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HomeMy WebLinkAbout09-8062IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, v' No. DQ -g)4--. ALICE BRICKER, Defendant u . [-? CIVIL ACTION - 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 ORIGINAL EN LA CORTE DE ALEGATOS COMLJN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA DIVISION CIVIL CHURCH OF GOD HOME, INC. Plaintiff, V. No. ALICE BRICKER, Defendant. CIVIL ACTION - 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 CHURCH OF GOD HOME, INC. Plaintiff, : V. No. 09- Sb (,-z ALICE BRICKER, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff Church of God Home, Inc., ("Plaintiff") by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Alice Bricker ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant is an adult individual who currently resides at 1710 Lisburn Road, Carlisle, Pennsylvania 17013. 3. On or about July 27, 2006, Defendant applied for the admission of her mother, Auralia Thomas, to Plaintiff's skilled nursing facility. At that time, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's mother with skilled nursing services in exchange for Defendant's promise to pay a specific monetary fee from her mother's assets, the assignment to Plaintiff of her mother's right to apply for and obtain Medical Assistance benefits in the event that she became insolvent, and, in furtherance of that assignment, agreed to "cooperate fully" in the process of qualifying her mother for Medical Assistance benefits. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 4. After Defendant's mother became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that she needed to secure Medical Assistance benefits for Mrs. Thomas, and an application for Medical Assistance benefits subsequently was filed on behalf of Mrs. Thomas. 5. That application for Medical Assistance benefits was denied on March 9, 2009, because Defendant did not provide the information and documentation required by the Cumberland County Assistance Office ("CAO") to qualify her mother for benefits. A true and correct copy of the PA-162 is attached hereto as Exhibit "B." 6. A second application for Medical Assistance benefits was filed on behalf of Mrs. Thomas, and denied on April 24, 2009, also for failure provide information. A true and correct copy of the Pa-162 is attached hereto as Exhibit "C." 7. Plaintiff has filed another application for Medical Assistance benefits. However, if Defendant fails to provide the CAO with the information necessary to qualify her mother for Medical Assistance benefits, that application will also fail, and Plaintiff will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it. 2 COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 8. The allegations contained in Paragraphs 1 through 7 are incorporated herein by reference as if fully set forth at length. 9. Defendant breached her Agreement with Plaintiff by failing to act in accordance with the terms of the same, as she has failed to provide necessary documentation required to process and approve her mother's application for Medical Assistance benefits. By doing so, Defendant has interfered with Plaintiff's right to receive the Medical Assistance benefits that have been contractually assigned to it. 10. Plaintiff is entitled to the aforementioned Medical Assistance benefits and cannot exercise its rights under the assignment clause to receive payment until Defendant's mother's application is approved. 11. Upon information and belief, at all times material hereto, Defendant's mother was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her in accordance with the terms and conditions of the Agreement. 12. Defendant's breach of his Agreement with Plaintiff has irreparably harmed Plaintiff. 13. Only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. 3 WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BQGAR LLC l Dated: By: Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff 4 VERMCATTON The undersigned hereby verifies that the statements of fact in the £ozegving document are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unswom falsification to authorities. Dated: I?C]V . ??? !1_1_T Nlidiele Shughaxt, Billing Church of God Home, Ind EXHIBIT "A" (TO COMPLAINT) CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT 77? J UL AGREEMENT is made on this a27 day of JUL 206 , by and between The Church of God Home, Inc., called Facility," a Pennsylvania non-profit corporation located at 801 North Hanover Street, Carlisle, Cumberland County, Pennsylvania, and called "Resident" and &z-ICE (-D9) C1e.LK called "Responsible Party" The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and understand that the submission of false information may constitute grounds to terminate this Agreement.' The Resident has applied for admission to the Facility and the Facility has approved the. Application for Admission. Therefore, the Facility, The Resident and Responsible Party agree to the following terms': 1. PROVISION OF SERVICES. The Facility will provide Resident with: (a) Skilled nursing care, i.e. professionally supervised nursing care and related health services under a plan of services regularly provided under a plan of care supervised by licensed personnel and, as required by the Resident's,medical condition, assistance with activities of daily living. (b) Accommodations consistent with the level of care provided to the Resident including heat, air conditioning, electricity and hot and cold water. (c) Bed, bedding, blankets and laundered bed linens, towels .and wash cloths. (d) Three meals each day, except as otherwise medically indicated. (e) Activity programs and social services. 2. RECURRING CHARGES. In exchange for the above services, the Resident shall pay the following recurring charges: (a) For skilled nursing care: $ I 'IC?=? dollars per day. P_draission and Care Agreement - continued 3-. NON-RECtMRSNG CHP?GES . The Resident shall pay the following non-recurring charges: (a) P_ security deposit in the amount of thirty--one (31) tames the current daily rate for the level of care required by the resident, will be billed after admission day. The amount of the security deposit is $ 6e) I No interest will be paid on the security deposit. A security deposit will not be charged to residents who are receiving benefits for room and board provided by Medicare, until the Medicare benefit concludes. An applicant who is. covered by Medicaid is not required to pay a security deposit. (b) The cost for enrollment in the community ambulgnce and ALS (Advance Life Support) Unit is $ Al This fee must be paid prior to admission and will be.billed annually to the.-Resident. a, MISCELLANEOUS CHARGES AND OUTSIDE SERVICES. Resident is responsible to pay for other services provided by the-Facility which are not covered by the daily rate/charge.- A list of such services/charges . is attached to this Agreement on the "Chart of Costs." The services of a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, and. diagnostic services, will be made available at the Resident's expense. THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER OWN PHYSICIAN OR ANY OTHER SERVICE PROVIDER SO LONG AS THE PHYSICIAN OR OTHER SERVICE PROVIDER IS PROPERLY LICENSED OR REGISTERED UNDER THE LAW, AND THAT ALL APPLICABLE GOVERNMENT RULES AND POLICIES OF THE FACILITY ARE MET. In addition to the Facility's charges, the Resident is responsible to pay -all fees and costs -for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement. The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist,. therapist, diagnostic or testing 'laboratory, pharmacist, pharmacy, hospital, or any other person,'facility or entity providing services or goods to or for the Resident, and for all drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or se-vices for the Resident. SUCH FEES P.ND COSTS ARE NOT INCLUDED IN THE HOME'S DAILY z FATE / CH_1RGE . Admission and Care Agreement - continued ~5. ADMISSION. The Resident will be admitted, or a bed will be reserved for Resident, beginning on 3 city a7 .20CUCa All pre-admission charges will be billed after admission, and recurring charges will begin to accrue as of the above-date. The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily rate for the reserved bed will continue to accrue and be payable until the reservation is terminated, even if the Resident does not enter the Home for whatever reason, including illness, injury, incapacity or death. G. PERIODIC BILLINGS AND PAYMENT DUE DATE. (a) On the first of. each month, Resident will be billed the current daily rate for Resident's current level of care times the number of days. in the month. The bill is due and payable, upon receipt. (b) Miscellaneous charges (refer to "Chart of costs,, attached to this Agreement) such as hair care, personal laundry, incontinency, supplies, etc., are. additional charges above the. daily rate. These miscellaneous charges will be added to, and included with,. your monthly bill. (c) Pharmacy charges will be billed as a separate part of the Facility's monthly bill, and will require a separate check. (d) Outside providers will bill directly and separately.. 7. C MNGES IN CHARGES. From time to time,the Facility may change the amount of its charges. In addition, from time to time, the Facility may change how and when its charges are -computed, billed or become due. The Facility reserves the right to make any such changes at any time.-Written notice of any such changes will be given to the Resident thirty (30) days in advance of implementation, unless' the change is required earlier under any federal or state law or assistance program. B. PARTICIPATION IN "MEDICARE /MEDICPSD" PROGR34MS. The Facility participates in the Medicare program administered pursuant to Title XVIII of the Federal Social Security Act and the Pennsylvania Medical Assistance Program ("Medicaid") administered pursuant to the Pennsylvania state plan and Title XIX of the Federal Social Security. Act. However, the Facility reserves the right to withdraw from the Medicare/Medicaid programs at any time in accordance with the law. Admission and Care Ag-_eement - continued -9. OBLIGATIONS OF RESPONSIBLE PARTY. The Responsible party is responsible for services and supplies that are billed through the Facility or billed directly to the Resident or Responsible Party by any other provider. The Responsible Party _Js responsible to pay all fees and costs from Resident's resources. 10. READMISSION - BED HOLD POLICY. the Facilit fora . If the Resident leaves y period of hospitaliLation, therapeutic leave, or any other reason, other than the Resident's death, and if the Resident is not eligible for, or receiving medical assistance, the Resident's bed will be reserved, and charges for the reserved bed will continue to accrue, unless the Resident or Responsible Party -otherwise directs in writing. If the Resident or Responsible Party elects not to reserve a bed, then the Resident will be eligible for readmission upon the availability of the first bed suitable for the Resident's level of care. If the Resident Is receiving medical assistance benefits and - the Resident leaves the Facility for "a period of hospitalization or therapeutic leave, the Resident's bed will be reserved for the applicable maximum number of days paid for the reserved bed under the Pennsylvania.Medical Assistance- Program. The current bed reservation period is fifteen for hospitalization, regardless of level of care, fifteen1 (15) days for therapeutic leave for residents receiving skilled nursing care,,. and thirty (30) days for therapeutic leave for residents receiving intermediate care. The bed reservation period may be subject to change in accordance with any changes in the'Medical Assistance Program. If the period of hospitalization or therapeutic leave ends within the reservation period under the Medical Assistance Program, the Resident may return to the Facility. If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania. Medical Assistance Program, the Resident must wait until a suitable bed becomes available for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time of readmission, ,the Resident recnzires the services provided by the Home. 11. REFUNDS . The security deposit for private pay residents , after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty Resident's discharge from the Facility or death) days after the Residents on Medical Assistance will receive their rTehund,ifsang due,, within ninety (90) days. There will be no other refunds, in the absence of an overpayment, under this Agreement. 12.. PERSONAL FINANCES, The Resident has the right to manage his/her personal funds. The Resident is and will be responsible to provide his/her personal funds. If the Resident elects, the Resident may designate, in writing, that the Pacility hold and manage the Resident's personal funds. If the Resident Admission and Care Agreement - continued desig=a.tes someone other than the Facility to manage his/her personal funds, the Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to make any designation, and 'is responsible for his/her own personal funds unless such designation is made. The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal funds by providing the Facility a written notice signed and dated by the Resident or Responsible Party. If the Resident transfers to the Home, responsibility to -manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which is. provided at the time of your admission, and the Facility's personal funds management policy. The Facility may deduct, at any time, charges due to the Facility under this agreement from. the Resident's personal funds managed by the Facility. 13. TERMINATION ?_ TRANSFER OR DISCHARGE. (a) By the Resident: .The- Resident may terminate this Agreement upon thirty (30) days written notice to the Facility. If the Resident leaves the -Facility for any reason other than a medical emergency or his/her death, the Resident must give written notice to the. Facility at least thirty (30)'days in advance of the departure/ transfer/discharge or termination of the Agreement. If advance written notice is mot given to the Facility, there will be due to the Facility its daily and other charges then in effect for the Resident's current level of care for the required thirty (30) day notice period. The charge applies whether or not the Resident remains at the Facility during the thirty'. (30) day period. (b) By the Facility: The Facility may terminate the Resident's stay and transfer or discharge the Resident if: (I) the transfer or discharge is necessary.to meet the Resident's welfare which cannot be. met by the Facility; (II) the Resident's health or condition has improved sufficiently that'the Resident no longer needs the services provided by the Facility; (III) the safety or heal th 'of individuals in the Facility is or otherwise would be endangered; Admission and Care Agreement- conthuUed IV. The charges or other amounts due to the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Residents behalf by Medical Assistance under the Medical Assistance Proffam or by Federal Medicare benefits under Title XVIII of the Federal Social Security Act: or V. The Facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none. a Family member or legal representative of the Resident. if known to the Facility. at least thirty (30) days in advance of such a transfer or discharge. However, in any case. describe in subparagraph (1). (I1) and (111) above, or if the Resident has not resided at the Facility for at least thirty (30) days. the Facility will give such notice before transfer or discharge as is practicable under the circumstances. 14. THIRD PARTY PAYMENTS- The Resident may be or may become eligible to receive financial assistance. reimbursement or other benefits from third- parties. such as through private insurance. employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program. Medicare benefits. supplementary medical or other health insurance, supplemental security income insurance. or old-a^e survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident. the Resident/Responsible Party shall, at all times, cooperate fully with the f=acility and each third-party payments. Cooperation includes. when requested. providing information. signing and delivering documents, and having the Facility designated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other Governmental assistance. reimbursement or benefits to the extent of all charges due tile Facilim The Resident irrevocably authorizes the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law. the Resident hereby assigns now or hereafter payable to the extent of all charges due to the endorse and turn over to the Facility any payments received from third-parties to the extent necessary to satisfy the charges under this Agreement. Admission and Care Agreement- continued 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, personal possessions. and other items of property. The facility may limit the amount or type of property that the Resident may keep at the facility if there is insufficient space, or if medically indicated or necessary to protect the rights or welfare of others. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse regarding resident's personal property. If nametag labels are needed for clothing items, please leave them at the nursing station. 16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply frilly with all governmental laws and regulations, the provisions of this Agreement and the facility's existing policies, rules and regulations which may, from time to time. be altered or amended. 17. MISCELLANEOUS PROVISIONS a. The Resident and Responsible Party acknowledge that they are adult individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by the lays of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs- personal representatives, successors and assigned. c. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by competent legal authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been part of this Agreement. d. The Facility reserves the right to modify unilaterally the terms of this Agreement to conforni to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (30) days notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. Resident/Responsible Party Resident, N L ?? f t}y?i'? S Facility RetSresentative Date EXHIBIT "B" (TO COMPLAINT) CUMBERLAND CAO MEDICAID P.O. HOB. 599 NOT ELIGIBLE 33 t9ESTt4INSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 '01010000000`' CHURCH OF GOD HOME ATTN: BILLING 801 N. HANOVER STREET CARLISLE PA 17013 Notice ID: 91820174 PAGE 1 OF 1 CO RECORD :- :DIST:- CAT -GG i`@S 21 0122974 0 PAN 80 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 03/09/2009 NOT: 042 OPT:O TYPE: N IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. You failed to provide the following information by 3/5/09: MA 51 with options determination report; Signed PA Q authorization for release of information; verification of all gross monthly income; Statements for all bank accounts, cd iras, annuities,keoghs, stocks bonds, annuities as of requested effective date Personal care account balance, deed to property, current market value,if sold dispositon of funds received and settlement paperwork; verification of all resources sold transferred or given away; Statements for all bank accounts from 1/1/05 to 11/25/08 including PNC, citizens and member's 1st; disposition of $75320 received from cash out of CD; tax assessment of property sold in 2007; verification that your total resources are below the $8000 limit REGULATION5:55 PA Code 201.1; 201.3 ER Fin, -N MAR 3 2009 APPEAL AND FAIR HEARING If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 03/22/2005 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. APPLICANT NAME AND ADDRESS AUDALIA A THOMAS CHURCH OF GOD H014E 801 NORTH RA14OVER STREET CARLISLE PA 17013 CAO ADDRESS CU14BEP-LAND CAO P.O. BOX 599 33 WEST14INSTER DRIVE CARLISLE PA 17013-0599 LEGAL HELP IS AVAILABLE AT MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 91820174 CO ?r`AEGORDi ::D157 :CAT:;?. GG PS 21 0122974 0 PAN 80 WORKER: J PEIPER APPEAL: 03/22/2009 TELEPHONE: 4800) 269-0173 MAIL DATE: 03/09/2009 NOT: 042 OPT: 0 TYPE: N IF YOU ::WISH TO APPEAL, COMPLETE THE BACK OF !THIS FORM 'AND RETURN _ THE BOTTOM PORTION TO :CAO. s 0 0 0 0 a 0 0 0 0 PAMA162A CONTINUED ON REVERSE SIDE PA/MA 162 12103 EXHIBIT "C" (TO COMPLAINT) cUMBERILAND CAO MtiJIC;AIIJ P.O. Box 599 NOT ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 10101d000000* CHURCH OF GOD HOME ATTN: BILLING 801 N. HANOVER STREET CARLISLE PA 17013 Notice IU: 93779574 CO :'.':RECORD ':[OtST::;:CAT:GG 21 012974 0 PAN 00 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 04/24/2009 NOT: 042 OPT: 0 TYPE: N IF YOU DO NOT 11NOERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. You failed to provide the following informaiton by 4/23/09: Verification of disposition of the $102,000 received for 1/2 the value of the property sold at 1642 W. York Street Mechancisburg PA 17055; Statements for citizens bank account XXXXX 3894 from 9/1/07 to present showing deposit of money received from transfer of the home and dispositions of funds in account REGULATIONS:55 PA Code 201.1; 201.3 If you disagree with our decision, you have the right to appeal. for a complete explanation of your right to appeal and to a fait hearing. It you are currently receiving benefits and your.. oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/07/2009 your assistance' will continue pending the hearing decision, except when the change is due to State or Federal law. NAME ? AND DD- AUDALIA A THOMAS CHURCH OF GOD HOME 601 NORTH HANOVER STREET CARLISLE PA 17013 N m@@ 0TH APR 2 7 2009 PAGE 1 OF 1 MIDPENN LEGAL SERVICES 401-405 LOUTKER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 93779574 s ADDRESS, CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 :;?4 vRECORD;`i;i sDIST'=<s;;CA rt -`GGs;{-AS =(-s CO a 21 0122974 0 PAN 00 WORKER: J PEIPER APPEAL: 05/07/2009 TELEPHONE (800) 269-0173 MAIL DATE: 04/24/2009 NOT: 042" C)PT: 0 TYPE: N IF. YOU :WISH TO APPEAL-, COMPLETE THE BACK OF THIS FORM: AND RETURN THE BOTTOM P. ORTIdN 'TO. GAO. - 0 0 0 0 0 0 0 0 0 PAMA162A CONTINUED ON REVERSE SIDE PAIIVIA 162 12103 CA ^ ru?C FILED r;T .Y OF THE- FF^ 2009 PI ru) V 20 Ai i I I: li 3 CDIY; N Y x'78. so ??L Al? eK4 /o7/S ?- a 33877 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. 6q- W Wp ALICE BRICKER, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES Petitioner Church of God Home, Inc., ("Petitioner") by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Petition against Respondent, Alice Bricker ("Respondent"), pursuant to Pa. R.C.P. § 1531, and, in support thereof, avers: 1. Contemporaneous with the filing of this Petition, Petitioner (as Plaintiff) filed a Complaint against Respondent (as Defendant). See Complaint attached as Exhibit "A." 2. Respondent entered into an Admission Agreement ("Agreement") with Petitioner in conjunction with the admission of her mother, Auralia Thomas ("Mrs. Thomas"), to Petitioner's skilled nursing facility. See Admission Agreement attached to Complaint as Exhibit "A." 3. In the Agreement, Petitioner was assigned Auralia Thomas's rights to Medical Assistance benefits (hereinafter "the Assignment Clause"). See Complaint. ORIGINAL 4. Accordingly, Petitioner now stands in the shoes of Auralia Thomas and has assumed her rights with respect to her Medical Assistance benefits. See Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) (" [A]ssignee stands in the shoes of the assignor and assumes the rights of the assignor."). 5. Petitioner cannot exercise its rights to Mrs. Thomas's Medical Assistance benefits until the Cumberland County Assistance Office ("CAO") processes and approves the application for Medical Assistance benefits, which cannot be done until Respondent provides the documentation the CAO requires. 6. Respondent's failure to provide the documentation that the CAO requires to process and approve her mother's application for Medical Assistance benefits breaches the Assignment Clause and interferes with Petitioner's rights to the Medical Assistance benefits. 7. Failure by Respondent to comply with the terms of the Agreement and provide the verifications required by the CAO to render a decision on her mother's eligibility for Medical Assistance benefits will result in the denial of Medical Assistance benefits for Auralia Thomas. 8. The very nature of Respondent's breach presents an issue of immediate and irreparable harm to Petitioner, as Petitioner cannot realize the benefit of the bargain promised to it under the Assignment Clause - specifically, its right to Auralia Thomas's Medical Assistance benefits, and by extension, its right to be compensated for the skilled nursing services it has provided and continues to provide to Respondent's 2 mother - until Respondent provides the CAO the documentation it needs to process and approve her mother's application. 9. The requested injunction would restore the parties to the status quo as it existed immediately prior to Respondent's breach of the Agreement. 10. Greater injury would result from the denial of the requested injunction than from the granting of the same. Absent the injunction, without the documentation necessary to secure Medical Assistance benefits, Auralia Thomas's application for Medical Assistance benefits will fail, and Petitioner's ownership rights in those benefits and its ability to receive compensation for the skilled nursing services it has provided and continues to provide to Auralia Thomas under the Agreement will be forever lost. 11. Petitioner's right to relief is clear. 12. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent and her mother have been financially unable to fully compensate Petitioner for the services that it has rendered and continues to render to Respondent's mother. 13. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. [REMAINDER OF PAGE INTENTIONALLY LEFT BLANK] 3 WHEREFORE, Petitioner respectfully requests that the Court schedule a hearing on its request for injunctive relief and thereafter issue a decree ordering specific performance of the contractual duties of Respondent. Dated: Respectfully submitted, SCHUTJER BOGAR LLC By Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Petitioner 4 EXHIBIT "A" (TO PETITION FOR PRELIMINARY INJUNCTION) IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. No. ALICE BRICKER, Defendant. CIVIL ACTION - 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 DIVISION CIVIL CHURCH OF GOD HOME, INC. Plaintiff, V. No. ALICE BRICKER, Defendant. CIVIL ACTION - 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 CHURCH OF GOD HOME, INC. Plaintiff, V. No. ALICE BRICKER, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff Church of God Home, Inc., ("Plaintiff") by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Alice Bricker ("Defendant"), and in support thereof, provides as follows: 1. Plaintiff is a foreign corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant is an adult individual who currently resides at 1710 Lisburn Road, Carlisle, Pennsylvania 17013. 3. On or about July 27, 2006, Defendant applied for the admission of her mother, Auralia Thomas, to Plaintiff's skilled nursing facility. At that time, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Defendant's mother with skilled nursing services in exchange for Defendant's promise to pay a specific monetary fee from her mother's assets, the assignment to Plaintiff of her mother's right to apply for and obtain Medical Assistance benefits in the event that she became insolvent, and, in furtherance of that assignment, agreed to "cooperate fully" in the process of qualifying her mother for Medical Assistance benefits. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 4. After Defendant's mother became a resident of Plaintiff's skilled nursing facility, she apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff notified Defendant that she needed to secure Medical Assistance benefits for Mrs. Thomas, and an application for Medical Assistance benefits subsequently was filed on behalf of Mrs. Thomas. 5. That application for Medical Assistance benefits was denied on March 9, 2009, because Defendant did not provide the information and documentation required by the Cumberland County Assistance Office ("CAO") to qualify her mother for benefits. A true and correct copy of the PA-162 is attached hereto as Exhibit "B." 6. A second application for Medical Assistance benefits was filed on behalf of Mrs. Thomas, and denied on April 24, 2009, also for failure provide information. A true and correct copy of the Pa-162 is attached hereto as Exhibit "C." 7. Plaintiff has filed another application for Medical Assistance benefits. However, if Defendant fails to provide the CAO with the information necessary to qualify her mother for Medical Assistance benefits, that application will also fail, and Plaintiff will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it. 2 COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 8. The allegations contained in Paragraphs 1 through 7 are incorporated herein by reference as if fully set forth at length. 9. Defendant breached her Agreement with Plaintiff by failing to act in accordance with the terms of the same, as she has failed to provide necessary documentation required to process and approve her mother's application for Medical Assistance benefits. By doing so, Defendant has interfered with Plaintiff's right to receive the Medical Assistance benefits that have been contractually assigned to it. 10. Plaintiff is entitled to the aforementioned Medical Assistance benefits and cannot exercise its rights under the assignment clause to receive payment until Defendant's mother's application is approved. 11. Upon information and belief, at all times material hereto, Defendant's mother was financially unable to fully compensate Plaintiff for the services that it has rendered and continues to render to her in accordance with the terms and conditions of the Agreement. 12. Defendant's breach of his Agreement with Plaintiff has irreparably harmed Plaintiff. 13. Only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. 3 WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BpGAR LLC Dated: By: Brandon S. Williams Attorney I.D. No. 200713 (717) 909-5922 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 417 Walnut Street, 401 Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff 4 VERIFICATION The -undersigned hereby verifies that -the statements of fact in the foregoing document are -true and correct to the best of my knowledge, information and belief. I understand that any false statem.er?ts therein are subject to the per?alties contained in 18 Pa, C. S. § 4904, relating to unworn falsification to an+oriti es. Dated: ITV . (6,1 C q Michele Shughart, Billing Church of God Home, In$ EXHIBIT "A" (TO COMPLAINT) CHURCH OF GOD HOME, INC. ADMISSION AND C.A= AGREEMFM 206 THIS AGREEMENT is made on this -27 174- day of J ?UL?. L by and between The Church of God Home, Inc., called thef "Facility," a Pennsylvania non-profit corporation located at 801 North Hanover Street, Carlisle, Cumberland County, Pennsylvania, and L ?A ! A6 ? called "Res ident" and ?-I C E t° 1 CK.L/? called "Responsible Party" The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and understand that the submission of false information may constitute grounds to terminate this Agreement_* The Resident has applied for admission to the Facility and the Facility has approved the.. Application for Admission. Therefore, the Facility, The Resident and Responsible Party agree to the following terms•c 1. PROVISION OF SERVICES. The Facility will provide Resident with: (a) Skilled nursing care, i.e. professionally supervised nursing care and related health services under a plan of services regularly provided under a plan of care supervised by licensed personnel and, as required by the Resident' s. medical condition, assistance with activities of daily living. (b) Accommodations consistent with the level of care provided to the Resident including heat, air conditioning, electricity and hot and cold water. (c) Bed, bedding, blankets and laundered bed linens, towels .and wash cloths. (d) Three meals each day, except as otherwise medically indicated. (e) Activity programs and social services. 2. RECURRING CHARGES. In exchange for the above services, the Resident shall pay the following recurring charges: (a) For skilled nursing care: $?=v dollars.per day. Admission and Care Agreement - continued - 3-. N01T-RECtTP.R1'NG CHPRGES. The Resident shall pay the ollowing non.-recurring charges: (a) A security deposit in the amount of thirty-one (31) times the current daily rate for the level of care required by the resident, will be billed after admission day. The amount of the security deposit is $ No interest will be paid on the security deposit. A security deposit will not be charged to residents who are receiving benefits for room and board provided by Medicare, until the Medicare benefit concludes. An applicant who is covered by Medicaid is not required to pay a security deposit. (b) The cost for enrollment in the community ambulance and ALS (,Advance Life Support) Unit is $ ? . This fee must be paid prior to admission and will be billed annually to the.-Resident. 4. MISCELLANEOUS CEARGES AND OUTSIDE SERVICES. Resident is responsible to pay for other services provided by the-Facility which are not covered by the daily rate/charge. A list of such services /charges. is attached to this Agreement an the 'Chart of Costs." The services of a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, and- diagnostic services, will be made available at the Resident's expense. THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER OWN PRYSICIAN OR ANY OTHER SERVICE PROVIDER SO LONG AS THE PHYSIC=AN OR OTHER SERVICE PROVIDER IS PROPERLY LICENSED OR REGISTERED UNDER THE LAW, AND THAT ALL APPLICABLE GOVERNMENT RULES AND POLICIES OF THE-FACILITY ARE MET. in addition to the Facility's charges, the Resident is responsible to pay 'all fees and costs 'for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement. The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist,. therapist, diagnostic or test ing'laboratory, pharmacist, pharmacy, hospital, or any other person,' facility or entity providing services or goods to or for the Resident, and for all drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or services for the Resident. SUCH FEES AND COSTS ARE NOT INCLUDED IN TH? HOME'S DAILY RATE/CHARGE. Admission and Care Agreement - continued 5. ADMISSION. The Resident will be admitted, or a bed will be reserved for Resident, beginning on 3 c1 t y a7 20C)( All pre-admission charges will be billed after admission, and recurring charges will begin to accrue as of the above date. The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily rate for the reserved bed will continue to accrue and be payable until the reservation is terminated, even if the Resident does not enter the Home for whatever reason, including illness, injury, incapacity or death. 6. PERIODIC BILLINGS AND PAYMENT DUE DATE. (a) On the first of.each month, Resident will be billed the current daily rate for Resident's current level of care times the number of days. in the month. The bill is due and payable- upon receipt. (b) Miscellaneous charges (refer to "Chart of Costs" attached to this Agreement) such as hair care, personal laundry, incontinency, supplies, etc-, are. additional charges above the daily rate. These miscellaneous charges will be added to, and included with,. your monthly bill-' - (c) Pharmacy charges will be billed as a separate part of the Facility's monthly bill, and will require a separate check. (d) Outside providers will bill directly and separately. 7. ' CHANGES IN CHARGES. From time to time,the Facility may change the amount of its charges. In addition, from time to time, the Facility may change how and when its charges are -computed, billed or become due. The Facility reserves the right to make any such changes at any time. *Written notice of any such changes will be given to the Resident thirty (30) days in advance of implementation, unless' the change is required earlier under any federal or state law or assistance program. • a. PARTICIPATION :EN "MEDICARE/MEDTCA=" PROGR.ALMS. The Facility participates in the Medicare program administered pursuant to Title XVIII of the Federal Social Security Act and the Pennsylvania Medical Assistance Program ("Medicaid") administered pursuant to the Pennsylvania state plan and Title XIX of the Federal Social Security. Act. However, the Facility reserves the right to withdraw from the Medicare/Medicaid-programs at any time in accordance with the law. Admission and care Agreement - continued -9-. OBLIGATIONS OF RESPONSIBLE PARTY. The Responsible Party is responsible for services and supplies that are biped through the Facility or billed directly to the Resident or Responsible Party by any other Provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. 10. READMISSION - BED HOLD POLICY. If the Resident leaves the Facility for a period of hospitalization, therapeutic leave, or any other reason, other than the Resident's death, and if the Resident is not eligible for, or receiving medical assistance, the Resident's bed will be reserved and charges for the reserved bed will continue to accrue, unless the Resident or Responsible Party -otherwise directs in writing. If the Resident or Responsible Party elects not to reserve a bed, then the Resident 4rill be eligible for readmission upon the availability of the first bed suitable for the Resident's level of care. if the Resident is receiving medical assistance benefits and • the Resident leaves the Facility for - a period of hospitalization or therapeutic leave, the Resident's bed will he reserved for the applicable maximum number of days paid for the reserved bed under the Pennsylvania.Medical Assistance Program. The current-bed reservation period is fifteen (15) days for hospitalization., regardless of level of care, fifteen (15) days for therapeutic leave for residents receiving skilled nursing care,.. and thirty (30) days far therapeutic leave for residents receiving intermediate care. The bed reservation period may be subject to change in accordance with any changes in, the' Medical Assistance Program. if the period of hospitalization or therapeutic leave ends within the reservation period under the Medical Assistance Program, the Resident may return to the Facility. If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania. Medical Assistance Program, the Resident must wait until a suitable bed becomes available for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time of readmission, the Resident recsuires the services provided by the Home. 11. REFIINDS. The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Resident's discharge from the Facility or death. Those Nursing Residents on Medical Assistance will receive their refund, if any due,* within ninety (90) days. There will.be no other refunds, in the absence of an overpayment, under this Agreement. 12.. PERSONAL FINANCES. The Resident has the right to manage his/her personal funds. The Resident is and will be responsible to provide his/her personal funds. If the Resident elects, the Resident may designate, in writing, that the Facility hold and manage the Resident's personal funds. If the 'Resident Admission and care Agreement - continued designates someone other than the Facility to manage his/her personal funds, the Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to make any designation, and 'is responsible for his/her own personal funds unless such designation is made. The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal funds by providing the Facility a written notice signed and dated by the Resident or Responsible Party. . If the Resident transfers to the Home, responsibility to -manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which is- provided at the time of your admission, and the Facility's personal funds management policy. The Facility may deduct, at any time, charges due to the Facility under this agreement from. the Resident's personal funds managed by the Facility. 13. TERMINATION, TRA'N'SFER OR 'DISCHARGE. (a) By the Resident: .The- Resident may terminate this Agreement upon thirty (30) days written notice to the Facility. If the Resident leaves the-Facility for any reason other than a medical emergency or his/her death, the Resident must give written notice to the. Facility at least thirty (30), days in advance of the departure/ transfer/discharge at termination, of the Agreement. If advance written notice is not given to the Facility, 'there will be due to the Facility its daily and other charges then in effect for the Resident's current level of care for the required :thirty (30) day notice period. The charge applies whether or not the Resident remains at the Facility during the thirty.(30) day period. (b) By the Facility: The Facility may terminate the Resident's stay and transfer or discharge the Resident if: (I) the transfer or discharge is necessary.to meet the Resident's welfare which cannot be. met by the Facility; (II) the Resident's health or condition has improved sufficiently that'the Resident no longer needs the services .-provided by the Facility; (III) the safety or health of individuals in the • Facility is or otherwise would be endangered; Admission and Care Aureement- continued IV. The charges or other amounts due to the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf by Medical Assistance under the Medical Assistance Program or by Federal Medicare benefits under Title XV11I of the Federal Social Security Act: or V. The Facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none. a Family member or legal representative of the Resident, if known to the Facility. at least thirty (30) days in advance of such a transfer or discharge. However. in any case. describe in subparagraph (1). (I1) and (Ill) above, or if the Resident has not resided at the Facility for at least thirty (30) days. the Facility will give such notice before transfer or discharge as is practicable under the circumstances. 14. THIRD PARTY PAYMENTS- The Resident may be or may become eligible to receive financial assistance. reimbursement or other benefits from third- parties. such as through private insurance, employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program, Medicare benefits. supplementary medical or other health insurance, supplemental security income insurance. or old-aye survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident. the Resident/Responsible Party shall, at all times, cooperate fully with the Facility and each third-party payments. Cooperation includes. when requested. providing information. signing and delivering documents, and having the Facility designated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other governmental assistance. reimbursement or benefits to the extent of all charges due the Facility. The Resident irrevocably authorizes the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law. the Resident hereby assigns now or hereafter payable to the extent of all charges due to the endorse and turn over to the Facility any payments received from third-parties to the extent necessarv to satisfy the charges under this Agreement. Admission and Care Agreement- continued 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, personal possessions. and other items of property. The facility may limit the amount or type of property that the Resident may keep at the facility if there is insufficient space, or if medically indicated or necessary to protect the rights or welfare of others. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse regarding resident's personal property. If nametan labels are needed for clothing items, please leave them at the nursing station. 16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply filly with all govenunental laws and regulations, the provisions of this Agreement and the facility's existing policies, rules and regulations which may, from time to time. be altered or amended. 17. MISCELLANEOUS PROVISIONS a. The Resident and Responsible Party acknowledge that they are adult individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs- personal representatives, successors and assigned. c. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by competent legal authority to be invalid, the other provisions shall remain in fill] force and effect as if the invalid provision bad not been part of this Agreement. d. The Facility reserves the right to modify unilaterally the terns of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (;D} days notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. Resident/Responsible Party Resident Name Facility RelSresentative 7,27-a Date EXHIBIT "B" (TO COMPLAINT) CUMBERLAND CAO MEDICAID P.O. BOX 599 NOT ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLO 0036 101010000000x' CHURCH OF GOD HOME ATTN: BILLING 801 N. HANOVER STREET CARLISLE PA 17013 Notice ID: 91820174 PAGE 1 OF I CO RECORD < i:, DIST .% GAT .P'GG 21 0122974 0 oaf] 60 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 03/09/2009 NOT: 042 OPT: o TYPE: N IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY QUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY. You failed to provide the following information by 315/09: MA 51 with options determination report; Signed PA 4 authorization for release of information; verification of all gross monthly income; Statements for all bank accounts, cd iras, annufties,keoghs, stocks bonds, annuities as of requested effective date Personal care account balance, deed to property, current market value,if sold dispositon of funds received and settlement paperwork; verification of all resources sold transferred or given away; Statements for all bank accounts from 1/1/06 to 11/25/08 including PNC, citizens and member's lst; disposition of $75320 received from cash out of CD; tax assessment of property sold in 2007; verification that your total resources are below the $8000 limit REGULATIONS:55 PA Code 201.1; 201.3 MAR 2009 APPEAL AND FAIR HEARING, If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 03/7212009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. or., I AUDALIA A THOMAS CHURCH OF GOD HONE 801 NORTH HA14OVER STREET CARLISLE PA 17013 f ADDRESS? CU14BFP_LAND CAO P.O. BOX 599 33 WEST14INSTER DRIVE CARLISLE PA 17013-0599 MIDP£NN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 91820174 6 O r? O O O a 0 CD'. iRECORDi: `ii :plST:at: CAT d::S GG':;: PS '<;i.si 21 0122974 0 PA14 80 WORKER: J PEIPER APPEAL: 03/22/2009 TELEPHONE: (800) 269-0173 MAIL DATE: 03109/2009 NOT. 042 OPT: 0 TYPE N PAMA162A CONTINUED ON REVERSE SIDE PA/MA 162 12103 EXHIBIT "C" (TO COMPLAINT) CUI.IBER1-nJD CAO MLDIGAIIJ P.O. BOX 599 NOT ELIGIBLE 33 WESTMINSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CSLD 0036 `01010000000} CHURCH OF GOD HOME ATTN: BILLING 601 N. HANOVER STREET CARLISLE PA . 17013 Notice W: 93779574 PAGE 1 OF 1 co .':RECORD ::;'.;::?IST:`.S 21 0122974 0 PAN 00 WORKER: J PEIPER TELEPHONE: (800) 269-0173 MAIL DATE: 04/24/2009 NOT: 042 OPT: 0 TYPE: N IF YOU DO NOT UNDERSTAND OUR DeCJS1UN Ux nave am QUESTIONS, PLEASE CONTACT YOUR WORW IMMEDIATELY, You failed to provide the following informaiton by 4/23/09: Verification of disposition of the $102,000 received for 1/2 the value of the property sold at 1642 W. York Street Mechancisburg PA 17055; Statements for citizens bank account XXXXX 3694 from 9/1/07 to present showing deposit of money received from transfer of the home and dispositions of funds in account REGULATIONS:55 PA Code 201.1; 201.3 . If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearing. If you are currently receiving benefits and your.. oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 05/0712009 your assistance' will continue pending the hearing decision, except when the change is due to State or Federal law. AUDALIA A THOMAS CHURCH OF GOD HOME 801 NORTH HANOVER STREET CARLISLE PA 17013 CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 APR 21 2009 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 93779574 -Cl) RECORDr`i ==i)1.ST,=-:?CAT(_;GG < PS `i 21 0122974 0 PAN 00 WORKER: J PEIPER APPEAL: 05/07/2009 TELEPHONE (800) 269-0173 MAIL DATE: 04/24/2009 NOT: 042 "OPT: 0 TYPE: N 0 0 0 ??s o PAMA162A CONTINUED ON REVERSE SIDE PAIMA 162 12103 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Alice Bricker 1710 Lisburn Road Carlisle, PA 17013 Defendant Date: < < a °? William Keslar, Paralegal FILF.C?-" =F1CF CF THE: H' LDIT--IMY 2 009 KUN 41 0 t i 1 3 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. Plaintiff, V. ALICE BRICKER, Defendant. No. dQ -e 1. !t? c l? l S'L. CIVIL ACTION - EQUITY i111ww ORDER ?'?'l AND NOW, this day of I" 2009, a hearing in the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for T , 200-0-,at • * V 0 o'clock P.m. in Court Room No. , Cumberland County Courthouse. BY TH RT: J? 7HE P f O ?APy 2009NOV 25 ?? ffl. c' f CUM6. (1