Linda Scisciani, Paralegal