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HomeMy WebLinkAbout01-22-10s IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ~ IN RE: LOUISE CARL, An Alleged Incapacitated Person _Po ~~,~~ ~-c~_. rn _ ~ _~ a_:1'3 ~- O.C. No. 2109-04~? TYPE OF PLEADING: -..~ N N .. _.,_ . , ~~; _ 4 . _.,. t' .,_.7 f .... ~ ~ ~`, ') r' PETITION UNDER ~ 5511 OF THE PROBATE, ESTATES AND FIDUCIARIES CODE TO ADJUDGE LOUISE CARL TO BE TOTALLY INCAPACITATED AND APPOINT A PERMANENT PLENARY GUARDIAN FOR HER PERSON AND ESTATE FILED ON BEHALF OF: Petitioner, Guardian Elder Care, LLC d/ b/ a Forest Park Health Center COUNSEL OF RECORD FOR PETITIONER: Brandon S. Williams Attorney I.D. No. 200713 417 Walnut Street, 4~ Floor Harrisburg, PA 17101 717) 909-5922 Chadwick O. Bogar Attorney I.D. No. 83755 417 Walnut Street, 4~ Floor Harrisburg, PA 1710 (717) 909-5920 ORIGINAL IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: LOUISE CARL, An Alleged Incapacitated Person O.C. No. 2109-04~ -~ o .,. J t.t PETITION UNDER $ 5511 OF THE PROBATE, ~` r r; ESTATES AND FIDUCIARIES CODE TO AD UDG~; t LOUISE CARL TO BE TOTALLY INCAPACITATED-' z; AND APPOINT A PERMANENT PLENARY GUARDIT FOR HER PERSON AND ESTATE To The Honorable Presiding Judge of Said Court: :+~ x~• .: ca AND NOW, COMES, Guardian Elder Care Home and Community Services, LLC d/b/a Forest Park Health Center ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, and hereby petitions for an adjudication of incapacity and appointment of a permanent plenary guardian of the person and estate of Louise Carl and, in support thereof, represents as follows: 1. The alleged incapacitated person, Louise Carl ("Ms. Carl"), is a 72-year- ~~ ~ _I l I i ,~ ~ i„J r` ~~ ~.,~ old individual who currently resides at Petitioner's skilled nursing facility located at 700 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Petitioner is a domestic limited liability corporation, with its principle place of business located at 1217 Slate Hill Road, Camp Hill, Pennsylvania 17011. 3. On August 22, 2008, Ms. Carl was admitted to Petitioner's Facility, and her friend, Fred Habig, signed the Admission Agreement. See Admission Agreement, attached as Exhibit "A." 4. Because the alleged incapacitated person resides in Cumberland County, this Court has Jurisdiction pursuant to ~ 711(10) of the Probate, Estates and Fiduciary Code and § 5512(a). 5. Upon information and belief, Ms. Carl has no next of kin who are sui juris. 6. Petitioner is currently Representative Payee for the Social Security and Black Lung benefit income the alleged incapacitated person receives. 7. Petitioner receives Black Lung benefits in the monthly amount of $616.00, and Social Security benefits in the amount of $935.40 per month on behalf of the alleged incapacitated person. 8. Pursuant to Petitioner's efforts, Ms. Carl has been qualified for Medical Assistance benefits. Accordingly, pursuant to the direction of the Commonwealth of Pennsylvania Department of Public Welfare, the alleged incapacitated person's income has been used to satisfy the patient pay obligation portion of her long term care bill. 9. The alleged incapacitated person's treating physician is: Dr. Daryl Guistwite 522 South Pitt Street Carlisle, PA 17013 (717) 609-2052 10. Ms. Carl, the alleged incapacitated person, has been diagnosed by Dr. Guistwite as suffering from "failure to thrive-Adult Mental Retardation." Ms. Carl's mental conditions have caused her incapacity and require that she receive 24-hour-a- day care. 11. Because of Ms. Carl's diagnoses, she is totally unable to manage or even appreciate the significance of her personal and financial affairs and to make and communicate any decisions relating thereto, including the ability to communicate her need for assistance in these areas. 12. Presently, to the extent of Petitioner's knowledge and upon information and belief, Ms. Carl does not have a capable agent, guardian, or next-of-kin to manage her personal or financial affairs. 13. There are no less restrictive alternatives to the appointment of a permanent plenary guardian of the person and estate of the alleged incapacitated person. 14. The proposed guardian of the alleged incapacitated person is Brian D. Brooks d/ b/ a Pennsylvania Guardianship Association, P.O. Box 7295, Lancaster, Pennsylvania 17604. Brian D. Brooks does not have any adverse interest to the alleged incapacitated person and an acceptance to serve as guardian of the person and estate is attached hereto as Exhibit "B." 15. Brian D. Brooks has been suggested as guardian of the estate of Louise Carl because of his experience in dealing with incapacitated persons such as Ms. Carl. 16. This Court, by Order of May 21, 2009, had previously appointed Shaun O'Toole, Esquire Emergency Limited Guardian of the Estate of Louise Carl. 17. Upon information and belief, Ms. Carl was not a member of the Armed Service of the United States and, therefore, is not receiving any benefits from the United States Veterans' Administration. 18. Upon information and belief and to the extent of Petitioner's knowledge, the alleged incapacitated person does not have a will. WHEREFORE, your Petitioner prays your Honorable Court to award a citation directed to the alleged incompetent, Louise Carl, to show cause, if any there be, why she should not be adjudged incompetent and Brian D. Brooks d/b/a Pennsylvania Guardianship Association be appointed permanent plenary guardian of her person and estate. Respectfully submitted, Dated: 2q f ~ By. Ll Ql LI.LVl L J. V V 1111dIIIS - Attorney I.D. No. 200713 (717) 909-5922 Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 417 Walnut Street, 4~ Floor Harrisburg, PA 17101 Attorneys for Petitioner SCHUTJER BOGAR LLC 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: /-/~-~~/~' , -~ ~~ Dawn Jordan, Bill' g Supervisor Guardian Elder Care Services, LLC d/ b/ a Forest Park Health Center FOREST PARK HEALTH CENTER NURSING CARE ADIVIISSI.UN AGREEMENT This Nursing Care Agreement is made by and between Forest Park Hea1tl~ ~Cc~nter (hereinafter called "Facility") - .~~__~,,~~ 1 (hereinafter called Resident } Y. ~~ ' '~~ ~`'~'~~ ~ ~'~ (hereinafter called "Financial Responsible .Person"), and {if an ~ ~.d ~ ~ -~` ~ `~' ~ ~ {hereinafter called "Health Care Res onsibl } P ~ Person"}. Resident, Financial Responsible Person, and Health Care Responsible Person (if any) affirm that the information provided in alI admission documents is true and correct to the best of their knowledge, and acknowledge .that the submission of any false information and/or omission of material information may result in the termination of this Agreement and personal financial liability, including attorney fee's, costs, interest and lost revenue. .~ Therefore, Facility, Resident, Financial Responsible -Person and Health Care Responsible Person agree to .the following terms and: conditions: I- PR4VISIDN OF SERVICES. 1.1 Nursing Services. Beginning on ~ ~~ ~~. -- ~c,~ the designated admission date, Facility will provide Resident with (a) the routine nursin services described in the Rate Schedule attached to this Agreement and incorporated bg reference; {b) private or / semi-private accommodations; {c) three meals each day and snacks, except as otherwise medically indicated; {d) blankets, bed linens, towels and wash cloths; (e) launderin of linens and towels, b ' (f) housekeeping services; (g) activity programs and social services as established by Facility; (h) routine ersonal laundry; (i) hospital gowns and routine surgical dressings; and (j}~ certain ~ e of over the counter medications: as provided by law. Not included in the dail p r ~ntr'avenous services and supplies; oxygen and supplies; incontinence y ro~ucts• ambulance costs, physician fees; most pharmaceutical drugs; personal dry pleanin ; rned~cal tests; Iaboratory tests; private telephone/services or television; x--rays; or special nursing supplies not considered routine. ~.2 Ancillary Services. Facility will provide ancillary services identified in the Admission .Package of information provided prior to or at the time of admission at the option and upon the request of the Resident, or upon the direction of Resident's treating physician or Facility's Medical Director. The ancillary services and associated charges are .identified in the Admission Package of information and are subject to change at the discretion of Facility. I.3 Services of Other Providers. The services of outside providers such as a licensed physician, dentist, licensed pharmacy for the provision of pharmaceutical . supplies, a licensed hospital, diagnostic services, laboratory, x-ray, podiatry, aptorr~etry, medications, ambulance services and hearing aid repair may be available from time to time at the Facility. These services are available under guidelines and procedures established by Facility and may be utilized by Resident at his or her own expense. :Resident may choose to utilize providers of his, or her own cl-coice; however, the services and goods provided must meet the standards established b Fac~Iaty. Y 1.4 Role of Primary Medical Physician and Medical Director. The Resident shal~I obtain the services of a qualified. physician who will provide medical care during the Resident's stay at Facility. The Resident`s physician is an independent licensed professional who is not an employee of the Facility but who shall comply with Facility's rules, regulations, policies and procedures. Facility is not obI' ted to rovide Resident with any medicines, ~ p treatments, special diets or equipment without specific orders or directions from Resident's Primary Medical Physician. In the event Resident's personal physician is unavailable, Facility's Medical Director may issue appropriate orders. Resident is responsible to pay for all services ox equipment ordered b Resident's Primary Medical Physician or Facility's Medical Director for Resident's care ~ 2. CHARGES. 2.~ Recurrin~/Periodic Charles for Routine Nursing Services. Resident shall pay the Basic Daily Rate, specified in the rate schedule in effect at the hme the service is rendered, .for routine nursing services provided t~ Resident. The Basic Daily Rate may be changed from tune-to-time in accordance with the provisions of Section 3.3. Charges for a resident whose payor source is other than Medicare Part A or Medical Assistance will begin on the designated admission date or actual admission, whichever is sooner; charges for a resident whose payor source is Medicare Part A or Medical Assistance will begin no sooner than the date of adrnissio~. (The term "Medical Assistance" is a reference to Pennsylvania's Medicaid program.) 2.2 Additional Charges for Ancillary Services. Resident shall pay for other services and supplies provided by or through the Facility, which are not covered by the Basic Daily Rate as set forth in the Admission Package of information provided prior to or at the time of admission and in effect a t the tune such ancillary services are rendered. 2.3 Charges for t3utside and NorY Faciliit~ Services. In addition to Facility's charges, Resident shall pay all fees and costs for goods or services furnished to or for Resident by anyone other than Facility as described in Subsection 1.4 (Role of Primary Medical Physician and Medical Director) unless otherwise covered in full b Medicare or Medical Assistance or another third- ar a or. Resident or Responsible Person is obligated to pay such fees and costs whether the goods and services are i any 2 f furnished by a person or provider made available by Facility, or by ~a person or provider selected by Resident, and whether the goods or services axe provided at Facility or elsewhere. These fees and costs are not included in the Basic Daily Rate. Fees for professional services rendered by a physician are not included in the Basic Daily Rate and will be charged directly to the Resident by the physician. 3. PERIODIC BILLINGS AND PAYMENT DUE DATE. 3.1 Monthly Statements and Other Biliin~. Vllhen permitted by Iaw, prepayment for the basic monthly rate of the current month is required at the time of admission. FaciiIity will mail to Resident or Financial Responsible Person at the beginning of each month a billing statement reflecting charges for nursing services for the upcoming month and charges for ancillary services and supplies, which were incurred in the prior month. Statements are due and payable on receipt. All payments shall be directed..to: ~ GUAI{DIAN LTC MAr+TAGEMENT INC. PO BOX 24Q BROCKWAY, PA 15824 3.2 Late Charles and Cost of Collection. Any invoices not paid within thirty {30) days of the date of the invoice are subject to a late charge of one and one-half percent {1.50%} per month; for the annual rate of eighteen percent (18%), and Resident or Financial Responsible Person is obligated to pay any late char es. In the event Facility initiates any legal actions or proceedings to collect ~paymentg due from Resident under this Agreement, Resident or Financial Responsible Person shall be responsible to pay all attorney`s fees, costs, interest and lost revenue incurred by Facility in pursuing the enforcement of Resident and/or Financial Responsible person's obligations under this Agreement_ 3..3 Modification of Char es. Facility reserves the right to change the Room Rate Schedule. reflecting the amount of any of its charges or how and when charges are computed, billed or become due. Facility shall provide thirty (30) days advance written notice of any such changes. 3.4 Obligations of Resident's. Estate and Assi~z~tment of Property. Resident and Financial Responsible Person acknowledge that the charges for services provided under this Agreement and any and all costs incurred by Facility to enforce this Agreement remain due and payable until fully satisfied. In the event of Resident's discharge for any reason, including death, this Agreement shall operate as an assignment, transfer and conveyance to Facility of so much of Resident's property as is equal in value to the amount of any unpaid obligations under this Agreement. This assignment shall be an obligation of Resident's estate and may be enforced against Resident's estate. Resident's estate shall be liable to and shaiI pay to FaciIiry an amount equivalent to any unpaid obligations of Resident under this Agreement. 4. OBLIGATIONS OF FINANCIAL RESPONSIBLE PERSON. 4.1 ~ General. Resident shall have the right to identify a Health Care Responsible Person (usually this person is the Resident's Power .of Attorney or Guardian of his -or her Person}, who shall be entitled to receive notice in the event of transfer or dischprge or material changes in the Resident's condition, and changes to the Admission Agreement_ Resident is not required to Warne a Health Care Responsible Person. Resident elects to name as his-/her Health Care Responsible Person. Resident shall ident y a Financial Responsible Person (usually this person is the Resident's Financial Power of Attorney or Guardian of l~s/her Estate) at the time of admission. Resident elects to name '~" as his/her Financial Responsible Person. Resident's Financi 1 Responsible Person shall sign this Agreement in recognition of this designation with the intent to be legally bound by alI provisions in this Agreement. The Financial Responsible Person shall be obligated to .fulfill the financial duties on behalf of the Resident imposed by this Agreement. The Facility may petition a court to appoint a Guardian and take other legal action if Facility reasonably believes that the Resident's needs are not being properly met or the .duties unposed by this Agreement are not being fulfilled -by either the Health Care or Financial Responsible Person. lesident, Resident's estate, or Health Care or Financial Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. 4.2-. Obligations and Potential Liability. This Agreement shall not be construed or operate as a third party guaranty. Financial Responsible Person is obligatted to pay Facility from Resident's financial resources for services and supplies provided to Resident in accordance 'with this Agreement. If :the Financial Responsible Person. has previously transferred, converted and/or withholds. or misappropriates Resident`s financial resources for personal benefit or gifts, or ocher?wise has not or does not use the Resident's financial resources to fulfill Resident's financial obligations to the Facility for services and supplies provided to Resident in accordance with this Agreement, then Financial Responsible Person shall be liable for payment up to the value of the misused. or misappropriated property. Financial Responsible Person is also obligated to pay Facility for all losses or damages incurred by~ Facility by khe failure of the Financial Responsible Person to fulfill his/her duties under this Agreement, Failure to do so will resul# in legal action by Facility to assure payment for amounts that are Resident's obligations. In the event Facility initiates any IegaI actions or proceedings to collect .payments due from Resident and Financial Responsible Person under this Agreement, or to enforce Responsible Person's obligations under this Agreement and/or the Responsible Person Agreement, then Resident and Financial Responsible Person shall pay all damages; attorney's fees and costs incurred by Facility in pursuing the enforcement of Resident's andfox Financial Responsible Person`s financial or other obligations under this Agreement. Such damages, fees and costs may include, in the discretion of Facility, an amount equivalent to revenue Lost by Facilfty due to Financial Responsible t1YVTLL Person's failure to timely submit or complete a Medical Assistance application or to cooperate with tie Pennsylvania Departm~ent~ of Public jlllelfare (hereinafter "DPW") in the Medical Assistance eligibility determination. The failure to initiate, make or complete the Medical Assistance application process on the Resident's behalf may result in the discharge of Resident for non-payment and personal liability to Financial Responsible Person for losses incurred by Facility for Financial Responsible Person's failure to apply timely for Medical Assistance benefits. Facility reserves the right to assist Financial Responsible Person in making application for Medical Assistance. If Facility, .in its sole discretion, however, decides to. assist the Financial Responsible Person in the l~ledical Assistance application process, Resident and the Financial Responsible Person are still. fully obligated to initiate, make and complete the Medical Assistance .application. The Facility's. assistance in the Medical Assistance application process does not waive Resident's or Financial Responsible; Person's duty or responsibility to timely complete and submit a Medical Assistance application if the Resident`s financial resources become insufficient to pay amounts due under this Agreement. When Financial Responsible Person makes application for Medical Assistance benefits, Financial Responsible Person shall assign the Patient Pay amount to the Facility as estimated by Facility and County Assistance Office in accordance with DPW Regulations..See Section 5.3. If. Resident is determined to be i~neiigible for Medical Assistance because .Financial Responsible Person fails to provide or submit necessar documents or fails to appeal timely so that Facility is unable to ;obtain Medical Assistance reimbursement, then Facility may terminate this Agreement for non- payment of stay, and Financial Responsible Person shall be liable for any Iosses, including attorney's. fees, ousts, interest and lost revenue, sustained by the Facility as a result of such failure: Financial ,Responsible Person shall be responsible for compliance with all other appIicabie terms of this Agreement. 5. MEpICARF~/MEDICAL ASSISTANCE PROGI~AMS_ 5.1 : Participation ~'n Pro ams. Facility currently participates in the Pennsylvania Medicaid program ("IVledical Assistance"} and the federal Medicar program. Facility reserves the right to~ withdraw from the Medical Assistance or Medicare programs at any time in accordance with taw. 5.2 Actions of Medical Assistance and Medicare A encies. The Pennsylvania Department of Public Welfare ("DPW") is responsible for administerin benefits under the Medical Assistance program. The Centers for Medicare and Medic Assistance Services ("CMS"), of the United States Department of Heath and Human Services, is responsible for administering the Medicare program throu h an intermediary. Resident and Financial Responsible Person acknowledge that Facgili is not responsible for, and has made no representations regarding, the actions or decisions of DPW, CMS or the Medicare intermediary in administering the programs. 1()07fifi Jr 5.3 Medical Assistance $enefits. (a) Cabligations of Resident. Resident is obligated to make full and complete disclosure regarding aII .financial resources and income during the application process, including all transfers of assets and/or financial resources having taken .place within the preceding .five .years of the date of application for admission to Facility. Failure to identify all resources, income, and transfers or the submission of false information may result in the termination of this Agreement and financial liability. Resident and/or Financial Responsible Person is obligated to notify Facility when only Fifteen Thousand Dollars ($15,000), or the value thereof, exists to satisfy the Resident's financial obligations under this Agreement. Resident is obligated to apply for Medical Assistance benefits at such time as Resident's resources will no longer be sufficient to pay all Facility charges for Resident`s care and stay. fib) Patient Pay Amount. For residents approved for Medical Assistance benefits, Facility will accept payment from DPW and, if applicable, the Resident's Patient Pay Amount as determined by DPW as payment n~ full only for those services covered by the Medical Assistance program: During the period of time that the application for ~ Medical Assistance benefits is pending, Resident and/or Financial Responsible Person is obligated to assign such Patient Pay Amount as estimated b, Facility and the Local County Assistance Office, less any qualified medical expense deductions, on a monthly basis at the time of application for Medical Assistance benefits: Services not covered by Medical Assistance are identified in the Medicaid Handout, and. Resident remains obligated to pay for such services. (c) Determination of Eligibil ty. Resident and Financial Responsible Person are obligated to cooperate fuilly in any Medical Assistance ell ibili determination or redetermination process_ In the event that Resident's ell ibilgi for Medical Assistance benefits is denied, interrupted or terminated due to th ~ failure of Resident or Financial Responsible Person to cooperate in the Medical Assistance application, redetermination or appeal process, the' Resident and Financial Res onsible Person shall be liable for. the applicable Basic Daily Rate plus charges for ncillar services and supplies, during any period of non-payment. ~ y ~d) Authorization to AvvIy for an for Appeal rMedicai Assistance . In the event of Resident's ~ncapac~ty and in situations where Resident's resources are depleted or appear to be depleted to the extent that Resident can no longer pay privately for nursing care, and it appears that Resident has become or will become eligible for Medical Assistance benefits to cover the cost of Resident's continued stay in the Facility; and if there is no other legal representative of Resident known to the Facility or other friend or relative known to the Facility who is authorized and/or is available or willing to act on Resident's behalf, after the Facility has made a good faith effort to identify such persons; then Resident hereby authorizes the Facility to request, file and/or apply for Medical Assistance benefits on behalf of Resident for the limited purpose of assisting Resident to secure payment through the Medical Assistance ~ t~o;~ 4 program for iesident's continued. stay in the Facility, In the event the application for Medical Assistance benefits filed on behalf of the Resident is denied, ar in the event Medical Assistance benefits are granted and subsequently discontinued, Resident hereby authorize$ the Facility to file an Resident's behalf an appal of an such denia of Medical Assistance eligibility or discontinuance of~ MedicaI Assistance benefits~~ I to take such actions to secure Resident's Medical Assistance benefits as the Fac lied deems reasonably necessary or appropriate and consistent with law. Resident warrants. and represents that. the financial information disclosed in the admission documents is true and accurate and may be relied on by the Facility in pursuing Medical Assistance benefits on behalf of .Resident. 5.4 Medicare Part A and Part B Benefits. To the exten~~ that Resident is a beneficiary under either Medicare Part A or Medicare Part $ insurance and the nursing. services or ancillary services or supplies ordered by a physician are covered b such insurance, the Facility or oilier provider will bill the char es for y services or supplies to the Medicare program. The Resident is res onsibI .the covered pay any coinsurance or deductible amounts under Medicare Part a for and shall Insurance. Facility shall accept payment from the Medicare intermedia a or Part B full only for those services deemed to be covered in full under the Medicare Part A ~n the, Medicare Part B program. Services not covered by Medicare are identified in the Admiss2on Package of information provided prior to or at the time of admission. 5.5 . Non-Covered Services. Resident is and remains obligated to a Facility for services and supplies not covered by the Medical Assistance or the 1VI p y programs edlcare 5.6 Medicare Part D Pxescri Lion Dru Benefits. {a) Enrollment in Medicare Part D Plan. If Resident is an eligible beneficiary under the Medicare Part D insurance program and has enrolled or has b mandator~ly enrolled in a Medicare Part D Prescription Drug or Medicare Advanta e n Plan {"l'DP"}, Resident shall advise Facility in writing of Resident's chosen PDP u on admission. In the event that Resident. becomes an eligible beneficiar under MedP Part D after admission, or subsequently chooses to enroll in a PDP f Ilowin adm s re Resident shall notify Facility in writing.oE Resident`s chosen PDl' rior to e ~ sion, the PDP, .Resident shall advise Facility if Resident elects to than e PDPs and llrnent In provjde written notice of such eIectio.n, including the name/ide ht of the n w a~I selected PDP prior to the effective date of the change in the PDP. y e ly {b) Resident's Res onsibiIi to Pa for Pharmaceuticals. Resident is responsible to pay the charges for all prescription and other drugs or medications while a resident in Facility, except to the extent that such drugs and medications are covered in whole or in part by any applicable government reimbursement ro am. So of the charges for prescription drugs and other drugs a.nd medications rrla be ov or alI by certain benefits available through Medicare fart D or other private insurance ered or 1 fVY7[L governmental insuranr%benefitpr~grams,-includin~Ivl~d~i~a~e-Pa~t-i~~~B-l~-the' ~ - provided to Resident is denied by any applicable governmental reimbursement program or other potentially available third party payor or insurance program, then Resident or Responsible Person shall remain responsible to pay for all such. prescription drugs, supplies,. other medications or..pharrnaceutiraLs~. __ ._.. _ _ .. (c) Actions of Medicare Part D Plan. Facility is not responsible for and has made no representations regarding the actions or decisions of any PDP, including, but not limited to, decisions relating to the establishment of the PDP formulary, denial of coverage issues, or contractual arrangements between the PDP and the Resident, and with xespect to any decisions made by the PDP relating to any Iong term care pharmacy provider that may be ender contract with Facility. (d) Dually Eligible Residents. If Resident becomes eligible for Medicaid at any:time during Resident's stay at Facility, and also qualifies for benefits under the Medicare Program, then Resident shad be required to enroll in a PDP to ensure coverage~of Resident's prescription. drug needs. Resident and/or Responsible Person shall take aII necessary action to enroll Resident in a PDP, and shall advise Facility of such enrollment upon Resident's acceptance into the PDP. Resident acknowledges that should Resident and/or Responsible Person fail to select a PDP, then the federal Centers for Medicare and Medicaid Services ("CMS") will assign Resident to a PDP. Resident.shall provide written notice to Facility of the name. of the Resident's PDP and the effective date of enrollment. (e), Biilin~ and Resident Cost.Sharing Qbli ations. To the extent that Resident is a beneficiary under Medicare Part D, and the pharmacy prescriptions and/ or services ordered by a physician are covered by Medicare Part D, then the Pharmaceutical Provider (as required by Iaw} shall bill the charges for tl-~e covered services to the Resident's PDP. Resident is responsible for and shall pay any and all cost=sharing amounts alaplicable~under Medicare :Pant D insurance_ Facility shall not be responsible to pay for any fees or cost-sharing amounts, including co-insurance and deductibles, relating to the provision of covered Medicare Part D pharmaceuticals to Resident. To the extent that Resident may qualify as a "subsidy eligible individual" who would be entitled to a reduction or elimination of some or alI of the cost-sharing or premium amounts~under the Medicare Part D benefit, Resident and/or Responsible Person has the sole responsibility to apply for such benefits. tf). Authorization to Request and/or Appeal Coverage Determinations. In the event that Resident is denied coverage under Resident's PDP for pharmaceutical services or supplies prescribed by Resident's attending physician, then the following shall apply: (1} Resident and/or Responsible Person may independently (i} request an exception from Resident's PDP to cover non-formulary or non-covered 1IX}%(~f, O Medicare Part D rugs that are otherwise needed or required by Resident; (.ii) file a request for a redetermination of any coverage denial issued by Resident's PDP ; (iii} file an appeal with the appropriate agency and judicial tribunals to challenge any denial of a request for redetermination. ` (2) In the event of Resident's incapacity, anti if there is no other ]egal representative of Resident known to the Facility or any other friend or relative known to the Facility who is authorized and/or.is promptly available or willing to act timely on behalf of Resident, or if R•esident's physician is unable or unwilling to act on behalf of Resident, then Resident authorizes Facility to ~(i) xequest an exce tion from Resident`s PDP tq cover non-formulary or non-covered Medicare Part D dru s that are otherwise .needed or required by Resident; (ii} file a request for a redetermination of any coverage denial issued by Resident's PDP; (iii} file an appeal with the appropriate agency a.nd judicial tribunals to challenge any denial of a request for redetermination. j(3) Iii the event of an initial denial of coverage.b the Resident's PDP, then pending the outcome of an exception request, a request .for redetermination or an appeal, and in the event that Resident's attending physician fails to prescribe a clinically and reasonably acceptable substitute prescription medication, Resident authorizes the Facility's Medical Director to prescribe a clinically and reasonably acceptable. substikute prescription medication which is covered by Resident's PDP, i.f such clinically and reasonably acceptable substitute is. available.] • (4} If a request for exception filed by Resident,;Facility or any other authorized representative} is ultimately denied followin either recon " by the PDP or appeal to an appropriate tribunal, and if the re ~ ested harmaderation q p ceu heals are. deemed medically necessary by Resident's physician, and na reasonably acceptable substitute, as determined by Facility's IVledicaI Director, from the forrnular of Resident's PDP exists, then Facility shall make arrangements to provide the re uested pharmaceuticals to Resident through an arrangement with an outside pharmac . In any such situation, Resident shall be responsible to pay all fees and costs for the non- covered. pharrnaczuticals, consistent with the requirements of this Section. (g) No Effect on Medicare Part A Covered Nursin Services. Resident's Medicare Part D prescription drug benefits do not apply while the Resident's stay in Facility is covered under Medicare Part A. While Resident is in Facility on a Medicare Part A stay, Resident's pharmaceutical needs generally are covered by the Medicare Part A program.. ~• MANAGED CARE ORGANIZATIONS, 6•~ Participation in Managed Care Or~anizations..Facility may be an authorized provider of skilled nursing services to members of certain rnana ed care organizations ("MCC~s"}. The MCOs for whom Facility is an authorized. prow der are identified in:the Admission Package of information provided prior to or at the time of admission 6.2 Enrollment in a Managed Care Or anization. Resident shall notify Facility in writing prior to enxolIing with a MC:O. or switching Resident's MCO enrollment. . r' 6.3 Actions of 1VIanaged Care Organizations. Resident acknowledges that an MCO for whom Facility is not an authorized provider may not approve payment for services provided by Facility. Resident acknowledges that .Facility is not responsible for end has made no representations regarding the actions or decisions of any 1V1C0 for whom Facility is an authorized provider, including decisions relating to denial of coverage. 6.4 Obligations of Resident. Facility will accept payment from the MCO as payment in full only for those services and supplies covered by the IviCO and determined to be paid in full by Agreement between Facility and MCO_ Resident is responsible for any co-payments or other costs assigned to Resident under the specific terms of the managed care plan. Resident also shall pay for any services or supplies not covered by the IVlCC) under the specific terms of the managed care plan. Co-payments and other costs assigned to Resident and charges.for services or supplies not covered by the specific terms of the managed care plan are identified in the Admission Package of information provided prior to or at the time of admission. Managed care plans typically require pre-authorization of services by the MCO. If Resident chooses to have services which the MCO refuses to pre-authorize, Resident shall pay Facility for those services. Resident shalt pay the Facility in a timely manner for all non-covered services retroactive to the date of the initial delivery of services. 6.5~ Withdrawal from Participation in the 1VIC0. Facility reserves the right to terminate its contractual relationship and its status as an authorized provider with one or more of the listed MCOs at any time in accordance with law and the terms of the applicable agreement. In the event that Facility terminates its contractual relationship° with the MCO in which Resident is enrolled, Resident may convert his or her coverage to a health plan for whom Facility is an authorized provider or transfer to a Facility that is an authorized provider for Resident's MCO. Facility shall provide thirty (30) days advance notice of its decision to withdraw as a participating provider from Resident's MCC) so Resident and the MCO can coordinate a transfer to another Facility. 6.6 Notice of Change in Insurance Coverage. Resident and/or Financial Responsible Person shall notify the Facility immediately of any change in Resident's insurance status or coverage. 7. DURABLE FINANCIAL POWER-OF-A'Y'I'ORNEY. Resident is strongly encouraged to Furnish to Facility, no later than the date of admission or within five days} of admission, a Durable Financial Power-of- Attorney executed by Resident relating to financial decisions and payment for services. The Durable Financial Power-oF-Attorney shall be maintained in, tl~e~files of Facility. The name, address and phone number of .Attorney-in-Fact: In the event a Durab.Ie Financial Power-of-Attorney does not exist and if Resident is eon~petent or becomes competent to declare an individual to serve as Power-of-Attorney, every effort will be expended to obtain such. authorization as soon as practicable. In the event Resident fails to designate an Agent under aPower-of- Attorney, Resident shall be responsible to pay for any guardianship proceedings related to the appointment of someone or a legal entity to make decisions an behal f of Resident, if and when Resident Tacks capacity to make such decisions as determined by Facility. 8. THIRD-PARTY PAY1ViENT5. 8.1 Eligibility for Third-Party Payments. Resident may be or may become eligible to receive financial assistance, reimbursement, or other benefits from third parties, such as private insurance, employee benefit plans, Medical Assistance benefits under tthe Pennsylvania Medical Assistance Program, Medicare benefits, .managed care ;coverage, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance. It is the responsibility of the Resident to apply for these benefits. If Resident is or becomes eligible. to receive payments from any third parties for ;Resident's stay and care, Facility reserves the right to collect such payments directly from the third-party source. The Resident and Financial Responsible Person shall at all times cooperate fully with Facility and each third-party payor to secure payment. Cooperation includes providing information, signing and delivering documents, and assigning to Facility (to the extent permuted by Iaw}any payments for the Resident from Federal Social Security benefits or from any other federal or state governmental assistance programs, reimbursement or benefits to the extent of all amounts due the Facility. Resident and Financial Responsible Person agree to reimburse Facility for any and alI costs incurred by Facility to coIIect such payments directly from the third-party source. 8.2 Assignment of Pa, ments. Although it is the responsibility of Resident and Financial Responsible Person to secure payment from third-party resources, including but not limited to Medical Assistance Benefits, Resident irrevocably authorizes Facility to makes such claims and to take such actions as it deems necessary to secure for the Facility receipt of third-party payments, including but not limited to Medical Assistance Benefits, to reimburse Facility for its charges for the stay and care of Resident. (This includes but is not limited to filing an application far Medical Assistance Benefits and pursuing any and all appeals there from in the event the app}ication .is denied.) To the fullest extent permitted by Iaw, as security for payment of FaciIity's charges, Resident hereby assigns to Facility all of Resident's rights to any third-party payments now or subsequently payable to the extent of all charges due under this Agreement_ (This includes but is not limited. to Medical Assistance Benefits.) .Resident or Finanrial~ Responsible Person promptly shaIi endorse and turn over to Facility any payments received from third parties other than Medical Assistance Benefits which are paid directly to Facility to the extent necessary to satisfy the charges under this Agreement. t 8.3 Insurance. In the event of an initial or subsequent denial of coverage by the Resident's insurance company, Resident shall pay ~aciIity timely for all noncovered services retroactive to the date of the initial delivery of services. 9. PERStJNAL FINANCES. 9.1 Personal Funds Mana eg. ment. Resident is responsible to provide his or hex personal funds, and .Resident has the right to manage his or her personal funds. Resident may authorize Facility, in waiting on a document provided by Facility, to hold Resident's personal funds, and may revoke at any time Facility's authorization by providing Facility with a written notice signed and dated by Resident or either Responsible Person. If Resident authorizes Facility to hold Resident's personal funds, the Facility shall hold, safeguard and. account for Resident's personal funds in accordance with applicable provisions of Facility Policy. This section does not refer to the financial assets of the Resident except for those funds required by law or established by Facility policy as the minimal personal funds of Resident. The Facility does not assume any obligation to provide financial or investment advice, nor to file any tax documents or other reporting documents except as required by the Iicensurefcertification regulations governing nursing facilities. 9.'~ Refunds of Personal Funds. Any personal funds or valuables of Resident held by Facility will be refunded within thirty t30) days after deductions for payment of any outstanding bills or. other amounts due the Facility after Resident`s discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such entities or persons entitled to the refund under current law. . 9.3 Refunds of Prepayments or Qverpayments. Any prepayments or overpayments made by Resident and held by Facility will be refunded within thirty (30} days after Resident's discharge or death after deductions for payment of any outstanding bills or other amounts due the Facility. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such other entities or persons entitled to the refund under current law_ No interest shall accrue on any funds required to be refunded under this Agreement. ~~ 10. CHANGES IN ROOM ASSIGNMEI~ITS. Facility reserves the right and discretion to transfer Resident to another room or bed within the Facility consistent with the safety, care and welfare needs of Resident. Facility reserves the right and discretion to transfer Resident's roommate, if anv,>~at any time consistent with the needs of the Faciliky. t lI. TERMINATIONS, TRANSFER OIZ DIS+CH ARGE. 11.1 Resident Initiated. Resident may terminate this Agreement upon fifteen {15) days, written notice to Facility. If Resident leaves Facility for any reason other than a medical emergency or death, Resident must give written notice to Facility at least fifteen (15} days in advance of transfer, discharge or termination of this Agreement.. If advance written notice is~ not given to Facility, there wilt be due to Facility the applicable Basic Daily Rate and other charges then in effect for Resident's stay and care for the required fifteen {1~5) day notice period. The charge applies whether or not the Resident remains at Facility during the fifteen (15) day notice period. The charge specified in this section does not apply to a resident whose payor source is Medicare Part A or Medical Assistance. 11.2 Fa~iility Initiated. Facility may terminate this Agreement and Resident's stay and transfer or discharge Resident if. (a} Transfer or discharge is necessary to~ meet Resident's ~/Velfare;-and Resident's needs cannot be met in Facility. (b) Resident's health has improved sufficiently so that Resident no longer needs the services provided by Facility; _ (c) The safety or health of individuals in Facility is or otherwise would be endangered; {d} ~ Resident has failed, after notice, to pay for (or to have paid or treated as paid under the Medicare or Medical Assistance Programs} charges for Resident's care and stay at Facility; {e) Facility ceases to operate. 11.3 Notice and Waiver of Notice. Facility will notify Resident and Health Care Responsible Person (or if none, a family member or legal representative of Resident, if known to Facility] at least thirty {30) days in advance of transfer or discharge. However, in a.ny case described in Subparagraphs (a), (b}, (c) above. Facility will give only such notice before transfer or discharge as is reasonable or as required by applicable law under the circumstances. r 11.4 Withdrawal against Advice. In the event Resident withdraws from the Facility against the advice of his/her attending physician and/or without approval of the Facility, all of Facility's responsibilities for the care of Resident are terminated, effective at such time as Resident withdraws from the Facility_ 12. READMISSION -BED HOLD~POLICY. 12.1 Private Pay Residents. If Resident leaves Facility for a period of hospitalization, ,therapeutic leave, or any other reason (other than Resident's death), arzd if Resident is not eligible for, or receiving, Medical Assistance benefits, Resident's bed will be reserved through payment of the Basic Daily Rate. Facility,wiIl continue to hold the bed until notified in writing by Resident or both Responsible Persons that khe bed is no longer desired. If Resident elects in writing not to reserve a bed, then Resident will be; discharged from Facility and readmission to Facility shall be subject to bed availabiIity.,; 12.2 Medical Assistance Residents. If. Resident is eligible for, or is receiving Medical Assistance benefits, and Resident leaves Facility for a period of hospitali.2ation or therapeutic leave, Residerit's bed will be reserved far the applicable maximum number of days, paid for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation period may be subject to change in accordance with any changes in the Programs. If the period of hospitalization or therapeutic leave exceeds the maximum. time for reservation of a bed under the Programs, Resident will be entitled to the first available accommodation suitable for Resident's level of care if, at the time of readnussion, Resident requires the services. provided by the Facility. Alternahvely, following the Ia.pse of the bed reservation period covered by the Medical Assistance Program,. Resident may reserve a bed by electing to pay the Medical Assistance per diem rate charged immediately prior to the leave, and by providing written notice and advance payment for the days included in the reservation period.. 12.3 Medicaie Residents. In the event that a Resident eligible for Medicare Part A benefits is transferred to or readmitted to a hospital, 1Viedicare Part A eligibility will be terminated on the day the Resident is admitted to the hospital. Resident's bed will be reserved at Basic Daily Rate, unless Resident or Responsible Person elects, in writing, not to reserve a bed. 13. FACILITY RULES, REGULATIONS, POLICIES AND PROCEDURES. Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement, and Facility's rules, regulations, policies and procedures as made available .by Facility. Facility reserves the right to amend or change its rules, regulations, policies and procedures. Facility's rules, regulations, policies and procedures shall not be construed as imposing contractual obligations on Facility or granting any contractual rights to Resident, and are subject to change from time-to-time. ~amss y ~ 14. PERSONAL AND OTHER PROPERTY. 14.1 Responsibility for Maintenance and Loss. Resident is responsible for furnishing ar~d maintaining his or her own clothing and other .items of property as needed or desired. Resident may obtain at his or her own expense, casua.Ity insurance to cover potentia~ damage to or loss of any of Resident's personal property. If damage or loss occurs to resident property, the Facility will investigate each incident of Ioss or damage to determine liability and assess responsibility depending on the facts and f circumstances ofd each incident. Facility shall be responsible for :only such losses or damages as are attributed by Facility .to the negligence or culpability of the Facility. x4.2 Disposi#ion and SEora~e Upon Resident's Death. In the event of Resident's death, Facility shall contact Resident's authorized representative within twenty-four {24} hours to arrange for an inventory of Resident's personal property. The Facility is authorized to transfer Resident's personal property to a duly authorized representative of,Resident's estate.or to such parties or persons entitled to the property under current law. The duly authorized representative of Resident's estate or other persons entitled to property under current law must acknowledge, in writing, the receipt of the personal property transferred to his or her custody by Facility. After completing an inventory, Facility, in its sole discretion, may move and place Residen.t's personal property into storage at Facility's expense. if property held in storage is not claimed within thirty (30.} days, Facility shall send a notice; to the authorized representative via certified mail that if items in storage are not removed within fourteen (14) days; Faciii ty may dispose of Resident's property. 14.3 _Disposition and Storage Upon Resident's Transfer or Discharge. If Resident's personal property is not claimed or removed within twenty-four {24} hours of Resident's permanent transfer or discharge, Facility shall move and place Resident's personal property in storage until claimed. If Resident's personal property remains unclaimed for seven (7} days after permanent transfer or discharge, Resident shall be obligated to pay a storage fee as assessed by Facility. After a thirty (30} day period in storage, the Facility may dispose of Resident's property. The Facility is not responsible for any damages incurred to Resident's property if storage becomes necessary. Resident or Resident's estate shall be obligated to pay all costs of storage or disposition and shall bear the risk of loss or damage to' the property. 14.4 Damage to Room .ox Facility Propert-X. Resident or Resident's estate is responsible for any damages caused to Facility property beyond normal wear and tear, and shall pay for the repair and replacement of damaged property, based on the actual charge to Facility for such repair or replacement. 15. RESIDENT RECORDS. Resident records sh°all be handled in accordance with the Facility's Privacy T'olicy that Resident hereby acknowledges receiving. t Nl'ftt 16. MEDICAL TREATMENT' AUTHORIZATICJI~t. Resident authorizes Facility to provide care and treatment in accordance with. orders of Resident's personal physician and consistent with the terms of this Agreement. 17. DEATH OF RESIDENT. In the. event of Resident's death, Facility shall notify the person{s) designated by Resident. Facility is authorized to arrange for the transfer of Resident's body to the designated funeral home. Resident's estate is responsible for the payment of all costs associated with the transfer and funeral expenses and Facility reserves the right to require proof of financial responsibility for payment of burial expense prior to admission_ Pers~On or Funeral Home to be notified: ~1 dc~-~n , P~1 ~ ~c~S ~'7 t )~~- ~a ~ Resident shall notify Facility of any change of Person or Funeral Home to be notified. .~ 18. CAPACITY OF RESIDENT AND GUARDIANSHIP. if resident is, or becomes unable, to understand or communicate, and is determined after admission to be incapacitated by Resident's Physician or Facility's Medical Director, Facility shall have the right, in the absence of Resident's prior designation of an authorized legal representative, or upon the unwillingness or inability of the legal representative to act, to commence a legal proceeding to adjudicate Resident incapacitated and to have a court appoint a guardian for. Resident. The cost of the Iegal proceedings, including attorney's fees, shall be paid by Resident or .Resident's estate. 19. FACILITY 'S GRIEVANCE PR+~CEDURE. 19.1 1Zeportin~ Complaints. IE Resident, Responsible Persons, or Resident's attorney-in-fact believes) that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, Resident Responsible Persons,. or Resident's attorney-in-fact shall make his/her complaint known to Facility's staff. Resident, Responsible Persons; or Resident's attorney-in--fact must first notify Facility of any such complaints, and provide the Facility with sixty (b0) days to resolve the complaint satisfactorily to Resident before the Resident may pursue rnediation_ This notice requirement is not intended to preclude Resident, Responsible Persons, or Resident's attorney-in-fact from filing a complaint with any appropriate governmental regulatory agency. 1 t'YYlLL ~ ~ com ~ ~ 19.2 Fa P aixtt ~, cilr and s Obli ations, peSPonsible pets provide a °ns• resp°nse to Facility will t f2esi revJey„ denr~Residen~ s and ~nvesti at faith I9.3 attorr~e g e the attempt to ~andato Y'ifl`fact relatin resole ~le~ia~'ou. ~,he o, g .toy this a an '`agreement thr Agreement n con~.oversY, dis parties agree tiv~thl ough ne d the pate that the n ~~ da s nitia gotiation, urovision o f nri d'Sagreement a3'• Shall in good dispute or di a of i I notice Sh ld the se ces b t - resin fr shall be ~eement °f th.e dis Paj'tles be Y he Facilit g °n~ or c°n~ucte ~° rnediati° P.ute unable y under this accordance d at the pacili n before~arhe part'eS shall to reach a re Parties tivit with AL'~,R p ~ ty °r at a sit n Jrnpart-ial 'submit the c SOluti°n cofl tl'ov h t~teir ne P °n-S, inc ~ e within media for °n t~'overs $otiah'o s ~u1es o f a reasonable d~S~a which Y. their ersY, dispute or di ns and attexn rice o ined~ation dispute t sat pt to Procedure, The f F as roe hrough m g eerztent. facilitate mediator ac1lity in ided ediation, then In the an amicable r will assist th a rbi tra do to this eve e p is. n unless an'ggreetnent_ T the dispute ma the parties are esolution o f r row '4n and them d until the m he Parties a y °n~Y be reso unable to reso he edlatio after ~' ~'ee that Ived b Ive n is completed. ,s first submitted they ma3' notY arbitration medic 1'he Parties a to rt~edi~tion ~ roceed to al Assistan b't'ee that t rider th - or ludi~ial ce eIigibili his roe' - js res actions' whic S - aPplrcationspn . ls~on does no P°nsible ' h Assist Parl~es eek to a t cover ance ap 1 • duties to compel co/or appeals and jssues ref doe a fire s not affe. g' to o °es not coves .'cation and a undertake, cornmPliance kith t ct a utst actin -'Peal ~ ro Plet~e a he Resi nY +civ~l andirrg deb ns by the P Cess, dent s that or their is and Facilit ~'he Parti sd cO°perate aile ehjs provision d for pa~'n~ents Y to come also agree '~j~th the med. g d inCaP`~c~ty of~~es not appl to for Services re 1 PaYn-tent or that thjS provls~cal '.the ~esi Y an ndered. Seek collectio ton dent, Y guardianshi Further, the n ° f P pr°ceedings reSU Parties agree ~Ioc~,ever~ botThe costs of t decide to r h parties w. he mediat~° 1t~ng from the for the redietaln legal COUnsj be resp°nsible Kill be split e mediation, strjbution of the el The mediatorfor their °wn ~ Dally bej-y,,een t costs bet-yveen theshall hav torneys fees sho e parties. parties i f ithe right Co su uld either t is deemed ap gest or resol If negotiate uhOn Fill a reSOlution p Qpriate d by both Partiesbe reduced to ~, -reached at wring ontroversY, dis ut he s,gned seal rig ,n the form o~a~On, the ar . P e or disagl.eemeernent agree of a settlement a ties agree tha t nt. rr1e t will be the fi ~eement Such ands. een exclude (a} real resolution jgned actions .i d Fromm `~~ce tion From of the vitiated b mandat ~8,pp~~ ma Y F~cili or3' media(~Q edi~i.~n. T an y of t y be reSOIved ~', and dis n ~i'°., guardia hose disputes he matters excl through the utes involving a reship prose which ha ~~~ Ucied fro,n-t rna~~e °f the~udj~~a,°unts In con~ovejngs, colt echo a Lary media do SYstent. In sitva titer, ~~ less than n, npsF~. _ those matters may coons relate ex the dispute• .. Any legal a . ` ~ urisaiction °v xoce5s- aye l Actions. se the mediation u whirl, ~rctay h e in. Collection balance re uirea tO u co q • • ated in any ~~ and V enu t the unp3'a Urisdiction d ling ~ c°llec inst the .~esident• be filed an _ Consent to to a claim t°o~0~ a Mate ~b~ acility related ollars ~~' he ~eSident,s anent initiated by the pht ,thousand D reSentatiVe °f under this ~~~ of Any legal acti°n ~1 oriZed rep Pleas in .eXCess.. of a anth eSSed or claimed o~ Comn1Or' fight of any charges peTSOS~~ chaY.ges ass in the C°v~ °Te man ~eSponsible ~ ment of any eXclusively versy • racial a contT°. °f no e eXClusiv~y la- F ins n from the non d and litigated an amount. ~n enCed and lrtlga p.ennsyly any arise, g ~otnn,ence involVeS be Comm noldsville, business shall ~ . a- If the dY~putel1e action Shall on C°unty' Re e that tYle cen~al d co~er't penr,Sylvani a~g,ooo>> t effers owledg vania an ackn and Dollars ~ M -02, bated in ~ peTSOn. Pe~syl pleas County j on ,.,thous 3 on51ble t'f -e Court of ~omn' actions - strict Court' ~~nancial ReSp k,Nay, jef f erson rt and ~D~ or FI 13roc Cou to collection d' is l~ted to ,District ~eSident an cility f the said ' on shall apply o Y of ° the Pa ~; venue ° ''f leis sects 0 office an :~ vania• be tiara enn y t to the }urisdic aunty ~ p s 1 rat has the rlgk` ediation of ref fersOn C e pacility• °unsel• ~e51d d under tl-'s m Facility initiated by th ht to Le a1 C Initiate al rights' c ~.~ proCeedings es ixrnportant lei sistance of legal dress as Tior to any e and 1. in ad. b legal •counse xoyis1On advic rovis1On P e5ented y .this rnediation~ P eSident obtain th or mediation p repr because ends that TZ ands y provision- , o f this rn ura ~ and r'eco al significancy. St for mediation enco elgto review the g Any reque one ~~.) coons eras- Mediation- la se °f this Agreen' rior to they P e failure to signing a hlmitati°n for the Facility P '~ 'l'irn ' ted t° use occurred- Th all operate td~ submit to the dlsp a sh re nested and ,rise the deSlgnated bm a remedy, ust be a event g~v~ng f oT relief °r will be of a dispute ~ which the the Facility within claim ~Q patties date on or f or ria Te f and eas from~the eSt for mediation eo for ~ediation,nd or ch dispute' y regv cent reQu olu to any su submit ato any..subsea l reeding of a a res lion specific as a bar or legs p sting a action gating or ling Arbitration 'ederal c°urt or to a }~aYred f ram fined - din ~bltxationltional .state or f te, a neutral f orevy'r and Bxn shad f a d'spu to the .4 MandatO tiliZed instead °f the outCOrne ° ens Tenders 19 u deterrr,;,nzng to this A~eem ~ final ate res°lut1On or jug the parties star's decis'Or' ' der a ess of disp edge andf osen by an Arbitx and hen PrOC teal °f a l ch Generally sides °f the story bed by the systeri-• ~~ ,, ATbitrator(s} ~ both parhes• both establis t is thixd park ~ ~ is binding °n bitTator will hear an the .rules andatory, as i r e d rt' andatory ,~hich ~- 'The A m°n .se when Arbitration is decision: , en to ~appe s law., corn to the paxt1eS. ~ d cost of and n°t °p faixt~es , the partieS- based on Selected by rocess available e formalities a decision or- Assaciarion legal p acing the tam it is the o~y of r ith the g°al ed prbitxati ree1nent, under tY'is has been selected w Arbitration art system- the co „tiliZ~ng (a} Contractual and/or Property Dama eg 'Disputes. Unless resolved, or settled by mediation, any controversy, dispute, disagreement or claim of any kind or nature, arising from, or relating to this Agreement, or concerning any rights arising from or relating to an alleged breach of this Agreement, with the exception of (1) guardianship proceedings resulting from the alleged incapacity of the Resident; {2) collection actions, initiated by Facility for .nonpayment of stay which results in a financial Loss to .Facility; and (3} disputes involving amounts in controversy of less than Eight Thousand Dollars {$8,000), shall be settled exclusively by arbitration. This means that Resident will not be able 'to file a lawsuit in any court to resolve any disputes or claims that Resident may have against Facility. It aIs© means that Resident is relinquishing or giving up all rights~that Resident may have to,a jury trial to resolve any disputes or claims against Facility. It also means that Facility is giving up any rights Facility may have: to a jury trial or to bring claims in .a court against Resident. Subject to Section 19.4{E), the Arbitration shall be administered by ADR Options, Inc., in accordance with the ADR Options Rules of Procedure, and judgment on any award rendered by the arbitrators} may be entered in any court having appropriate jurisdiction_ Resident acknowledges and understands that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident relinquishes and gives up Resident's rights to a jury trial on any matter submitted to arbitration under this Agreement. (bj Personal Ynjur~or Medical Malpractice-. Unless resolved or ~. settled by mediation, any claim that Resident may have against Facility for any personal injuries sustained by Resident arising from or relating to a{~y alleged medical malpractice, inadequate care, or any other cause or reason while residing at Facility, shall be settled, exclusively by arbitration. This means that Reside~-t will not be able to file a lawsuit in any court to bring any claims that Resident nnay have against Facility for personal injuries incurred while residing at Facility. It also means that Resident is relinquishing or giving up all rights that Resident may have to a jury trial to litigate any claims for damages or Losses allegedly incurred as a result of personal injuries sustained while residing at Facility: Subject to Section 19.4{f}, the Arbitration shall be administered by~ ADR Options, 1nc., in accordance with the ADR Qptions Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident acknowledges and understands that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident relinquishes and gives up Resident's right to a jury trial on any claims for damages arising from personal injuries to Resident which are submitted to arbitration under this Agreement. (c} Exclusion From Arbitration. Those disputes which have been excluded from mandatory arbitration (i.e., guardianship proceedings, collection actions initiated ;by Facility, and disputes involving amounts in controversy of less than X8,000) may be resolved through the use of the judicial system. In situations involving any of the matters excluded from mandatory arbitration, neither Resident nor Facility are required to use the arbitration process. Any legal actions related to those matters e may be filed and litigated in any court which may have jurisdiction over the dispute. This mandatory arbitration provision shall not impair the rights of Resident to appea) any transfer and jor discharge action initiated by the Facility to the appropriate administrative agency, and after the exhaustion of such administrative appeals, to appeal to the court exercising appellate jurisdiction over the administrative agency. (d) Right to Legal Counsel. Resident has the right to be represented by legal counsel in any proceedings initiated under this arbitration provision. Because this arbitration provision addresses important .legal rights, Facility encourages and ~ recommends that Resident obtain the advice and assistance of legal counsel to review the legal significance of this mandatory arbitration provision prior to signing this Agreement. (e) Location of Arbitration. The. Arbitration will be conducted at.a site selected~by Facility, which may be at the Facility or at a site within a reasonable distance of Facility. ~- ~ (f) Time Lirniitarion for Arbitration. :Any request for arbitration of a dispute must be requested. and submitted to ADR Options, inc., within one (1) year fran4~ the conclusion of mediation. In the event ADR Options, Inc., is unable or unwilling to :serve, then the request for Arbitration must be submitted to Facility within thirty (30) days of receipt of notice or other .deterrniriation of ADR Options, Inc.'s, unwillingness ar inability to serve as a neutral arbitrator. Facility shall select an alternative neutral arbitration service within thirty (30} days thereafter and the selected Arbitration Agency's procedural rules shall apply to the arbitration proceeding. The failure to submit a request for Arbitration to ADR Options, Inc., or an alternate neutral arbitration service selected by Facility, within the designated time (i.e., one (~} year from the conclusion of mediation) shall operate as a bar to any subsequent request for Arbitration, or for any claim for relief or a remedy, ar to any action or legal proceeding of any kind or, nature, and the parties will be forever barred from arbitrating or litigating a resolution to any such dispute. (g) Limitation on Damages and A]location of Costs fo_r Arbitration. The costs of the arbitration shall be borne equally by each party, and each party shall be responsible for their own legal fees. (h) Limited Resident Right to Rescind this Mandatory and Binding Arbitrafion Clause (Sections 19.4fa-h} of this Agreement). Resident, or Resident's spouse or personal representative in the event of Resident`s incapacity, have the right to .rescind this mandatory arbitration clause by notifying Facility in writing within thirty (30) days. Such notice must be sent via certified mail to the attention of the Administrator of the Facility and the notice must be post marked within thirty (30} days of the execution of this Agreement.. The notice may also be hand-delivered to the Administrator within the same thirty (30) day period. The filing of ~a claim .in a court of law within the thirty (30} days provided for above will automatically rescind the mandatory arbitx•ation clause without any further action by Resident, or Resident's spouse or personal representative. 2U. NOVICE. Wherever written notice is required to be given to Facility under this Agreement, it sha1I be sufficient if notice is provided by personally delivering it or by first-class mail, return receipt requested. Administrator Forest Park 1-lealth Center 700 Walnut Bottom Road Carlisle PA I7013 (717)9b0-7700 Notice to Resident will be provided by personal delivery to Resident`s room, or where applicable, by first-class mail to Responsible Person(s) or other designated person. 21. RESIDENT OBLIGA TIONS. If Resident is responsible for any actions or omissions that cause damage or injury to other persons and residents or the property 'of other persons or residents, then Resident shall be~Iiable for such damage to the fullest extent permitted by law. 22. IN'DEMN~IFICATION . Resident is responsible to pay for any damages or injuries caused by resident to other persons, residents or staff anc~ shall indemnify and hold Facility harmless from any claims, actions or proceedings against Facility resulting from Resident's actions or omissions. 23. MISCELLANEOUS PROVISIONS. 23.1 Governing Law. This Agreemenk shall be' governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. 23.2 Severability: The various. provisions of this Agreement shall be severab]e orte from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction and authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. 23.3 Captions. The captions used in connection with the sections and subsections of this Agreement are inserted only for the purpose of reference_ Such captions shall not be deemed to govern, limit, modify, or in any manner affect the scope, meaning or intent of~ the provisions of this Agreement, nor shal3 such captions be given any legal effect. ~.4 Entire Agrreement. The Admission Agreement consists of the entire .Agr~ernent between the parties and supersedes, merges .and replaces, all prior negotiations, q~fers, warrantees and previous representations, understandings or agreements, oral or written, between the parties. { 235 Modifications. Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in law or regulation. To the extent reasonably passible, the Facility will give Resident and Resident`s Responsible Persons} thirty (30} days advance written notice of any such modifications_ 23.b Waiver of Provisions. Facility 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 bX Facility unless such waiver is in writing by Facility_j Any waiver by Facility shall not be deemed a waiver of any other term, provision, or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and ef=fect. t 24. ACKNOWLEUGMEI*JTS. 24.1 Facili .. Char a Schedules. Resident and Responsible Person(s) acknowledge the receipt of a~ copy of the Facility Charge Schedules provided with the Admission Packjage and the opportunity to ask. questions about Facility's charges. 24.2 Resident Ri~gh*s. Resident and Responsible Person(s) acknowledge being informed. orally and ~in writing of Resident's Rights as specified in the current publication required by law and further acknowledge having an opportunity to ask . f questions about those rights. The Notice of Rights of Nursing Facility is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on Facility or granting any contractual rights to Resident. 24.3 Advance Directives. acknowledge being informed, orally and directives and medical treatment decisions. .Resident and Responsible Person{s) in writing, of Facility's policy on advance 24:4 A eesnent. Resident and Responsible Person(s) acknowledge that they have read and understand the terms of this Agreement, that the terms have been explained to them by a representative of Facility, and that they have had an opportunity to ask questions about this Agreement. i rxrrr,~ .,., r ~ w 24.5 Admissions Package. Resident and Responsible Person(s) acknowledge the receipt of a copy of the Facility's Admission Package and the opportunity to aslc questions about Facility's policies contained therein. The Admission Package content is subject to change from time-to-time and shall not be construed as imposing any contractual obligations .on Facility or granting any contractual rights to Resident. 1N WITNESS WHEREOF, the parties,. intending to be legally bound, have si.gn~d this Nursing Facility Agreement on this _: ~~ day of ~1 0,.~. JJ'' - _ ~ t,. /~ ' ~'• 'v r Witness ~ ! Resident: ~.''"? Vl/itness Financial Responsible Person . ~ tt-.Q.~-4..£- ~ r.~-~~t bVitness ~~~ Health Care Resp sible Person (if any} Forest Park Health Center Facility J , ~• ~ ~ / ~' ~_ A r N ACCEPTANCE OF PROPOSED PERMANENT PLENARY GUARDIAN OF THE ESTATE Brian D. Brooks d/b/a Pennsylvania Guardianship Association, the permanent plenary guardian of the person and estate proposed in the foregoing petition for appointment of a permanent plenary guardian of the person and estate of Louise Carl, the alleged incapacitated person, agrees to accept the appointment as permanent plenary guardian of the person and estate and avers that he is not a fiduciary of an estate in which the alleged incapacitated person has an interest, and the permanent plenary guardian of the person and estate of Louise Carl has no interests adverse to her. Dated: ~ /~~~~~ c rian D. Brooks d/b/a Pennsylvania Guardianship Association