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HomeMy WebLinkAbout09-7484IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. LISA STARR, Defendant No. (A - 1748y ekil(Tem CIVIL ACTION - LAW/ EQUITY NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 (800) 990-9108 EN LA CORTE DE ALEGATOS COMiJN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. No. LISA STARR, Defendant CIVIL ACTION - LAW/ EQUITY AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. LISA STARR, No. 01 - 7 y Pl C'?j 7^? Defendant CIVIL ACTION - LAW/EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Presbyterian Senior Living d/b/a Green Ridge Village ("Plaintiff'), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following Complaint against Lisa Starr ("Defendant"), and in support thereof, states: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 210 Big Spring Road, Newville, Pennsylvania 17241. 2. Defendant is an adult individual who currently resides at 308 Middle Road, Newville, Pennsylvania 17241. 3. On or about February 27, 2006, Defendant made application on behalf of her mother, Margaret Gaylor ("Mrs. Gaylor"), for admission to Plaintiff's skilled nursing facility. 4. On or about February 27, 2006, Plaintiff and Defendant entered into a written Long Term Care Admission Agreement ("Agreement"). A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. Pursuant to the Agreement, Plaintiff agreed to provide Mrs. Gaylor with skilled nursing care and services in return for Defendant's promise to make payment for the skilled nursing care and services from Mrs. Gaylor's resources. 6. On or about May 3, 2006, Plaintiff filed an application with the Commonwealth of Pennsylvania Department of Public Welfare requesting Medical Assistance - Long Term Care benefits for Mrs. Gaylor. 7. That original application was denied by the Cumberland County Assistance Office ("CAO") on or about June 5, 2006, because Defendant failed to provide the verifications necessary for the CAO to render a decision on Mrs. Gaylor's eligibility for benefits. 8. Pursuant to a second Medical Assistance - Long Term Care benefits application filed by Plaintiff, Mrs. Gaylor was eventually qualified for benefits effective August 1, 2007. A true and correct copy of the eligibility determination is attached hereto as Exhibit "B." 9. When the CAO issued its Notice of Eligibility for the August 1, 2007 qualification, it determined that Mrs. Gaylor was responsible for a monthly patient pay obligation toward her cost of care to be paid from her income. 10. When Defendant refused to make prompt payment from Mrs. Gaylor's resources pursuant to the Agreement and Mrs. Gaylor's Medical Assistance benefits qualification, Plaintiff filed an action to recover the income and resources from Defendant who, upon information and belief, had been using Mrs. Gaylor's income for her personal benefit. 2 11. On or about April 15, 2009, Defendant entered into Settlement Agreement and Mutual Release ("Settlement Agreement") agreeing to pay Plaintiff $23,682.23 on or before April 30, 2009, "in satisfaction of [Plaintiff's] claims against Defendant of the Patient Pay obligation of Mrs. Gaylor from August 1, 2007 to April 1, 2009." A true and correct copy of the Settlement Agreement is attached hereto as Exhibit "C." 12. On or about June 18, 2009, pursuant to Plaintiff's efforts, Mrs. Gaylor was qualified for benefits, under the original application, for an additional nine month period from November 1, 2006 to July 31, 2007. A true and correct copy of this eligibility determination is attached hereto as Exhibit "D." 13. Pursuant to this second period of eligibility, the CAO determined that Mrs. Gaylor was again responsible for a monthly patient pay obligation toward her cost of care, for the new period of eligibility, to be paid from her income during that time period. 14. To date, Defendant has failed to turn over Mrs. Gaylor's income and resources as directed by the CAO, both for the initial period of eligibility from August 1, 2007 to April 1, 2009, and also for the second period of retroactive eligibility from November 1, 2006 to July 31, 2007, in violation of the Agreement, the Settlement Agreement, and the Uniform Fraudulent Transfer Act. 15. As a result of Defendant's violations, there is an outstanding balance of $35,840.42, plus costs, interest, and attorney's fees, as provided in the Agreement. 3 16. Upon information and belief, Mrs. Gaylor's income that was to be used to satisfy her patient pay obligation has gone to her daughter, Defendant, who is agent for her mother pursuant to a power of attorney and who has refused to turn Mrs. Gaylor's income over to Plaintiff and has been using the same for her own personal enjoyment. COUNTI Breach of Contract 17. The allegations contained in Paragraphs 1 through 16 are incorporated by reference as if fully set forth at length. 18. Plaintiff has provided and continues to provide skilled nursing care and services to Mrs. Gaylor, Defendant's mother, in accordance with the Agreement. 19. Pursuant to Section V. C. 2 of the Agreement, Mrs. Gaylor is "required to use the Patient Pay Liability to pay [Plaintiff] for [her] care in conjunction with the MA Program." 20. Defendant has breached, and continues to be in breach of, the Agreement and Settlement Agreement entered into with Plaintiff, as she has refused to turn over her mother's Patient Pay obligation to Plaintiff due for the entire period of Mrs. Gaylor's residence at Plaintiff's facility. 21. The aforementioned breach of the Agreement and Settlement Agreement with Plaintiff has caused Plaintiff to suffer damages in an amount of $35,840.42, plus costs, interest, and attorney's fees, as provided in the Agreement. 4 WHEREFORE, Plaintiff respectfully requests that this Court enter judgment in favor of Plaintiff and against Defendant Lisa Starr in the amount of $35,840.42, plus costs, interest, and attorney's fees, as provided in the Agreement. COUNT II Violation of Uniform Fraudulent Transfer Act 22. The allegations contained in Paragraphs 1 through 21 are incorporated by reference as if fully set forth at length. 23. Upon Plaintiff's information and belief and to the extent of its knowledge, Defendant, acting as agent for Mrs. Gaylor, has transferred to herself certain of her mother's income, to wit, pension income and Social Security income, which was to be paid to Plaintiff for the cost of the care and services that it rendered to Mrs. Gaylor. 24. Upon Plaintiff's information and belief and to the extent of its knowledge, said transfers of Mrs. Gaylor's income to Defendant, made by Defendant acting on behalf of her mother when Mrs. Gaylor was already insolvent, were intended to avoid making said income available to pay Plaintiff for the care and services that it rendered to Mrs. Gaylor. 25. Defendant is a first transferee within the meaning of the Pennsylvania Uniform Fraudulent Transfer Act. 12 Pa. C.S. §§ 5105-5110 (2009). 26. Plaintiff was a foreseeable creditor within the meaning of the Pennsylvania Uniform Fraudulent Transfer Act. Id. 5 27. Defendant accepted, in her personal capacity, the above-referenced transfers of Mrs. Gaylor's income, with full knowledge that said transfers were being made when Mrs. Gaylor was already insolvent and with the sole purpose of avoiding those monies being available to pay Plaintiff for the care and services that Plaintiff rendered to Mrs. Gaylor in accordance with the terms and conditions of the Agreement. WHEREFORE, Plaintiff respectfully requests that this Court enter an order that voids the above-referenced transfers of income to Defendant and further orders that direct payment be made to Plaintiff to satisfy the outstanding Patient Pay obligation owed to Plaintiff in the amount of $35,840.42. Dated: /0-z?-09 Respectfully submitted, SCHUTJER BOGAR hLC B Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff 6 VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint 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.A. § 4904, relating to unsworn falsification to authorities. 4 ` Dated: ??' a?a C/)q - i - ?c Jeff Davis, of F al-Officer Presbyterian Senior iving d/b/a Green Ridge Village EXHIBITA'A'A" LONG TERM CARE ADMISSION AGREEMENT INTRODUCTION This Agr ment is betty en V Y ' r ,1 %a a 'Y , Resident's Represe a (referred to as Resident, or Resident in the Agreement) and ? U_?/k f;lliel Health Center, a licensed Long Term Care Facility (referred to as Health Center (this j greement), for admission of Resident to the Health Center on r? ?7 , 20 Date Resident requests ccupancy of Room a room for occupancy of of residents at a Daily Rate of $ r ? Resident may request a room change and the Health Center will make every effort to honor such requests as soon as possible. However, a room change may result in a change in the Daily Rate upon occupancy of the new room- In the event of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any change, thereby giving Resident sufficient time to request a room change (for example from a -private to a semi-private room) or to transfer to another nursing facility. The Health Center agrees to accept payments from Medicare and other contracted third party payers for Resident's stay if Resident meets all qualifications required-by Medicare or other third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by Medicare or other third party payers. If Resident qualifies for Medical Assistance CMX), the Health Center agrees to accept the Patient Pay lda6ility (as defined below) as determined by the County Assistance Office with the balance of the payment for covered services coming from the MA Program. 11. DEFINITIONS A Daily Rate. The rate the Health Center charges a private pay resident for room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongs, and recreational programs for each day a Resident is at the Health Center. t Physician services are not included in the Daily Rate. B. -Healthcare Surrogate.' An adult who is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for him/herself. C. Medical Director. The physician designated by the Health Center to be responsible for resident care policies and the coordination of medical care in the Health Center. D. Clinical Records. All records (excluding financial records) pertaining to a particular Resident that are prepared and maintained by Health Center. E. Paflent pay Liability. The amount of personal funds, as determined by-the Commonwealth County Assistance office, that a Resident who is receiving MA must pay monthly to the Health Center in addition to the payment from the MA program. F. Personal Needs Services Personal services such as telephone service, laundry, beauty and hair care (exclusive of routine assistance with grooming), and newspaper delivery provided by the Health Center to Residents for their convenience at Residents' expense. G_ Private Pay Resident. A Resident who pays the Daily Rate and all other fees of the Health Center from his/her own resources (including private insurance and Medicare Part B) and who is not covered by or has exhausted Medicare Part A and MA coverage. H. - Resident Funds. Personal funds of a Resident that the Resident has authorized in writing that the Health Center shall manage for the Resident I_ Residenf s Representative. A person who is-responsble for making decisions on behalf of the Resident and has been so designated in writing by the Resident or a court of competent jurisdiction. If a Guarantor Agreement is attached to this Agreerrient, the Resident's Representative is only obligated to make payment from the Residents personal funds. Reference in this Agreement to Resident shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf. J. Skilled Nursing Care. Professionally supervised nursing care and related medical and other health services provided to an individual not in need of hospitalization, but whose-needs are above the level of room and board and can ;only be met. in a long-term care nursing facility on an inpatient basis because of age, illness, disease, injury, convalescence or physical or mental infirmity. K. Specialty Care Servicbs Medical services ordered by a physician for a Resident that are not included in the Daily Rate. Medicare and Medicaid each include certain Specialty Care Services in the.per diem rates, but neither include-all such services. L , Transfer. and Discharge. Movement of a resident to abed outside of the certified facility or unit whether that bed is in the same-physical plant or not Transfer and discharge do not refer to movement of a resident within the same certified facility. lll. HEALTH CENTER OBLIGATIONS: The Health Center will: A. pnivide, as part of the Daily Rate, room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongings; and recreational programs. General nursing care does not indude private duty nursing. B. provide Specialty Care Services ordered by Resident's treating or attending physician: Although additional fees for spedialty.services maybe covered by third party payers, the Specialty Care Services identified on Exhibit A are not included in the daily rate, and are billed at the rates set forth In Exhibit A Any items ordered by a physician, which are not identified on the Exhibit A will be provided at charges identified by the Health Center prior to the delivery of the service. C. provide Personal Needs Services, at Resident's expense (at the rates set forth on the Fee Schedule attached as Exhibit A) and at Resident's request, including but not limited to: 1 . Beautylbarber services 2. Newspaper delivery and personal reading materials 3. Local and long distance telephone services 4. Cable services, depending on cable provider. 5. Personal laundry, dry cleaning and mending 6. Personal clothing. D. provide safekeeping of Resident Funds, if authorized in writing by the Resident; and make those funds available, at Resident's request, during normal business hours. 1 Resident may manage his/her financial resources if (s)he wishes. 2: Residents may keep a limited amount of funds at the Health Center, the maximum amount, which is specified from time to time by the Health Center. 3. Requests for withdrawals in excess of $50.00 require advance notice to assure availability of cash at the Health Center. Resident Funds shall be retained in compliance with State and Federal regulations. Resident Funds exceeding $50.00 shall be placed in an interest bearing account, A written quarterly statement of these funds shall be provided to Resident- Resident agrees to return signed dopy to facility if required. E. provide refunds of unused advance payments and Resident Funds within thirty (30) days after deductions for payment of any outstanding bills or other amounts due the Health Center after Resident's discharge or death. In the event of Resident's death, refunds will be made to the authorized representative of Resident's estate. F. assist Resident in applying for and obtaining private insurance and/or public benefits to cover the cost of the Resident's care. G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of the Health Center only for medical reasons, for Resident's welfare, because the safety or health of individuals in the Health Center is endangered, because the Resident has failed, after reasonable notice, to pay for a stay at the Health Center, or with the voluntary consent of Resident. Except in emergency situations, at least thirty (30) days' notice will-be provided to Resident and Resident's Representative to assure that the?`transPer is safe.and orderly. The Health Center reserves the right and discretion to move Resident to another room or bed within certified parts of the Health Center consistent with the safety, care and welfare needs of the Resident H. arrange for Resident's trabdef oi• discharge upon the order of Residents personal physician when he/she deems it necessary to receive services the Health Center is not quarified to provide or at Resident's request I. honor Resident's Rights as outlined in the Department of Public Welfare Admissions Notice Packet (MA 401)- J. hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. Resident shall indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Residents actions or omissions. Health Center will be responsible for loss of or damage to Resident's personal property by Health Center staff. K. provide Resident with a locked drawer or box for Resident's valuables or for medications retained for self-administration. Resident may self-administer medications only in certain circumstances and may not have medications in his/her room without physician authorization. L. provide Resident with a choice of pharmacy if Resident does not wish to utilize the pharmacy provider designated by the Health Center. With this choice, pharmacy must provide medications in compliance with all applicable laws and under a delivery system that is consistent with the one used by the Health Center, must provide a monthly written profile of all drugs provided to the Health Centers consultant pharmacist, and must be delivered from the provider pharmacy in tamper-proof containers, directly to the Health Centers licensed nursing staff. M. provide Resident with a choice of attending physician who will provide medical care during the Residents stay at the Health Center and who shall comply with the Health Centers rules, regulations, policies and procedures and all applicable laws and credentialing standards. Resident may also designate an alternate attending physician in the event that ttie primary attending physician is unavailable. In the event that Resident's attending physician(s) are unavailable, the Resident authorizes Health Center's Medical Director or other physician designated by the Health Center to issue appropriate orders. IV. RESIDENT OBLIGATIONS The Resident agrees to: A. by signing this Agreement, Resident certiftes that (s)he is competent, and has never been adjudged incompetent, and is entering into this Agreement of his/her own free will. 1 . In the event Resldentlhas been adjudged incompetent, Resident's healthcare surrogate will attest, in a separate document that (s)he has the legal authority to act on behalf of the Resident. B. provide the Health Center with all information about Resident's health status and financial resources. Failure toi accurately identify resources and income, or the submission of false information may amount to a violation of law and may result in the termination of this Agreement by and at the option of the Health Center_ C. provide the Health Center with a copy of all current insurance cards. Resident wits provide the Health Center with changes in insurance covera.ge or financial status in a timely manner, and wili update the information provided to the Health Center from time to time, as requested. Resident understands that making incomplete or inaccurate disclosures will be considered a breach of this Agreement. D. authorize the Health Center to provide care and treatment to Resident consistent with the terms of this Agreement and to carry out the orders of the Resident's treating. or attending physician or of the physician designated by the Health Center. Resident also authorizes the Health Center to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident may be transferring. E. authorize the Health Center to make Resident's Clinical Records available to Health Center staff and agents. Resident also authorizes the release of the Resident's Clinical Records to any other health care provider from whom Resident receives treatment, to third-party payors of health services, and to any managed care organization (MCO) in which Resident may be enrolled. Resident also authorizes the release to the Health Center of records prepared and maintained by any third-party payor of health care services pertaining to health care services rendered to the Resident by the Health Center. Resident also acknowledges receipt of the "Release for Electronic Transmission of Minimum Data Set" CWDS"), which explains the MDS system of records using Resident data. Resident's Clinical Records will remain otherwise confidential, and shall not be made available to anyone other than Resident or authorized agents of the state or federal governments without the express written authorization of Resident or without a subpoena or other judicial order- F. cooperate fully with the Health Center and any third party payer to secure payment. Resident authorizes the Health Center to collect any payments made by third parties on Resident's behalf directly from the third party payer. Resident also authorizes the Health Center to make claims, file appeals or grievances, and take other actions necessary and appropriate to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident to-the fullest extent permitted by law. Provided that Resident may, but shall not 1Ve requird to authorise the HeaRK Oenter to, pursue grievances or appeals an Resided. s behalf under Pennsylvernla's QuaPty Health Care Accountability and Protection Act, to.the fullest &%Wnt permitted by law and as security for paymrefit of the Health Center's charges, Resident hereby assigns to the Health Center all of Residents rights to any third-party payments now or subsequently payable for services rendered by or provided under arrangement through the Health Center. G. pay the Daily Rate established for the accommodation requested. Payment is due 30 days in advance, ahd Resident agrees to make full payment by the first of eadh month. Collection procedures are initiated after thirty (30) days of unpaid balances. Iriferest shall be charged on unpaid balances. 1 . if the Health Center initiates any legal actions to collect payments due from Resident under this Agreement, Resident shall be responsible to pay all attorney's fees and costs incurred by the Health Center in enforcing Resident's financial obligations under the Agreement 2. This Agreement shall serve as an assignment to the Health.Center of as much of Resident's property as equals the amount of any unpaid obligations under this Agreement, and this assignment shall be an obGgatioh of Residents estate that may be enforced against Resident's, estate. Resident's estate shall be liable to and shall pay to the Health Center. an amount equivalent to any unpaid obligations of Resident under this Agreement. This Crability shall apply whether or not Resident is occupying the Health Center at the time of Resident's death. H. pay for additional items, services and equipment not included in the Daily Rate as identified by the Fee Schedules, attached as Exhibit A. understand that Resident will be notified thirty (30) days in advance of changes In the Daily Rate except when Resident requests room change, changes in charges for Specialty Care Services or Personal Needs Services, or changes in billing procedures, and agree that the changes will be effective upon the date designated by the Health Center. J. understand that the Resident may continue to live at the Health Center as long as Resident continues to pay the Daily Rate. Resident may be discharged for non-payment of incurred charges or transferred for the benefit of the Resident or others, as set forth in Section 111(H) of this Agreement. K. acknowledge that non-payment of the Daily Rate for a private room will result in a room change. L. acknowledge that the Health Center has the discretion, with thirty (30) days' notice, to transfer Resident to another room or bed within the Health Center consistent with the safety, care and welfare needs of Resident. The Health Center also has the discretion, upon thirty (30) days' advance notice, to transfer or change Resident's roommate, .if any, at any time consistent with the needs of the Health Center. M. terminate this Agreement upon written notice to the Health Center, but if Resident leaves for any reason other than a medical emergency or death, Resident must give reasonable advance written notice to the Health Center. N. notify the Health Center at least two months before the Resident has insufficient resources, fund- or income to meet his/her financial obligations and to apply for MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not eligible for MA, Resident agrees to vacate the Health Center. o. pay co-payments and/be deductibles for services covered by the Medicare Program or other third party payer, and pay the Health Center within thirty (30) days of receipt of services for those services not covered by the Medicare Program or other third party payer. P. pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. Q. to the extent otherwise permitted by law, assume responsibility.for any damages or injuries caused by acts or omissions of the Resident to other persons, residents or staff. R_ comply with reasonable rules, regulations, policies and procedures that the Health Center establishes from time to time and makes available to Residents, subject to reasonable accommodation of Residents Individual needs and preferences. The Health Center's rules, regulations, policies and procedures are for purposes of internal management and shall not be construed as imposing contractual obligations on the Health Center and are subject to change from time to time. S. acknowledge receipt of the Resident Handbook, a document that provides Residents with Health Center rules, regulations, poricies and procedures. T. acknowledge receipt of information on Advance Directives in the absence of providing the Health Center with an existing Advance Directive or Living Will. U_ provide the Health Center with a copy of any and all Durable Powers of Attorney, Guardianships, and/or Advance Directives pertaining to the Resident. V. acknowledge that (s)he has read and understands the terms of this Agreement, that the terms have been explained to them by a representative of the Health Center, and that (s)he has had an opportunity to ask questions about the Agreement. V. MEDICARE AND MEDICAID The Health Center is certified to participate in the Medicare and Medicaid Programs. The Health Center's parUcipatioil in these programs is subject to termination by either the Health Center or the responsible government entity.- The Pennsylvania Department of Public Welfars (DPW) is responsible for administering benefits under the Medicaid Program and the Centers for Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program through an intermediary. The Resident acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of DPW, CMS or the Medicare intermediary in administering these programs. A. Medicare if Resident is eligible for benefits under the Medicare Program, Resident understands -that certain skilled nursing and related health care services may be covered by Medicare. The Health Center will bill Medicare Part A on behalf of the Resident for stalled nursing services and payment will be made by Medicare Part A directly to the Health Center for services received by Resident When the Health Center notifies Resident that the nursing services being provided to the Resident no longer qualify as a slued service, the Resident may request that the Health Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for the charges incurred on the Medicare Part A non-covered days. The following describes coverage under the Medicare PartA Program: 1 . Medicare Part A covers from one (1) to one hundred (100) days at the Health Center. Qoverage is not guaranteed and is limited to the unused days in the Resident's benefit period. Conditions stipulated by Medicare must be met for coverage to begin and remain in force. 2. The Medicare Part A Program pays for all covered charges from day one (1) through day twenty (20) if the criteria for skilled service is met. 3. The Medicare Part A Program pays a portion but not all of the charges from day twenty-one (21) through day one hundred (100). The'Resident is responsible for and shall pay any co-insurance or deductible amounts as determined by the Medicare Part Kprogram. Depending on the circumstances, this payment may be made by personal health insurance, MA, or personal funds. 4. The Medicare Part A Program covers the following services: room and board, linens, meals, most prescription medications, therapy services, most medical supplies, non-private duty nursing services, most recreational services, most social services, and most personal hygiene items provided by the Facility. (Note: only the type and brand of personal hygiene items provided by the Health Center are included.) 5. Sorne items and services not covered by the Medicare Part A Program include, but are not limited to: personal clothing, eyeglasses, hearing aids, services of a beautician or barber, guest meals, special or - atternative meals not required for therapeutic purposes or as a nutritional substitute, services not deemed medically necessary, and personal telephgne service. The Fee Schedule for items and services provided to Medicare Part A eligible Residents that are not covered by Medicare Part A is attached as, Exhibit A. 6. Beck hold days are not covered by the Medicare PartA Program. (See Section VII.) 7. Residents covered by Medicare Part A should not go out on overnight leave as this may disqualify them from further coverage by Medicare Part A. 8. Residents maybe covered for therapy and other ancillary services under the Medicare Part B Program. The Health Center or provider approved 'by. Health Center will bill Medicare Part B directly for these services. The Residents are responsible for the annual deductible and the co-insurance payment for Medicare Part B covered services. 9. Resident is responsible to pay the Health Center for services and supplies not covered by the Medicare Program. 10. In the event that Medicare coverage is changed by law, those changes will control and take precedence over any contrary provision in this Agreement. B. Medicare Managed Care• The Health Center participates as a provider of skilled nursing services under 'some, but not all Medicare MCOs. Requirements for eligibility for Medicare payments, deductibles and co- Insurance may be different from those discussed in Section V(A). Pre= authorization of services is required by Medicare MCOs, and If the Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Health Center for those services. If the MCO refuses coverage on the grounds that it does not consider an item or service to be medically necessary, Health Center or MCO will provide an Advance Beneficiary Notice of that determination. The Health Center will communicate directly with Resident's Medicare MCO to obtain authorization for continued Medicare managed care coverage- Z. The Health Center will accept payment from the Medicare MCO as payment in full only for those services and supplies covered by the Medicare MCO. Resident is responsible for any co-payments or other costs assigned to Resident or not covered by the MCO under the specific terms of the managed care plan. 3. Resident acknowledges that an MCO for which the Health Center is not an authorized provider may not approve payment for services provided by the Health Center, so that Resident may be required to pay the Health Center directly. Resident also acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of any MCO for which the Health Center is an authorized provider, including decisions relating to a denial of coverage or refusal to pay orr behalf of the Resident 4. The Health Center reserves the right to stop its participation in any MCO at any time and in its sole discretion. To the extent practicable, the Health Center will provide advance notice to Residents enrolled in a particular managed care plan or insurance program of its decision to stop participation In that managed care plari or Insurance program. C. Medical Assistance Program 1. Residents who qualify for coverage under the MA Program must apply for and be approved for these services at the County Assistance Office. It is Resident's responsibility to pursue MA coverage Until approval of MA coverage Is obtained, the Health Center will consider Resident to be a Private Pay Resident 2. Resident will be required to use the Patient Pay Liability to pay the Health- Center for the Resident's stay in conjunction with the MA Program. Periodic adjustments in the Patient Pay Liability are made by the County Assistance Office and when issued, will supersede all previous determinations. Resident shall arrange, if possible, for the designation of the Health Center for direct deposit of any Social Security or related benefits or any other income sources of the Resident in an amount not to exceed the Patient Pay Liability. 3. MA program coverage includes the following: room and board, prescription and non-prescription medications, meals, linen service; nursing services, incontinence care, social services, recreational activities, personal laundry, a hair cut every six (6) weeks, a shampoo and set every two (2) weeks, one permanent per year, and personal hygiene items provided by ttie Health Center. (Note that only the type and brand of personal hygiene items provided by the Health Center are included.) The MA Program limits the frequency of coverage for the purchase of eyeglasses, hearing aids, and dentures. 4. The Health Center v%(M not charge, solicit, accept: or receive monies from or on behalf of Resident for bed hold days covered by MA Program, except for the Patient Pay Liability, to cover the cost of Resident's stay or as a condition of admitting a Resident under the MA Program. 5. Some items and services not covered by the MA Program include, but are not limited to: personal telephone service, personal clothing, guest meals, brand name personal hygiene items, and additional services provided by a beautician other than those listed above. Resident is responsible for charges incurred for these services at the rates listed on the Fee Schedule attached as Exhibit A in addition to the patient pay liability amount. 6. Residents receiving MA coverage are permitted to keep the amount that has been designated as the Resident's personal needs allowance for personal spending. Personal funds may be given to the Health Center for safekeeping (see Health Center Obligations in Section ill). 7. The MA Program provides for bed hold days for limited periods of time during Resident's stay. a) Up to fifteen days bed hold. days are allowed when Resident is transferred to a hospital. b) Up to thirty days bed hold days are allowed annually for intermittent therapeutic leave from the Health Center. c) The bed hold days referenced above are based upon the law in effect at this time, and may be subject to change if the governing state law is changed. 8: The Health Center provides equal access to its services to all individuals, regardless of payor source. VI_ THIRD-PARTY PAYMENTS A. If Resident is or becomes eligible to receive financial assistance or . reimbursement from any third parties (such as private insurance, employee benefit plans, MA, Medicare, managed care coverage, supplemental medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance), the Health Center reserves the right to collect such payments directly from the third-party. "Resident shall cooperate fully with the Health Center and each third-party payor to secure payment, and Resident shag designate the Health Center, to the extent permitted by taw, as the recipient of direct deposit for receipt of Federal Social Security benefits or any other Federal or State government assistance, reimbursement, or. benefits to the extent of all amounts due the Health Center. B. Resident authorizes the Health Center to make claims and to take necessary actions to secure receipt of third-party payments to reimburse the Health Center for its changes for the stay and care of Resident. To the fullest extent permitted by law, as security for payment_of the Health Centers charges, Resident agrees to assign to the Health Center Resident's rights to any third-party payments now or subsequently payable to satisfy all charges due under this Agreement. Resident shall endorse and turn over to the Health Center any payments received from third-party payor to the extent necessary to satisfy the charges under this Agreement. C. In the event of any denial of coverage by the Resident's insurance company, Resident shall pay the facility for all non-covered services retroactive to the date of the initial delivery of services. VIL READMISSION- BED HOLD POLICY X A R-ealih Center representative shall communicate worth Resident regarding Ks/her desire to continue to oedupy the Health Center bed during hospitalization or therapeutic leave. Verbal consent shall be given to the Health Center representative who shall.docurnent this consent in the clinical record. Written consent shall be obthined following the verbal consent. See Fee Schedule (Exhibit A) for bed-hold rates. B. Bed holds for Residents enrolled in the MA Program are subject to the provisions Qf Section 5(C)(7). C. Resident's belongings shall be removed from the Health Center within 24 hours if Resident does not execute a bed hold authorization. Belongings not removed in a timely fashion may be packed and stored. VIII: CIVIL RIGHTS COMPLIANCE All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in need of services and are not restricted to members of the Presbyterian Church. The Health Center does not discriminate on the basis of race, color, national origin, age, ancestry, sex, handicap or disability. IX. REGULATION The Health Center and Resident recognize that Health Center is licensed by the Pennsylvania Department of Health and is regulated by the DPW. The Health Center and resident recognize that Health Center is also regulated by CMS of the United States Department of Health and Human Services. -Both parties recognize that regulatory changes may alter the conditions of this agreement. X. GRIEVANCE PROCEDURE If Resident believes that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, on in any other way, Resident may submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow the Health Center's grievance procedure as described in the Resident Handbook. The Health Centers grievance procedure does not preclude Residents from pursuing grievances with appropriate regulatory agencies. XI. ARBITRATION Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or concerning any rights arising thereunder or the breach thereof shall be settled exclusively by arbitration, which shalt be conducted at the Health Center in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties and may be entered in any court having jurisdiction thereof. Provided, however, that this arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a resident under the Medicare or MA programs or an applicable state law. X-11 GOVERNING LAW This Agreement shaU be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania. The Agreement shall bd binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XiII. SEVERABILITY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction to be invalid, the other provisions shall remain in full force and effedt as if the invalid provision had not been a part of this Agreement. X1V, ENTIRE AGREEMENT This Agreement represents the entire understanding between the parties, and supersedes all previous representations, understandings or agreements, oral or written, between the parties. XV. MODIFICATIONS The Health Center has the right to modify unilaterally the terms of this Agreement to the extent necessary to conform to subsequent changes in law-or regulation. To the extent practicable, the Health Center will give Resident and Resident's Representative thirty (30) days advance written notice of any such modifications. XVI. WAIVER OF PROVISIONS The Health Center Executive Director reserves the right to waive any obligation of Resident under the provisions -of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Health Center unless and except to the extent that such waiver is in writing by the Health Center. Any waiver by the Health Center shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. Signatures - This Agreement and any addenda to this Agreement canstitute the entire Agreement and undarsfanding between the Health Center and the Resident with respect to the subject fter of this Agreement and supersede all prior Agreements and understandings. There are no Agreements, understandings; restrictions, warranties, or representations between the Health Center and the Resident other than those set forth in this Agreement, or incorporated in this Agreement by reference. This Agreement may be amended only by a document in writing signed by the Resident and the Administrator or Executive Director, and no acct or omission of any employee or agent of the.Health Center shall alter, change or modify any of the provisions of this Agreement. Administrator or Executi Director 3-a-e4p Date Resident Ua-k Witness Date a`Z 0 la Date g7 6 Date t i EXHIBIT "B" NOTICE TO APPLICANT YOUR ''RE!-EN' :PPLICAT!ON HAS BEEN RE:'iEWED AND YOUR ELIGIBILITY HAS BE EN DE7ERP.IINED FOR THE BENEFITS SHOWN BELOW CUMBERLAND CAO 33 WESTMINSTER DRIVE PO BOX 599 CARLISLE, PA 17013-0599 ? ASSISTANCE After the first check which may be a special amount you will receive $ CHECK ? Twice a Month ? Once a Month ? In the Mail ? At the Bank ?? MEDICAL ? ? You have a patient pay liability of $ ASSISTANCE for the period beginning and ending ? Effective Date ? FOOD You will receive $ for the month(s) of then you will receive food stamps in the amount of $ STAMPS a month from to ? In the Mail ? At the Bank 0 NURSING HOW CARE .+' Level of care authored you are expected to pay $ a month toward your care. ? SSOCIAL ERVICES ? y ?y ????y a H NAME SERVICE NAME 01 Margaret Gaylor 7 Recip# 1701812958 • • • • • - • egu auo) 41.71;178.1;181 ' Reason Code 985 Opt B You have been determined eligible for Medicaid including services in a Long-Terre Care facility effective 08/0112007. You will received a PA ACCESS card in the mail at the nursing home, do not discard this. As part of your eligibility, you are responsible for a monthly cost of care contribution from your income, the details of this calculation can be seen on the attachment. Please remember that you must report all changes to income or resources. If you have any questions please call at the number below. ""HE FOLLOWING'TEMS Name VVERE TAKEN CONSIDERA INTO GROSS M ARNEDINCOM E TION YOU Name R BENE GROS FITS S MO p $ $ $ $ $ $ Name UNEARNED INCOME Name UNEARNED I NCOME , $ $ $ $ $ $ TOTAL GROSS MONTHLY INCOME $ TOTAL GROSS MONTHLY INCOME I s GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MEDICAL COSTS $ E Telephone Water/Sewage _ ?rNt)mberof_ _ Electric Garbage/Trash Name GRO EARN SSS O ED F N Gas Utility Installation $ - Oil Other $ GROSS UTILITY COSTS/UTILITY STANDARD' $ $ RENT/MORTGAGE $ Name RN I N F TAXES $ $ INSURANCE COST ON HOME $ $ TOTAL SHELTER COST $ Is TOTAL GROSS MONTHLY INCOME $ NET MONTHLY INCOME/NET SEMI-ANNUAL INCOME $ INCOME LIMIT $ CO RECORD NUMBER CAT CTR DIG DIST 21 0109523 PAN 00 r Shutjer/Bogar, LLC ATTN: Brandon Williams 417 Walnut Street 4th Floor Harrisburg PA 17101 eA0 717-240-2707 L J Qrio€rntielstaiirl3wrI5?o QF1?veaY4iWSStI?S?S o>°?a??? ??ro r _. i. __ .. CLIENT ? APPEAL COPY Telephone Number I L EG,AI }IELP ISAVAILA6LE Al LEGAL SERVICES INC. 8 IRVINE ROW CARLISLE, PA 17013-0000 (717) 243-9400 ? CASE RECORD COPYI PAIFS 162 1/07 NAME Margaret Gaylor RECORD NUMBER 109523 Social Security Coming (50) Pens Interest GROSS MONTHLY INCOME MONTHLY INCOME AVAILABLE -PERSONAL CARE ALLOWANCE =COMMUNITY SPOUSE/ HOME MAI14TENANCE GROSS PATIENT PAY (53) 08/01/07 MO/YR 968.50 366.66 0.11 1,335.27 1,335.27 45.00 SSN# 203-10-0020 DOYAZ: kkp 01/2008 MO/YR MO1YR 991.40 366.66 0.11 1,358.17 1,358.17 45.00 MO/YR 0.00 0.00 1,290.27 1,313.17 - MEDICAL EXPENSES Drugs(54) Medicare(55) 93.50 96.40 BCBS/other Medical Ins. (55) Other(56) ----------------------------------- TOTAL MEDICAL EXPENSES NET PATIENT PAY (57) NOTE: Future changes in medical expenses should be reported to the nursing facility. /29/08 SIGNA 60,53 DATE REMINDER: The resource limit is $2,000, with $6000 disregard / $2,400. See attached Addendum EXHIBITA'A'C" nrR- ?_„.?wv? a:7C r.uuituii SMLEMENT AGREEMENT AND MiPI'UAL RELEASE THIS SETTL NMNT AGRL"BENT AND MUTUAL RELEASE (this "Agreement"), effective as of April.. 1, 2009, in full and final settlement of the dispute between the parties, as described more fully herein, is by and between Presbyterian Senior Living d/b/a Green Ridge Village (the "Company"), and Lisa Starr, an adult individual ("Defendant"). Recitals A. A dispute between the Company and Defendant has arisen out of circumstances related to the residence of the Defendant`s mother., Margaret Gaylor, at the Company's long term care facility. B. The C*nVmy 44as filed aComplaint against the -Ddendant in the Court of Comaton Pleas of Cumberland County, Penftsylvania, Docket Number No. 09-991 (the "Litigation"). C. The parties, wishing to: avoid the expense and disruption of the litigation, mutually desire to-enter into-a full and final settlement of their dispute. NOW TI-EREFORE, in consideration of their mutual promises and intending to be legally bound hereby, the parties hereto do hereby covenant and agree as follows: 1. Recitals.. -The foregoing background recitals are incorporated herein and made a part of this Agreement. 2. Payment. Defendant shall pay to the Company the sum of twenty-three thousand-, six hundred eighty--two-and 23/100 dollars (523,682.23) on or before April 30, rrR-;J-!VV7\W,_1-1) tu. -)l r vuuruii 2009, in satisfaction of Company's claims against Defendant for the Patient Pay obligation of Mrs. Gaylor from August 1, 2OG7 to April 1, 20099. The Company shall accept such payment in consideration for the mutual release and discharge herein. The parties agree that the acts shall constitute full satisfaction and release from any and all claims, demands, actions, causes of actions, suits, debts, and/or contracts arising out of the claims which could have been asserted in Litigation for the services rendered to Mrs. Gaylor from August 1, 2007 to April 1, 2009, as well as any events, facts, or circumstances related to the dispute. 3. Discontinuance-of-Li Immediately followingcomplete execution and deli-very of- thin: Agreement, and-payment-to Company-of the sum of $23,682.23 from Defendant, the Company, through legal -counsel, shall take all actions necessary or appropriate in --order to discontinue die-.Litigation with -pejudice, to include with prejudice to Defendant's rights to file- or-pursue arty further action:-(state, federal, or otherwise) based upon the allegations set forth in the Litigation. 4. Releases. 4.1. In exchange for the promises -and covenarnbs, contained herein, effective as of April 1, 2009 (the "Release Date"), the Company, on the one hand, and Defendant, on the other hand, shall and do hereby release, remise and forever discharge and hold harmlgss the other from any and all actions and causes of actions, claims, controversies, accounts, damages, demands, attorneys' fees, costs, loss of services, expenses, sanctions, compensation, suits, debts, documents, bonds, covenants, contracts, agreements, liens, .losses, and judgments (collectively, "Claims'), from August 2 r.uvDIuii 1, 2007 through and including the Release Date, arising out of or resulting from any events, facts, or circumstances related to the Litigation; provided, however, that this release shall not apply to any Claim to enforce or arising out of a breach of this Agreement. 4.2. These-releases shall be binding upon and shall inure to the benefit of the parties` respective parent-organizations, partners (general, limited or otherwise), subsidiaries,- affiliates,- predecessors,- successors -(by merges -or otherwise), assigns, insurers, subrogees, divisions; representatives, - directors, offkF rs, agents, servants, employees,- trustees-, beneficiaries,- attorneys, heirs,. executors,,, administrators, and personal representatives. 4.3. The obligations and liabilities- released and discharged include all such obligations and liabilities now existing or hereafter arising, whether fixed or contingent, and whether- tigtt*ted or uniiquidated. 5. Covenant-Not To Suet Except for (i) any. claim to enforce or arising out of a breach of this- Agreement; or -(ii) matters arising out of or relating to events or circumstances first occurring after the Release Date, the parties agree that they will not commence, maintain or voluntarily aid any action at law, proceeding in equity, or otherwise prosecute or sue the other, or any. of the. other's parent organizations, partners (general, limited or otherwise), - subsidiaries, affiliates, predecessors, successors (by merger or otherwise), assigns, insurers, subrogees, divisions, representatives, directors, officers, agents, servants, employees, trustees; beneficiaries, -attorneys, heirs, executors, administrators, and personal representatives, either affirmatively or by way of 3 cross-complaint, defemeor counterclaim or by any other manner at all, on any Claims released by the particular party in this Agreement. 6. Representations and Warranties. Each of the parties hereto hereby represents and warrants to-4nd with the other that: 6.1. The execution and delivery of this Agreement will not conflict with or result in any breach of any terms, conditiorts or provisions of or constitute a default under any agreement, conmnitment or other arrangement by which the particular party is bound or any decree, judgment, order; statute, rule or regulakion applicable to such party. 6.2. The particular party- has, full right,-power- and authority to execute, deliver and perform such panty's obligations under this Agreemnt (including, without limitation- intended, releasing the Claims pursuant- to this ,Agreement), and this Agreement constitutes a valid and binding obligation of such party and is enforceable against such party- in accordance- with its terms. Without limiting the foregoing (i) the person executing this Agreement on behalf of Defendant represents and warrants that he or she- has-,tlte full competency; power, and authority to- bind Defendant in accordance with the terms of this Agreement, and (ii) the person executing this Agreement on behalf of the Company represents and warrants that he or she has the full competency, power, and authority to bind the Company in accordance with the terms of this Agreement. . 6.3. No r]aim- released -by -the particular party pursuant to this Agreement is bell by or has-been (or will bey-assigned to any third party. 4 rrm-ID-CUU71wLu,+ IU;7J r UU 1/ V I I 7. Indemnity. The Company, on the one hand, and Defendant, on the other hand, shall and do hereby agree •to indenv*, defend- and Bold=-1?armless the other from any actions, losses, liabilities, damages and/or expenses (including attorneys' fees and costs) arising from or related to any misrepresentation or breaches of any warranties, covenants, or repres"tions of the Company, on the one hand, and Defendant, on the other hand, contained in this Agreement. 8. Confidentiality; Non-Dispara ement. 8.1. It is further understood, agreed-and made part hereof, that neither the Company nor Defendant shaaUieveal,.either4dir y or i %xectly, to any person or other entity -any aspect of (i) the dispute -referred- to herein, or (ii) this Agreement, including the facts of the dispute, the existence of this settlement or the specific terms and conditions of this Agreement (collectively, "Confidential Information"); Rrovided, however, that the parties may disclose Confidential- InformatiQR to taxing authorities, other govem.ment auttliori:ties; and the parties' -attorneys and accountants to the extent necessary to complete tax filings and to otherwise comply with law. Furthermore, the. parties,. their, attorneys, accountants and other representatives, shall- not in any way publicize or cause to be publicized Confidential Information in any news or communications media, including but not limited to newspapers, magazines, journals, radio, television, internet media, the world-wide web, on-line computer systems, or any law-related publications. Without. limiting the foregoing, the parties expressly agree to decline comment on any aspect of the dispute referred to herein or of this Agreement, without the express prior written consent of the, other party. The 5 I'll . 1 L V V J k- V/ parties acknowledge that this Section-S.1 constitutes a material- term and consideration for this Agreement. 8.2. Defendai?t,_agrees not to -make disparaging remarks about the Company, or its. operations or employem and the Company agrees not to make disparaging remarks about Defendant. Any breach of this Section 8.2 shall be deemed a material breach of this Agreement. 9. Advice of. Counsel. The Company and :Defendant each acknowledge- that they have- had the full opportunity to consult- with and obtained the advice of legal counsel prior to entering into this Agreement. The Company and Defendant each recognizes that they are mecuting and delivering-this Agreement, iptending thereby to be legally bound by the terms and provisions hereof, of their own free will, without promises or threats or the exertiorrgf duress upon them. 10. Miscellaneous. 10.1. All-.covenants, and agreements contained in this Agm. ement by or on behalf of any -o€ -the pales -hereto shall be binding upon, and shall inure to the benefit of, the-heirs, successom- and assigns of each of the pares hereto, whether so expressed or not. 10:2. This Agreement shall be governed and con-q{ued in accordance with the laws of the Commonwealth of Pennsylvania, without regard to choice-of-law provisions. The Court of Common- Fleas of Cumberland- County, Pennsylvania, or the United States District Court serving such County, shall be the exclusive forum for the resolution of all disputes arising hereunder or in p9nnection herewith. 6 nreR-' L_VU71WLUI ' u. J.J 10.3. The headings in this Agreement are for reference purposes only and shall not in any way affect the meaning or interpreta€iot? of this Agreement. 10.4. This Agreement represents the parties' entire understanding with respect to its-subject matter and supersedes all prior communications, understandings and agreements with respect thereto. 10.5. if-any provision-of this Agreementis held invalid or unenforceable, the remainder of this Agreement will not be- affected thereby and; the provisions of this Agreement shall be-severable in any such instance. 10.6. All representations and warranties contained hCr= will survive the execution and deliveFy of this- Agreement and any investigatiop made at any time by or on behalf of the parties. 10•.7. &acftparty will execute any-docun-*nts and talce such other actions as the other parties may reasonably request in order to accomplish the purposes of this Agreement. 10.8. This- ftreernent -ntay be amended, superseded, cancelled, renewed or extender, and the tern-&-and conditions- hereof may be waived, only by a written Instrument signed by the- parties or, in_ the- case, of a- waiver, by the party waiving compliance. 10.4. In addition to- any remedies the parties hereta may have at law or equity, this Agreement may be enforced by either party by seeking special or permanent injunctive relief, without the necessity of proving damages actual or otherwise. To the extent permitted by applicable law, the other party shall be obligated 7 to pay the costs and expenses incurred by the enforcing party, including (without limitation intended) reasonable fees and expenses of the enforcing party's legal counsel. 1x.10. The language of all parts of- this Agreement shall in all cases be construed as a whole, according to its fair meaning,. and not strictly for or against any of the parties hereto. 10.11. This Agreement may be executed in any number of counterparts (and delivered by first-class or first-class express mail, or by fax with confirmation in writing mailed gist-class}; each of wliich s1 ..lie ? -to-be an original as against any-party why signature-appears-thereorr, and all -of which shall together constitute one- and the same Wit. This - Agreement shall be binding when one or more counterparts-hereof; indiv-0vakly or-taken-together, shall-bear the-signatures of all of the parties reflected -ora this Agreement.as.the signatories. - [S A ES APPEAR ON PQLLOWING PAGE] 8 Lvv7lWLU/ , U , JJ IN WITNESS WHEREOF, the parties hereto, intending to be legally bound, do hereby execute- this Settlement Agreement and Mutual Release; on the date set forth along with their signatures which appear below. W TNESS/ATTEST: W %%-UI Lt^ KZ$t-&R rSS: COMPANY: ?? r' 4, ikle: CoU N S6G A2"9A G2??N /ell76? l/ru. GE DEFENDANT 4 !' I ated: < ??' d 9 9 Dated: S -/0 .1 © 9 EXHIBITA"D" 2009-06-18 09:14 CUMBERLAND CAD P.O. BOX 599 33 WESTMIN5TER DRIVE CARLISLE PA 1701340599 MARGARET G GAYLDR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 a pennsylvania P PAGE 1 OF 1 OEPARTmew of PUBLIC WELFARE Notice ID: 95305223 Record Number; 21 0109523 District: o Case Load: 0936 Worker: J PEIPER Phone: 1- (800) 269-0173 Mailing Date: o6/ls/zoes Reason: 985 Option: B Type: E Category: PAN PSG: 09 TT: You have been determined eligible for benefits effective 1110112006 to 03/3112007, You are eligible for Non-Money Payment Medicaid coverage including Services in a Long-Term Care Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment towards your cost cost of care are found in the LTC section. LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAD, please provide your record number, which is located on the top and bottom of this notice. Citation: 55 Pa, Code 140.201. 141.71. 178,1. 181.1. 181.11, 181.452. 181.453 If you disagma with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to afWLbpMk °_ If you are currently receiving bandits 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 07101 /2009 your assistance will continue pending the hearing decision, except when the change is due to state or Federal law. 004 MARGARET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 CUMBERLAND CAD P.D. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-4599 www.dpwmatp-pa.us MA LTC OFFICE OF INCOME MAINTENANCE ELIGIBLE NOTICE COMPASS www_compas%state.pa.us MIDPENN LEGAL SERVICES 401-495 LaUTHER STREET CARLISLE PA 17013 (717) 243-9400 21 0109523 0 PAN 00 Notice ID: 95305223 Worker. J PEIPER Phone: 1- (860) 269-0173 Mailing Date: 8511812oo9 Reason: 985 Option: B Type: E MA-LTC-F1Rl1NT-121181Q8 PA MAILTC-X 167r1 010t3 2009-06-18 09:14 Notice lu: 9e3o?1C3 azm? The following individual is affected by the action on the front of this notice. LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V 13ENEN rH R 02 ¦ . MA Eligibility Decision: wAiwdukft? Y I 0212007 0312007 Benefit Period 1112006 1212006 0112007 Income: Social Security/SSI 937.50 937.50 96.6 96.50 968. 50 66 366 Pension 366.66 366.66 67 0 3666.66 6 0,67 3666.66 0.67 1 0.67 Interest/Dividend 0.67 , TOW Income 1304.83 1304,83 1335.83 1335.83 1335.83 Deductions 0.00 0.00 0.00 0 , 0e 0.00 Netlncome 1304.83 1304.83 1335.83 1335.83 1335.83 Income Limit 1B09.00 1809,00 1869,00 1869.08 1669.00 LTC Eligibility Decision: The following amounts were used to compute your mon thly payment towa rds your cost of Long Term Care (LTC) Cost of Care Effective 1112006 12/2005 01 /2007 0212007 0312007 Total income 1304.83 1304.83 1335.83 1335.83 1336.83 Income Available First Month 0.00 0.00 0.90 0.00 0.00 Deductions: Personal Needs Allowance 40.00 40.00 40,98 40.00 40.00 1264.63 1264.83 1295.83 1295.83 1295.83 Medicare Premium Other.dnsurance Premium 88.50 0.00 88,50 0.06 93.50 0.00 93.50 0.00 93.50 0.00 The LTC facility will deduct the above medical expenses from your payment towards Cost of Care. The LTC facility may deduct additional medical bills including supplemental health insurance premiums, provided they are verified. IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM DETACH HERE -----------------.. _, .. . ?.-T _ ..°----------°??__?_______- ------------ DETACH HERE- Please check the box next to the type of hearing you want: 0 1 want a Telephone Hearing. I and my witnesses and anyone helping me will be at this phone number. ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? 1 want a Face to Face Hearing. I and. my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. 1 want a Face to Face Hearing. l and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the County Assistance Office. For the Hearing: ? Please check if you need special help because of a hearing impairment or disability. Describe: ? Please check if you need an interpreter. There will be no cost to me. What language? I WANT TO ASK FOR A HEARING BECAUSE: (Attach more pages if you need to.) CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. AODRESS TELEPHONE NO. DATE VA i Tf :MMP.?( •4 .M 4 VA9 i To,-m c- n,)l'fxlna 2009-06-18 09:14 CUMBERLAND CAO P,O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MARGARET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 Notice ID: 95305523 Record Number: 21 0109523 District: o Case Load: 0035 Worker: J PEIPER Phone: 1- (600) 259-0173 Mailing Date: 0611812009 Reason: 985 Option: B Type: E Category: PAN PSC:00 TT: You have been determined eligible for benefits effective 04/01/2007 to 0713112007. You are eligible for Non-Money Payment Medicaid coverage including Services in a Long-Term Care Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly Dayment towards your cost of care. Details of this monthly payment towards your cost cost of care are found in the LTC section. LTC section. Contact the CAD if you have questions or changes to report. When contacting the CAO, please provide.your record number, which is located on the top and bottom of this notice. Citation: 55 Pa. Code 140.201, 141,71. 178.1. 181.1. 181.11. 181.452. 151.453 If you disagree with'our dedsion, you have the right to appeal. 5m attached form for a comoleLe explanation of your right to sooeal and to a fj rin If you are eurrenly 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 0710112009 your assistance will confine pending the hearing decision, except when the change is due to State or Federal law. MARGARET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 CUMBERLAND CAD P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013- >a Pennsylvania P PA E 1 OF OEPARTMENT OF PUsuc wWAM WWW.epwsiate.pa.us MA LTC OFFICE OF INCOME MAINTENANCE ELIGIBLE NOTICE COMPASS W W W.Compa5s.state.pa.us MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (7171 243.9400 21 0109523 0 PAN 00 Notice ID: 95305523 Worker: J PEIPER Phone: 1- (800) 269-0173 Mailing Date., 06/1812809 Reason: 985 Option: B Type: E MA-LTC-FR0NT-12J18108 PA MAILTC-X 162.10108 2009-06-18 09:15 The following individual is affected by the action on the front of this notice. LINE FIRST NAME ACCESSIINDiVIDUAL NUMBER V BENEFIT PACKAGE 01 MARGARET 170181295 8 02 MA Eligibility Decision: Notice IL): 953008 3 Benefit Period 0412007 0512007 06/2007 0712007 Income: Social Security/SSI Pension Interest/Dividend 968.50 365.66 0.67 968.50 366.66 0.67 968.50 366.66 0.67 968,50 366.66 0.67 Total income 1335.83 1335.e3 1335.83 1335.83 Deductions 0.00 0.00 0.00 (3.60 Net income 1335.83 1335.83 1335.83 1335.83 Income Limit 1669.00 1859.00 1869,00 1869.00 • LTC Eligibility Decision: The following amounts were used to compute your monthly payment towards your cost of Long Term Care (LTC) Cost of Care Effective 0412007 0512007 0612007 07/2007 Total Income 1335.83 1335.83 1335.83 1335.83 Income Available First Month 0.00 0.00 0.00 0,00 Deductions: Personal Needs Allowance 40.00 44.00 40.00 45.00 1rb 1295.53 1295.83 1295.83 1290.83 Medicare Premium Other Insurance Premium 93.80 0,00 93.50 0.00 93.50 0.00 83.50 G. go The LTC facility will deduct the above medical expenses from your payment towards Cost of Care. The LTC facility may deduct additional medical bills including supplemental health insurance premiums, provided they are verified. IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM DETACH HERE-------_._?._?_^_r..^.r_^_._???`------, -°--^-^-----------°?---------- DETACH HERE- Please check the box next to the type of hearing you want: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will beat this phone number: ? I want a Telephone Hearing, I -and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? 1 want a Face to Face -Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. 1 and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the County Assistance Office. For the Hearing- M Please check if you need special help because of a hearing impairment or disability. Describe: 0 Please check if you need an interpreter. There will be no cost to me. What language? I WANT TO ASK FOR A HEARING BECAUSE: (Attach more pages if you need to.) CUENT SIGNATURE SIGNATURE CLIENT REP. 1 Tf`-IM0-nI Mr.Ma ADDRESS TELEPHONE NO. ADDRESS TELEPHONE NO. DATE DATE On 1 TP`•N{CC_Y 11r> •I wAr 0 OF TNc PAC! TAPY 2009 OCT 29 Fe 2:01 CUM *78.50 PD ATM (??'' l fly Co ?- IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, LISA STARR, Defendant CIVIL ACTION - EQUITY PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES, Presbyterian Senior Living d/b/a Green Ridge Village ("Petitioner'), by and through its attorneys, SCHUTJER BOGAR LLC, and pursuant to Pa. R.C.P. § 1531, files the within Petition for Preliminary Injunction and, in support thereof, avers: 1. Petitioner filed a Complaint against Respondent Lisa Starr ("Respondent") contemporaneous with the filing of this Petition for Preliminary Injunction. 2. The Complaint sets forth, in part, an equitable claim against Respondent relating to her fraudulent transfer of her mother's income to herself, in violation of the Uniform Fraudulent Transfer Act, 12 Pa. C.S. §§ 5105-5110. 3. The very nature of this claim, i.e., Respondent's fraudulent transfer of her mother's income to herself, in violation of the Uniform Fraudulent Transfer Act, presents an issue of immediate and irreparable harm to Petitioner, particularly as Respondent's mother was already insolvent at the time the transfers of income were made. ORIGINAL s 4. The requested injunction would restore the parties to the status quo as it existed immediately prior to Respondent's transfer of her mother's income in violation of the Uniform Fraudulent Transfer Act. 5. Greater injury would result from the denial of the requested injunction than from the granting of same, as, absent the avoidance of the transfers, Petitioner will not receive reimbursement for the care and services it provided to Respondent's mother, and Mrs. Gaylor is in jeopardy of losing her continuing Medical Assistance benefits. 6. Petitioner's right to relief is clear. 7. Petitioner lacks an adequate remedy at law, as, upon information and belief, at all times material hereto, neither Respondent nor her mother have been financially able to fully compensate Petitioner for the care and services that Petitioner has rendered and continues to render to Respondent's mother. 8. 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 this Honorable Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a decree directing Respondent to transfer back to her mother any and all of her mother's income that she has transferred to Respondent since the date of Respondent's mother's admission to Petitioner's skilled nursing facility. 2 Respectfully submitted, SCHUTJER BOGAR LLC Dated: /0 ' ?Z 7 O By Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4, Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Petitioner 3 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Plaintiffs Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Lisa Starr 308 Middle Road Newville, PA 17241 Dated: o William Keslar, Paralegal FILEo- a-I iCE F THE P"OT h43TA?Y 1009 OCT 29 PM 2= 02 CU" f)+?;VTY `S' ?:' A IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, V. LISA STARR, Defendant No. Oq Iy Pit C lid Tt--11 CIVIL ACTION - EQUITY PETITION FOR ACCOUNTING Petitioner Presbyterian Senior Living d/b/a Green Ridge Village, ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, files the within Petition for Accounting and, in support thereof, avers the following: 1. Petitioner, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a residential and skilled nursing care provider with its principal offices located at 210 Big Spring Road, Newville, Pennsylvania 17241. 2. Margaret Gaylor ("Mrs. Gaylor") is an adult individual currently residing at Petitioner's skilled nursing facility. 3. Respondent Lisa Starr is the daughter and agent through power of attorney for Mrs. Gaylor, and is an adult individual currently residing at 308 Middle Road, Newville, Pennsylvania 17241. 4. Mrs. Gaylor was admitted as a resident of Petitioner's skilled nursing facility on or about February 27, 2006. A true and correct copy of the Long Term Care Admission Agreement ("Agreement") is attached hereto as Exhibit "A." ORIGINAL 5. Ms. Starr, the daughter of Mrs. Gaylor, was the agent of her mother at the time of her admission to Petitioner's facility, and, upon information and belief, has continued to act as her agent-in-fact. 6. During the time from Mrs. Gaylor's admission to Petitioner's facility to present, Ms. Starr has exercised control over Mrs. Gaylor's income and assets. 7. Pursuant to Petitioner's efforts to qualify Mrs. Gaylor for Medical Assistance benefits, the Cumberland County Assistance Office ("CAO") determined that Mrs. Gaylor was eligible for Medical Assistance benefits effective November 1, 2006, and directed that Mrs. Gaylor's monthly income from that period forward be used to contribute to the cost of services provided by Petitioner. A true and correct copy of the CAO's determination is attached hereto as Exhibit "B." 8. Respondent Ms. Starr has failed to forward her mother's monthly income as directed by the CAO. 9. Upon information and belief, Ms. Starr has been using her mother's income for her personal benefit. 10. Petitioner is a creditor of Mrs. Gaylor, having provided skilled nursing services to her since her admission to Petitioner's facility. The current amount owed to Petitioner for services provided to Mrs. Gaylor is thirty-five thousand, eight hundred forty and 42/100 dollars ($35,840.42). 11. Ms. Starr failed to use Mrs. Gaylor's resources for her support, which was a violation of her fiduciary duties, and is the basis for the imposition of a surcharge 2 against her. See In re: Paxson Trust I, 2006 Pa. Super 9, 893 A.2d 99 (2006); In re Estate of Novosieleski, 2007 Pa.Super. 292, 937 A.2d 449 (2007). 12. If Ms. Starr does not return her resources to Mrs. Gaylor, there will be no means of compensating Petitioner for the skilled nursing care that Mrs. Gaylor has received. WHEREFORE, Petitioner requests that this Honorable Court issue a citation directed to Ms. Starr to show cause why an Order should not be entered requiring her to file a full and complete accounting of all transactions undertaken by her with respect to Margaret Gaylor's income and assets from February 27, 2006, to present, and to bring Margaret Gaylor's account with Petitioner current, or in the alternative be surcharged for the thirty-five thousand, eight hundred forty and 42/100 dollars ($35,840.42) in resources in question. Respectfully submitted, SCHUTJER BOGAR LLC Dated: I 7'a9 B Z Chadwick O. Boga Attorney I.D. No. 83755 (717) 909-5920 Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4+h Floor Harrisburg, PA 17101 Fax No. (717) 909-5925 Attorneys for Petitioner 3 VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Petition 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: ny 'e Jeff Davis, C'ltVf f inMEal Officer Presbyterian Senior Living d/b/a Green Ridge Village EXHIBIT 1111 A if (TO PETITION FOR ACCOUNTING) LONG TERM CARE ADMISSION AGREEMENT 1. INTRODUCTION rr This Agr ment is betty en ?YG ( Y?7 r Resident, or 1 C R C f YY , Resident's Represen a (referred to as Resident in the Agreement and Health Center, a t ?/k r; Vt? licensed Long Term Care Facility (referred to as Health Center this Agreement), for admission of Resident to the Health Center on r?l ?7 , 20_AQ ( e) Resident requests occupancy of Room{, a room for occupancy of a residents at a Daily Rate of $? (,p Resident may request a room change and the Health Center VAI make every effort to honor such requests as soon as possible. However, a room change may result in a change in the Daily Rate upon occupancy of the new room- In the event of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any change, thereby giving Resident sufficient time to request a room change (for example from a private to a semi-private room) or to transfer to another nursing facility. _ The Health Center agrees to accept payments from Medicare and other contracted third party payers for Resident's stay if Resident meets all qualifications required'by Medicare or other third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by Medicare or other thins party payers. If Resident qualifies for Medical Assistance CNIA"), the Health Center agrees to accept the Patient Pay Liability (as defined below) as determined by the County Assistance Office with the balance of the payment for covered services coming from the MA Program 11. DEFINITIONS A Daily Rafe. The rate the Health Center charges a private pay resident for room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Resident's personal belongs, and recreational programs for each day a Resident is at the Health Center. Physician services are not included in the Daily Rate. B. Healthcare Surrogate. An adult who is appointed to make healthcare decisions for Resident when Resident becomes unable to make them for himlherself. C. Medical Director. The physician designated by the Health Center to be responsible for resident care policies and the coordination of medical care In the Health Center. D. Clinical Records. All records (excluding financial records) pertaining to a particular Resident that are prepared and maintained by Health Center. E. Patient Pay Liability. The amount of personal funds, as determined by-the Commonwealth County Assistance Office, that a Resident who is receiving MA must pay monthly to the Health Center in addition to the payment from the MA program. F. Personal Needs Services Personal services such as telephone service, laundry, beauty and hair care (exclusive of routine assistance with grooming), and newspaper delivery provided by the Health Center to Residents for their convenience at Residents' expense. G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of the Health Center from hislher own resources (including private insurance and Medicare Part B) and who is not covered by or has exhausted Medicare Part A and MA coverage. H. , Resident Funds. Personal funds of a Resident that the Resident has authorized in writing that the Health Center shall manage for the Resident L Residents Representative. A person who is'responsible for making decisions on behalf of the Resident and has been so designated in writing by the Resident or a court of competent jurisdiction. If a Guarantor Agreement is attached to this Agreement, the Resident's Representative is only obligated to make payment from the Resident's personal funds- Reference in this Agreement to Resident shall also include, as appropriate, the Resident's Representative or other person authorized to act on Resident's behalf. J. Skilled Nursing Care. Professionally supervised nursing care and related medical and other health services provided to an individual not in need of hospitalization, but whose-needs are above the level of room and board and can ;only be met in a long-term care nursing facility on an Inpatient basis because of age, illness, disease, injury, convalescence or physical or mental infirmity. K. Specialty Care Services. Medical services ordered by a physician for a Resident that are not included in the Daity Rate. Medicare and Medicaid each include certain Specialty Care Services in the per diem rates, but neither include-all such services. L. Transfer and Discharge. Movement of a resident to a bed outside of the certified facility, or unit whether that bed is in the same-physical plant or not Transfer and discharge do not refer to movement of a resident within the same certified facility. Ill, HEALTH CENTER OBLIGATIONS: The Health Center will: A. provide, as part of the Daily Rate, room and board, general nursing care, housekeeping services, linen services, nutrition management, limited in-room storage of Residents personal belongings; and recreational programs. General nursing care does not include private duty nursing. B. provide Specialty Care Services ordered by Resident's treating or attending physician: Although additional fees for spedialty.services maybe covered by third party payers, the Specialty Care Services identified on Exhibit A are not included in the daily rate, and are billed at the rates set forth In Exhibit A Any items ordered by a physician, which are not identified on the Exhibit A will be provided at charges identified by the Health Center prior to the delivery of the service. C. provide Personal Needs Services, at Resident's expense (at the rates set forth on the Fee Schedule attached as Exhibit A) and at Resident's request, including but not limited to: 1 . Beauty/barber services 2 Newspaper delivery and personal reading materials r t 3. Local and long distance telephone services 4. Cable services, depending on cable provider . 5. Personal laundry, dry cleaning and mending 6. Personal clothing. D. provide safekeeping of Resident Funds, if authorized in writing by the Resident; and make those funds available, at Resident's request, during normal business hours. 1 Resident may manage his/her financial resources if (s)he wishes. 2: Residents may keep a limited amount of funds at the Health Center, the maximum amount, which is specked from time to time by the Health Center. 3. Requests for withdrawals in excess of $50.00 require advance notice to assure availability of cash at the Health Center. Resident Funds shall be retained in compliance with State and Federal regulations. Resident Funds exceeding $50.00 shall be placed in an interest bearing account. A written quarterly statement of these funds shall be provided to Resident. Resident agrees to return signed copy to facility if required. E. provide refunds of unused advance payments and Resident Funds within thirty (30) days after deductions for payment of any outstanding bills or other amounts due the Health Center after Resident`s discharge or death. In the event of Resident's death, refunds will be made to the authorized representative of Resident's estate. F. assist Resident in applying for and obtaining private insurance and/or public benefits to cover the cost of the Resident's care. G. transfer or discl'iarge Resident out of the medicare or Medicaid certified portion of the Health Center only for medical reasons, for Resident's welfare. because the safety or health of individuals in the Health Center is endangered, because the E esident has failed, after reasonable notice, to pay for a stay at the Health Center, or with the voluntary consent of Resident. Except in emergency situations, at least thirty (30) days' notice will-be provided to Resident and Resident's Representative to assure that th&transfer is safe and orderly. The Health Center reserves the right and discretion to move Resident to another room or bed within certified parts of the Health Center consistent with the safety, care and welfare needs of the .Resident. H. arrange for Resident's transfer oi- discharge upon the order of Residents personal physician when he/she deems it necessary to receive services the Health Center is not qualified to provide or at Residents request 1. honor Resident's Rights as outlined in the Department of Public Welfare Admissions Notice Packet (MA 401)- j. hold Resident responsible to pay for any damages or injuries caused by Resident to other persons, residents or staff. Resident shall indemnify and hold the Health Center harmless from any claims, actions or proceedings against the Health Center resulting from Resident's actions or omissions. Health Center will be responsible for loss of or damage to Resident's personal property by Health Center staff. K. provide Resident with a locked drawer or box for Resident's valuables or for medications retained for self-administration. Resident may self-administer medications only in certain circumstances and may not have medications in his/her room without physician authorization. L. provide Resident with a choice of pharmacy if Resident does not wish to utilize the pharmacy provider designated by the Health Center. With this choice, pharmacy must provide medications in compliance with all applicable laws and under a delivery system that is consistent with the one used by the Health Center, must provide a monthly written profile of all drugs provided to the Health Center's consultant pharmacist, and must be delivered from the provider pharmacy in tamper-proof containers, directly to the Health Center's licensed nursing staff. M. provide Resident with a choice of attending physician who will provide medical care during the Resident's stay at the Health Center and who shall comply with the Health Center's rules, regulations, policies and procedures and all applicable laws and credentialing standards. Resident may also designate an alternate attending physician in the event that tfie primary attending physician is unavailable. In the event that Resident's attending physician(s) are unavailable, the Resident authorizes Health Center's Medical Director or other physician designated by the Health Center to issue appropriate orders. IV. RESIDENT OBLIGATIONS The Resident agrees to: A. by signing this Agreement, Resident certifies that (s)he is competent, and has never been adjudged incompetent, and is entering into this Agreement of his/her own free will. 1 . In the event Residentbtis been adjudged incompetent, Residents healthcare surrogate will attest, in a separate document that (s)he has the legal authority to act on behalf of the Resident. B. provide the Health Center with all information about Resident's health status and financial resources. Failure to accurately identify resources and income, or the submission of false information may amount to a violation of law and may result in the termination of this Agreement by and at the option of the Health Center_ C. provide the Health Center with a copy of all current insurance cards. Resident will provide the Health Center with changes in insurance coverage or financial status in a timely manner, and will update the information provided to the Health Center from time to time, as requested. Resident understands that making incomplete or inaccurate disclosures will be considered a breach of this Agreement. D. authorize thp Health Center to provide care and treatment to Resident consistent with the terms of this Agreement and to carry out the orders of the Residents treating. or attending physician or of the physician designated by the Health Center. Resident also authorizes the Health Center to obtain all necessary clinical and/or financial information from th6 hospital or nursing facility from which Resident may be transferring. E_ authorize the Health Center to make Residents Clinical Records available to Health Center staff and agents. Resident also authorizes the release of the Resident's Clinical Records to any other health care provider from whom Resident receives treatment, to third-party payors of health services, and to any managed care organization (MCO) in which Resident may be enrolled. and Resident also authorizes the release to the Health Center of records prepared maintained by any third-party payor of health care services pertaining to health care services tendered to the Resident by the Health Center. Resident also acknowledges receipt of the "Release for Electronic Transmission of Minimum Data Set' ("MDS"), which explains the MDS system of records using Resident data. Residents Clinical Records will remain otherwise confidential, and shall not be made available to anyone other than Resident or authorized agents of the state or federal govemments without the express written authorization of Resident or without a subpoena or other judicial order. F. cooperate fully with the Health Center and any third party payer to secure payment. Resident authorizes the Health Center to collect any payments made by third parties on Residents behalf directly from the third party payer. Resident also authorizes the Health Center to make claims, file appeals or grievances, and take other actions necessary and appropriate to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident to•the fullest extent permitted by law. Provided that Resident may, but shall not Iffe requim$to autherike the Health enter to pursue grievances or appeals m Residefs behalf under PennsylvArMs (qua icy Health Care Ace©untWllity and Prater-ton Act, to.the fullest ant permitted by law and as security for payment of the Health Center's cfarges, Resident hereby assigns to the Health Center all of Residents rights to any third-party payments now or subsequently payable for services rendered by or provided under arrangement through the Health Center. G. pay the Daily Rate established for the accommodation requested. Payment is due 30 days in advance, and Resident agrees to make full payment by the first of eadh month. Collection procedures are initiated after thirty (30) days of unpaid balances. Iriferest shall be charged on unpaid balances. i _ -If the Health Center initiates any legal actions to collect payments due from resident under this Agreement, Resident shall be responsible to pay all attorney's fees and costs incurred by the Health Center in enforcing Residents financial obligations under the Agreement. 2. This Agreement shall serve as an assignment to the Health.Center of as much of Resident's property as equals the amount of any unpaid obligations under this Agreement, and this assignment shall be an obligation of Resident's estate that may be enforced against Residents estate. Resident's estate shall be liable to and shall pay to the Health Center-an amount equivalent to any unpaid obligations of Resident under this Agreement. This liability shall apply whether or not Resident is occupying the Health Center at the time of Residents death. H. pay for additional items, services and equipment not included in the Daily Rate as identified by the Fee Schedules, attached as Exhibit A. understand that Resident will be notified thirty (30) days in advance of changes In the Daily Rate except when Resident requests room change, changes in charges for Specialty Care Services or Personal Needs Services, or changes in billing procedures, and agree that the changes will be effective upon the date designated by the Health Center. J_ understand that the Resident may continue to live at the Health Center as long as Resident continues to pay the Daily Rate. Resident may be discharged for non-payment of incurred charges or transferred for the benefit of the Resident or others, as set forth in Section lli(H) of this Agreement. K. acknowledge that non-payment of the Daily Rate for a private room will result in a room change. L. acknowledge that the Health Center has the discretion, with thirty (30) days' notice, to transfer Resident to another room or bed within the Health Center consistent with the safety, care and welfare needs of Resident. The Health Center also has the discretion, upon thirty (30) days' advance notice, to transfer or change Resident's roomma_ te, .if any, at any time consistent with the needs of the Health Center. M. terminate this Agreement upon written notice to the Health Center, but if Resident leaves for any reason other than a medical emergency or death, Resident must give reasonable advance written notice to the Health Center. N. notify the Health Center at least two months before the Resident has insufficient resources, funds or income to meet his/her financial obligations and to apply for MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not eligible for MA, Resident agrees to vacate the Health Center. 0. -pay co-payments and/at deductibles for services covered by the Medicare Program or other third party payer, and pay the Health Center within thirty (30) days of receipt of services for those services not covered by the Medicare Program or other third party payer. P. pay for items and services requested by Resident and not covered by MA within thirty days of receiving the non-covered service. 0. to the extent otherwise permitted by law, assume responsibility"for any damages or injuries caused by acts or omissions of the Resident to other persons, residents or staff. R_ comply with reasonable rules, regulations, policies and procedures that the Health Center establishes from tiime to time and" makes available to Residents, subject to reasonable accommodation of Resident's individual needs and preferences- The Health Center's rules, regulations, policies and procedures are for purposes of internal management and shall not be construed as imposing contractual obligations on the Health Center and are subject to change from time to time. S. acknowledge receipt of the Resident Handbook, a document that provides Residents With Health Center rules, regulations, policies and procedures. T. acknowledge receipt of information on Advance Directives in the absence of providing the Health Center with an existing Advance Directive or Living Will. U. provide the Health Center with a copy of any and all Durable Powers of Attorney, Guardianships, and/or Advance Directives pertaining to the Resident. V_ acknowledge that (s)he has read and understands the terms of this Agreement, that the terms have been explained to them by a representative of the Health Center, and that (s)he has had an opportunity to ask questions about the Agreement. V. MEDICARE AND MEDICAID The Health Center is certified to participate in the Medicare' and Medicaid Programs. The Health Center's parUcipatioh iii these programs is subject to termination by either the Health Center or the responsible government entity., The Pennsyivaniq Department of Public w- elfare (DPW) is responsible for administering benefits under the Medicaid Program and the Centers for Medicare and Medicaid Services (CMS) is responsible for administering the Me-dicare program through an intermediary. The Resident acknowledges that the Health Center is not responsible for and has made no representations regarding. the actions or decisions of DPW, CMS or the Medicare intermediary in administering these programs. A. Medicare If Resident is eligible for benefits under the Medicare Program, Resident understands -that certain skilled nursing and related health care services may be covered by Medicare. The Health Center will bill Medicare Part A on behalf of the Resident for skilled nursing services and payment will be made bj Medicare Part A directly to the Health Center for services received by Resident_ . When the Health Center notifies Resident that the nursing services being provided to the Resident no longer qualify as a skilled service, the Resident may request that the Health Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for the charges incurred on the Medicare Part A non-covered days The following describes coverage under the Medicare PartA Program: 1 . Medicare Part A covers from one (1) to one hundred (100) days at the Health Center. Eoverage is not guaranteed and is limited to the unused days in the Residents benefit period. Conditions stipulated by Medicare must be met for coverage to begin and remain in force. 2. The Medicare Part A Program pays for all covered charges from day one (1) through day twenty (20) if the criteria for skilled service Is met. 3. The Medicare Part A Program pays a portion but not all of the charges from day twenty-one (21) through day one hundred (100). The'Resident is responsible for and shall pay any co-insurance or deductible amounts as determined by the Medicare Part A program. Depending on the circumstances, this payment may be made by personal health insurance, MA, or personal funds. 4. The Medicare Part A Program covers the following services: room and board, linens, meals, most prescription medications, therapy services, most medical supplies, non-private duty nursing services, most recreational services, most social services, and most personal hygiene items provided by the Facility. (Vote: only the type and brand of personal hygiene items provided by the Health Center are included.) 5. Sorne items and services not covered by the Medicare Part A Program include, but are not limited to: personal clothing, eyeglasses, hearing aids, services of a beautician or barber, guest meals, special or alternative meals not required for therapeutic purposes or as a nutritional substitute, services not deemed medically necessary, and personal telephgne service. The Fee schedule for items and services provided to Medicare Part A eligible Residents that are not covered by Medicare Part A is attached as Exhibit A. 6. Beck hold days are not covered by the Medicare PartA Program. (See Section VII.) 7. Residents covered by Medicare Part A should not go out on overnight leave as this may disqualify them from further coverage by Medicare Part A. 8. Residents maybe covered for therapy and other ancillary services under the Medicare Part B Program. The Health Center or provider approved by. Health Center will big Medicare Part B directly for these services. The Residents are responsible for the annual deductible and the co-insurance payment for Medicare Part B covered services. 9. Resident is responsible to pay the Health Center for services and supplies not covered by the Medicare Program. 10. In the event that Medicare coverage is changed by law, those changes will control and take precedence over any contrary provision in this Agreement. B. Medicare Managed Care. The Health Center participates as a provider of skilled nursing services under some, but not all Medicare MCOs, 1 . Requirements for eligibility for Medicare payments, deductibles and co- insurance may be different from those discussed in Section V(A). Pre= authorization of services is required by Medicare MCOs, and If the Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Health Center for those services. If the MCO refuses coverage on the grounds that it does not consider an item or service to be medically necessary, Health Center or MCO will provide an Advance Beneficiary Notice of that determination. The Health Center will communicate directly with Resident's Medicare MCO to obtain authorization for continued Medicare managed care coverage- 2. The Health Center will accept payment from the Medicare MCO as payment in full only for those services and supplies covered by the Medicare MCO. Resident is responsible for any co-payments or other costs assigned to Resident or not covered by the MCO under the specific terms of the managed care plan. 3. -Resident acknowledges that an MCO for which the Health Center is not an authorized provider may not approve payment for services provided by the Health Center, so that Resident may be required to pay the Health Center directly. Resident also acknowledges that the Health Center is not responsible for and has made no representations regarding the actions or decisions of any MCO for which the Health Center is an authorized provider, including decisions relating to a denial of coverage or refusal to pay orr behalf of the Resident. 4. The Health Center reserves the right to stop its participation in any MCO at any time and in its sole discretion. To the extent practicable, the Health Center will provide advance notice to Residents enrolled in a particular managed care plan or insurance program of its decision to stop participation in that managed care plan or Insurance program. C. Medics[ Assistance Program 1 . Residents who qualify for coverage unde'r the MA Program must apply for and be approved for these services at the County Assistance Office. It is Resident's responsibility to pursue MA coverage. Until approval of MA coverage -is obtained, the Health Center will consider Resident to be a Private Pay Resident_ 2. Resident will be required to use the Patient Pay Liability to pay the Health- Center for the Resident's stay in conjunction with the MA Program. Periodic adjustments in the Patient Pay Liability are made by the County Assistance Office and when issued, will supersede all prevlous determinations. Resident shall arrange, if possible, for the designation of the Health Center for direct deposit of any Social Security or related benefits or any other income sources of the Resident in an amount not to exceed the Patient Pay Liability. 3. MA program coverage includes the following: room and board, prescription and non-prescription medications, meals, linen service, nursing services, incontinence care, social services, recreational activities, personal laundry, a hair cut every six (6) weeks, a shampoo and set every two (2) weeks, one permanent per year, and personal hygiene items provided by the Health Center. (Note that only the type and brand of personal hygiene items provided by the Health Center are included.) The MA Program limits the frequency of coverage for the purchase of eyeglasses, hearing aids, and dentures. 4. The Health Center will not charge, solicit, accept or receive monies from or on behalf of Resident for bed hold days covered by MA Program, except for the Patient Pay Liability, to cover the cost of Resident's stay or as a condition of admitting a Resident under the MA Program. b. Some items and services not covered by the MA Program include, but are not limited to: personal telephone service, personal clothing, guest meals, brand name personal hygiene items, and additional services provided by a beautician other than those listed above. Resident is responsible for charges incurred for these services at the rates listed on the Fee Schedule attached as Exhibit A in addition to the patient pay liability amount. 6. Residents receiving MA coverage are permitted to keep the amount that has been designated as the Resident's personal needs allowance for personal spending. Personal funds may be given to the Health Center for safekeeping (see Health Center Obligations in Section 111). 7. The MA Program provides for bed hold days for limited periods of time during Resident's stay. a) Up to fifteen days bed hold days are allowed when Resident is transferred to a hospital. b) • Up to thirty days bed hold days are allowed annually for intermittent therapeutic leave from the Health Center. c) The bed hold days referenced above are based upon the law in effect at this time, and may be subject to change If the governing state law is changed. 8. The Health Center provides equal access to its services to all individuals, regardless of payor source. Vt. THIRD-PARTY PAYMENTS A. If Resident is or becomes eligible to receive financial assistance or . reimbursement from any third parties (such as private insurance, employee benefit plans; MA, Medicare, managed care coverage, supplemental medical or other health insurance, supplemental security income insurance, or old=age survivors' or disability insurance), the Health Center reserves the right to collect such payments directly from the third-party. 'Resident shall cooperate fully with the Health Center and each third-party payor to secure payment, and Resident shall designate the Health Center, to the extent permitted by law, as the recipient of drect deposit for receipt of Federal Social Security benefits or any other Federal or State government assistance, reimbursement, or benefits to the extent of all amounts due the Health Center. B. Resident authorizes the Health Center to make claims and to take necessary actions to secure receipt of third-party payments to reimburse the Health Center for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment. of the Health Centers charges, Resident agrees to assign to the Health Center Resident's rights to any third-party payments now or subsequently payable to satisfy all charges due under this Agreement. Resident shall endorse and turn over to the Health Center any payments received from third-party payor to the extent necessary to satisfy the charges under this Agreement. C. In the event of any denial of coverage by the Resident's insurance company, Resident shall pay the facility for all non-covered services retroactive to the date of the initial delivery of services. V11. READMISSION- BED HOLD POLICY X A Hvatih Center repmentatlve shall communicate with Resident regarding ma/her desire to continue to otpy the Health Center bed during hospitalization or therapeutic leave. Verbal consent shall be given to the Health Center representative who shall. document this consent in the clinical record. Written consent shall be obtained following the verbal consent. See Fee Schedule (Exhibit A) for bed-hold rates. B. Bed holds for Residents enrolled in the MA Program are subject to the provisions of Section 5(C)(7). C. Resideht's belongings shall be removed from the Health Center Within 24 hours if Resident does not execute a bed hold authorization. Belongings not removed in a timely fashion may be packed and stored. VlIL CIVIL RIGHTS COMPLIANCE All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in need of services and are not restricted to members of the Presbyterian Church. The Health Center does not discriminate on the basis of race, color, national origin, age, ancestry, sex, handicap or disability. IX. REGULATION The Health Center and Resident recognize that Health Center is licensed by the Pennsylvania Department of Health and is regulated by the DPW. The Health Center and Resident recognize that Health Genter is also regulated by CMS of the United States Department of Health and Human Services. Both parties recognize that regulatory changes may alter the conditions of this agreement X. GRIEVANCE PROCEDURE If Resident believes that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, on in any other way, Resident may submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow the Health Center's grievance procedure as described in the Resident Handbook. The Health Center's grievance procedure does not preclude Residents from pursuing grievances with appropriate regulatory agencies. Xi. ARBITRATION Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or concerning any rights arising thereunder or the breach thereof shall be settled exclusively by arbitration, which shall be conducted at the Health Center in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties and may be entered in any court having jurisdiction thereof. Provided, however, that this arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a resident under the Medicare or MA programs or an applicable state law. XIL GOVERNING LAW This Agreement shall be governed by and construed in accordance with the laws of the Gernmonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XIII. SEVERABILTTY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a 'court or administrative body of proper jurisdiction to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. XIV. ENTIRE AGREEMENT This Agreement represents the entire understanding between the parties, and supersedes all previous representations, understandings or agreements, oral or written, between the parties, XV. MODIFICATIONS The Health Center has the right to modify unilaterally the terms of this Agreement to the extent necessary to conform to subsequent changes in law-or regulation. To the extent practicable, the Health Center will give Resident and Resident's Representative thirty (30) days advance written notice of any such modifications. XVI. WAIVER OF PROVISIONS The Health Center Executive Director reserves the right to waive any obligation of Resident under the provisions-of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Health Center unless and except to the extent that such waiver is in writing by the Health Center. Any waiver by the Health Center shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. Signatures - This Agreement and any addenda to this Agreement constitute the entire Agreement ahd underaftnding between the Health Center and the Resident with respect to the subject ft &r cif this Agreement dnd supersede all prior Agreements and understandings. There are no Agreements, understandings; restrictions, warranties, or representations between the Health Center and the Resident other-than those set forth in this Agreement, or incorporated in this Agreement by reference. This Agreement may be amended only by a document in writing signed by the Resident and the Administrator or Executive Director, and no acct or omission of any employee or agent of the_Health Center shall after, change or modify any of the provisions of this Agreement. Administrator or Executi Director Resident Witness 3-a -d? Date Date _ 49- 0 6 Date Date E(TO PETITION FOR ACCOUNTING) CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 SCHUTJER BOGAR LLC 417 WALNUT STREET 4TH FLR ATTN: BRANDON WILLIAMS HARRISBURG PA 17101 pennsylvania DEPARTMENT OF PUBLIC WELFARE MA LTC www.dpw.state.pa.us ELIGIBLE OFFICE OF INCOME MAINTENANCE NOTICE COMPASS www.compass.state.pa.us Notice ID: 95305223 Record Number: 21 0109523 District: 0 Case Load: 0036 Worker: J PEIPER Phone: 1-(800) 269-0173 Mailing Date: 06/18/2009 Reason: 985 Option: B Type: E Category: PAN PSC: 00 TT: You have been determined eligible for benefits effective 11/01/2006 to 03/31/2007. You are eligible for Non-Money Payment Medicaid coverage including Services in a Long-Term Care Facility. A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthly payment towards your cost of care. Details of this monthly payment towards your cost cost of care are found in the LTC section. LTC section. Contact the CAO if you have questions or changes to report. When contacting the CAO, please provide your record number, which is located on the top and bottom of this notice. Citation: 55 Pa. Code 140.201, 141.71, 178.1, 181.1, 181.11, 181.452, 181.453 If you disagree with our decision, you have'the right to appeal: See attached form for a cd,rnplete I MIDPENN LEGAL SERVICES explanation of your right to appeal and to a fair hearing 401-405 LOUTHER STREET If you are currently receiving benefits and your oral request for a hearing is received in the County CARLISLE PA 17013 Assistance Office or your written request is postmarked or received on or before 07/01/2009 (717) 243-9400 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. ADDRESS i0-1PI i?ANi NAME AND MAR A ET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 21 0109523 0 PAN 00 Notice ID: 305223 Worker: J PEIPER Phone: 1-(800) 269-0173 Mailing Date: 06/18/2009 Reason: 985 Option: B Type: E IF YOU WISH TO APPEAL, COMPLETE THE BACK OF THIS FORM AND RETURN THE BOTTOM PORTION TO CAO. o o o ?- o MA_I 711 Ring PA MAILTC-X 162-10108 Notice ID: 95305223 Q • The following individual is affected by the action on the front of this notice. LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V BENEFIT PACKAGE 01 MARGARET 170181295 8 02 MA Eligibility Decision: Benefit Period 11/2006 1212006 01/2007 02/2007 03/2007 Income: Social Security/SSI Pension Interest/Dividend 937.50 366.66 0.67 937.50 366.66 0.67 968.50 366.66 0.67 968.50 366.66 0.67 968.50 366.66 0.67 Total Income 1304.83 1304.83 1335.83 1335.83 1335.83 Deductions 0.00 0.00 0.00 0.00 0.00 Net Income 1304.83 1304.83 1335.83 1335.83 1335.83 Income Limit 1809.00 1809.00 --1869.00 1869.00 1869.00 &7i:toiiLsiogon LTC Eligibility Decision: The followinn mmm int¢ ,warn i isart to commute your monthly payment towards your cost of Long Term Care (LTC) Cost of Care - Effective Date 11/2006 1212006 01/2007 02/2007 03/2007 Total Income 1304.83 1304.83 1335.83 1335.83 1335.83 Income Available First Month 0.00 0.00 0.00 0.00 0.00 Deductions: Personal Needs Allowance 40.00 40.00 40.00 40.00 40.00 Payment TgWardS !cost Of-Care 1264.83 1264.83 1295.83 1295.83 1295.83 Medicare Premium Other Insurance Premium 88.50 0.00 88.50 0.00 93.50 0.00 93.50 0.00 93.50 0.00 The LTC facility will deduct the above medical expenses from your payment towards Cost of Care. The LTC facility may deduct additional medical bills including supplemental health insurance premiums, provided they are verified. IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM - DETACH HERE--------------------------------------------------------------------------------------------------------------------- DETACH HERE Please check the box next to the type of hearing you want: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: ? I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO). ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. ? I want a Face to Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the County Assistance Office. For the Hearing: ? Please check if you need special help because of a hearing impairment or disability. Describe: ? Please check if you need an interpreter. There will be no cost to me. What language? I WANT TO ASK FOR A HEARING BECAUSE: (Attach more pages if you need to.) CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE SIGNATURE CLIENT REP. ADDRESS TELEPHONE NO. DATE 2009-06-18 09:14 CUMBERLAND CAD P.O. Box 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MARGARET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 Notice ID: 95305523 Record Number: 21 0109523 District: o Case Load: 0036 Worker: J PEIPER Phone: 1- (800) 259.0173 Mailing Date: 06/1812009 Reason: gas Option: B Type: E Category: PAN PSC: oo TT: You have been determined eligible for benefits effective 04101[2007 to 07/3112007. You are eligible for Non-Money Payment Medicaid coverage including Services in a Long-Term Care Facility, A PA ACCESS card will be issued unless you have previously received one. You will be required to make a monthlv Payment towards your cost of care. Details of this monthly payment towards your cost cost of care are found in the LTC section, LTC section. Contact the CAD if you have questions or chanaps to report. When contaotinA the CAO, please provide.your record number, which is located on the top and bottom of this notice. Citation: 55 Pa. Code 140.201, 141.71. 178.1. 181.1. 181.11. 181.452. 181.453 If you disagree with -our decision, you have the right to appeal. 5ee attached form for d caao exoianalion of your right to appeal and is a fall fjearIM If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 0710112009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. MARGARET G GAYLOR SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE PA 17257 CUMBERLAND CAD P.O. BOX 599 33 WESTMINSTER DRIVE 7013-0599 4 4/5 i pennsylvania P PAGE 1 OF 1 vipAe niMT OF PUSUC waFARE . ..epwstate.pa.us MA LTC OFFICE OFINCOMEMAINTENANCE ELIGIBLE NOTICE COMPASS www.corrmpass.state.pa.us MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243.9400 21 0109523 0 PAN 00 Notice ID: 95305523 Worker: J PEIPER Phone: 1- (e90) 269-0173 Mailing Date: 06/1812009 Reason: 985 Option: B Type: E MA-LTC-FRONT-12118108 PA MAILTC-X 162-10108 2009-06-18 09:15 The following individual is affected by the action on the front of this notice. LINE FIRST NAME 01 MARGARET 11213i .7T I, MA Eligibility Decision: Benefit Period Y 0412007 0512007 06!2007 07/2007 Income: Social Security/35I Pension Interestlpividond 968,50 366.66 0.67 968.50 366.66 0.67 968.50 366.65 0,67 968,50 366,66 0.67 Total Income 1335.83 1335.83 1335.83 1335.83 Deductions 0.00 0.96 0.00 0 , 00 Net Income 1335.83 1335 , 83 1335.83 1335.83 Income Limit 1869.00 1859.00 1869.00 1869.00 LTC Eligibility Decision: ... /. TP1\ The following amounts were used to compute your mon thly payment towards your COS! OT Long erm ,are kL ?l Cost of Care Effective 0412007 0512007 0612007 07/2007 Total Income 1335.83 1335.83 1335.83 1335.83 Income Available First Month 0.00 0.00 0.00 0,00 Deductions: Personal Needs Allowance 40.00 40.00 40.00 45,00 Y AfL 1295.83 1295.83 1295.83 1290.83 Medicare Premium Other insurance Premium 93.60 0.'00 93.50 0.00 93.50 0.00 93.50 0.00 The LTC facility will deduct the above medical expenses from your payment towards Cost of Care. The LTC facility may deduct additional medical bills including supplemental health insurance premiums, provided they are verified. IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM DETACH HERE .__--------°---.r_r_._.???_._.y?__`_------- ------------------------------- DETACH HERE- Please check the box next to the type of hearing you want: M 1 want a Telephone Hearing. I and my witnesses and anyone helping me will beat this phone number: Q I want a Telephone Hearing. I -and my witnesses and anyone helping me will be at the County Assistance Office (CAO). Q I want a Face to Faoe•Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff. I want a Face to Face Hearing. I and my witnesses and anyone. helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the County Assistance Office. For the Hearing: 0 Please check if you need special help because of a hearing impairment or disability. Describe: 0 Please check if you need an interpreter. There will be. no cost to me. What language? I WANT TO ASK FOR A HEARING BECAUSE: (Attach more pages if you need to.) CLIENT SIGNATURE ADDRESS V 81295 rELEPHONE NU. vsa I c Z3 Notice lu: 9530vW SIGNATURE CLIENT REP. ADDRESS rELEPHUNt NV. VAI e Dry 1 Tf`.NND_Y Irv> .1 nmr 1 T!"?IM011l19?Lme CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petition for Accounting was served via first-class, United States mail, postage prepaid, upon the following: Lisa Starr 308 Middle Road Newville, PA 17241 Respondent \ a 2';' a 9 Date: William Keslar, Paralegal FILED-.,,,' i?E OF TH- Lx I c: ?.: ARY 2009 QCT 29 Ph 2: OZ 6 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE, Plaintiff, _ V. No. Oq - '1?18q Civil lean LISA STARR, Defendant CIVIL ACTION - EQUITY PRELIMINARY DECREE NOV 0 Z 2009&1 1? AND NOW, this 0 day of N Oy twb tr 2009, upon consideration of the annexed petition, a citation is issued and directed to Ms. Starr to show cause why an Order should not be entered requiring her to file a full and complete accounting of all transactions undertaken by her with respect to Margaret Gaylor's income and assets from February 27, 2006, to the present. A copy of the petition shall be served with the citation. Citation returnable 30 days from the date of service. BY THE COURT: J. FILED-Q FiCE OF THE PFC? HONOTRAY 2009 NOV -5 PM 3: 48 rc,J,dI.V,A N, 00 - Coflt% M Lt . . rt-5 PRESBYTERIAN SENIOR LIVING d/b/a GREEN RIDGE VILLAGE PLAINTIFF V. LISA STARR, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : NO. 09-7484 CIVIL ORDER OF COURT AND NOW, this /ath day of November, 2009, upon consideration of Petitioner's Petition for Preliminary Injunction, IT IS HEREBY ORDERED AND DIRECTED that a hearing will be held on Monday, December 21, 2009, at 9:30 a.m. in Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. IT IS FURTHER ORDERED AND DIRECTED that pending the hearing, Defendant Lisa Starr shall expend no income from Margaret Gaylor's pension or social security income without express order of this Court. Failure of the Defendant to comply with this provision will render her subject to sanctions for contempt of court. By the Court, `'?` ?, L%11 - M. L. 'E?b`ert, Jr., J. /Brandon Williams, Esquire Attorney for Plaintiff 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Lisa Starr Defendant 308 Middle Road Newville, PA 17241 bas 12 b> -T mc-ULSCL /1 ,ZI0? X11 IF`L-I?-? - 29, f0`v' 12 P; 1 1: 18 SHERIFF'S OFFICE OF CUMBERLAND COUNTY R Thomas Kline Sheriff Ronny R Anderson Chief Deputy ~~uytitr ~i ~~ligl~f~.~~ri e~ i= , Jody S Smith Civil Process Sergeant Edward L Schorpp Solicitor ;: - ~ 2~ ~9 Q~~ - I ~'~ ~ 2~ !. ~~ C' !"-ti, viV;C ~. r~•._, _~;;~., _ Presbyterian Senior Living d/b/a Green Ridge Village vs. Case Number Lisa Starr 2009-7484 SHERIFF'S RETURN OF SERVICE 11/23/2009 12:08 PM -William Cline, Deputy Sheriff, who being duly sworn according to law, states that on November 23, 2009 at 1208 hours, he served a true copy of the within Complaint and Notice Pursuant to PA RCP No. 1018.1, Order of Court, Petition for Preliminary Injunction, Brief in Support of Petition for Preliminary Injunction, Preliminary Decree and Petition for Accounting, upon the within named defendant, to wit: Lisa Starr, by making known unto Robert Starr, husband of defendant at 308 Middle Road, Newville, Cumberland County, Pennsylvania 17241 its contents and at the same time handing to him personally the said true and correct copy of the same. SHERIFF COST: $38.80 November 30, 2009 SO ANSWERS, R THOMAS KLINE, SHERIFF ~' !~ Deputy Sheriff