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HomeMy WebLinkAbout04-2873IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. PHYLLIS CAROTHERS, Defendant. NOTICE No. ny -- aP?U CIVIL ACTION - EQUITY 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION -EQUITY AVISO USTED HA SIDO DEMANDADO/A EN COUTE. 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 O NO PUEDE PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Assoication 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. O4 - .203 PHYLLIS CAROTHERS, Defendant. CIVIL ACTION - EQUITY COMPLAINT C?ti?l. !E/tY?'1 AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("Plaintiff ManorCare'), by and through its attorneys, KENNEDY BOGAR LLC, and files the within complaint against Defendant, Phyllis Carothers, and in support thereof, provides as follows: Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Defendant Phyllis Carothers is an adult individual who currently resides at 154 Lincoln Street, Carlisle, Pennsylvania 17013. 5. On or about October 8, 2003, Defendant Phyllis Carothers made application on behalf of her Mother, Christine Brady, for admission to Plaintiff ManorCare's skilled nursing facility. 6. On or about October 8, 2003, Plaintiff ManorCare and Defendant Phyllis Carothers entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Phyllis Carothers' Mother with skilled nursing care and services in exchange for her promise to pay a specific monetary fee from Catherine Brady's assets and to make timely and proper application for Medical Assistance benefits on Ms. Brady when she became eligible for such assistance and pursuing any subsequent appeals if said application was denied. A true and correct copy of the Agreement is attached hereto as Exhibit "A". 8. Shortly after Christine Brady's admission to Plaintiff ManorCare's skilled nursing care facility, Ms. Brady allegedly became insolvent. As a result, pursuant to the Agreement Plaintiff ManorCare notified Defendant Phyllis Carothers of her contractual duty to make application for Medical Assistance, and she subsequently filed an application for Medical Assistance benefits on her Mother's behalf. 9. The application for Medical Assistance benefits referenced above was denied on June 3, 2004, because Defendant Phyllis Carothers failed to provide to the Cumberland County Assistance Office certain financial information. 10. Subsequently, Plaintiff ManorCare timely filed an appeal of the Cumberland Assistance Office's denial of Catherine Brady's application for Medical Assistance benefits, and said appeal is currently pending before the Pennsylvania Bureau of Hearings and Appeals. 11. If Defendant Phyllis Carothers fails to provide the documents requested by the Cumberland County Assistance Office prior to or at the time of the hearing scheduled on the aforementioned appeal, it will be denied, and any further appeal to the Commonwealth Court would be without merit. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE Plaintiff ManorCare v. Defendant Phyllis Carothers 12. The allegations contained in Paragraphs 1 through it are incorporated herein by reference as if fully set forth at length. 13. Defendant Phyllis Carothers breached her Agreement with Plaintiff ManorCare when she refused to make complete and proper application for Medical Assistance benefits when her Mother, Christine Brady, qualified for such benefits, and she continues to breach her Agreement with Plaintiff ManorCare by refusing to properly pursue the aforementioned appeal. 14. Defendant Phyllis Carothers' breach of her Agreement with Plaintiff ManorCare has irreparably harmed and continues to cause irreparable harm it. 15. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, KENNEDY BOGAR LLC Dated: By ek k ? ' Chadwick O. Bogar Attorney I. D. No. 83755 Bradley A. Schutjer Attorney I.D. No. 75954 P.O. Box 959 Camp Hill, PA 17001-0959 717.909.5290 Attorneys for Plaintiff 4 Rx. Date/Time JUN-14-2004(MON) 13:44 717 249 0647 JUN 14 2004 15.26 FR MANOR CARE-CARLISLE 717 249 0647 TO 9095925 JUN-I4-2004(MON) 10:38 Kenneoy / 6^9ar LLC (FAX)717 909 5925 'VE URCATION The undersigned hereby verifies that the statements of fact in the foregoing P. 002 P. 02/02 P, 006/006 Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 1S Pa. CS.A. § 4904, relating to unworn falsification to authorities. Dated: &j14'7 S JUN 14 2004 12:19 Amy M Director of Finance 717 909 5925 PonF.PA ** TOTAL PAGE.02 ** EXHIBIT "A" HCR Manor Care ADMISSION AGREEMENT Pennsylvania This Agreement is entered into by and among Manor Care Health Services, d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Christine R. Brady Responsible Party: Jennifer Reid Admission Date: 09/16/2003 Deposit: $ 0 Term: This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 1.05) or by a third party payor or managed care organization (see Section 1.06). 1.02 Ancillary Charges. The Resident will pay to Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. 1.03 Collections/Late Pavments. Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: -x-Medicare, _x Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Partv Pavors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) davs of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a 3 governmental payor, third party payer or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacy. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. H. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY 2.01 Legal Authority. The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely 4 and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Parry misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf of the Resident under Section 2.02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 5 3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Res dent may be transferred; the Center's liability insurance carrier; and any person authorized by la to review the medical records. 4.02 Consent to Treat. The Resident disclosure of Resident's protected health informa the Center, obtaining payment for healthcare ser% healthcare operation needs. The Resident and/o authorizes the appropriate staff of the Center (hereinafter "Treatment") as are necessary to m. but not limited to, assistance with bathing, hyg general nursing care, the administration of medi therapies, as prescribed by the Resident's person required from time to time in the exercise of provided to the Resident by federal and/or state h nd/or Responsible Party consent to the use and on for the purposes of receiving treatment from :es provided to Resident, and the Center's own Responsible Parry, by signing this Agreement, o perform such functions, care and services ntain the well-being of the Resident, including ne, dressing, toiletry, and daily activities; and ttions and treatments, and the performance of physician in the Resident's Plan of Care, or as ;ood nursing judgment, subject to any rights As applicable, the undersigned R legal authority to make health care decisions on b such authority have been delivered to the Cente behalf of the Resident to the Treatment described 4.03 Consent to Photograph. The R Center taking a photograph of Resident for use photograph in the Medication Administration R uses of the photograph for Center and staff to id 4.04 Notice of Services. Policies and t? Responsible Party acknowledge that the items lister copies of the items or policies and procedures, if ponsible Party represents that he/she has the alf of the Resident, that documents supporting and that such Responsible Party consents on lent and/or Responsible Party consent to the identifying the Resident, for placement of the rd or other records and for any other similar fv the Resident, dditional Information. The Resident and/or below have been explained and have received applicable. The Resident and/or Responsible 6 Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits. See Attachment C. b. SNF Medicare Determination Notice. See Attachment D. c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-1 and F-2. e. Center Supplement: 1. Policy and procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses anc phone numbers. 3. Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. f. The Resident Handbook. g. Resident/Patient Rights. h. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. 7 i. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-1 and G-2. j. Privacy Act Notification, See Attachment H. k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and I-2, 1. Ancillary Services Management Form. See Attachment J. 4.05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 8 4.08 Changes in the Law. Any provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Signature of Responsible Parry: /I y -"./ a?sJ Date: Dater /Q-- Center Representative: Date: (c". \J ?? ?? ? , Gt -, -n ? ? -r? , , -??>.? ?, JUL 0 7 2004 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. 04-2873 Civil Term PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION -EQUITY PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("ManorCare') pursuant to the provisions of Pa. R.C.P. § 1531, and makes the following petition for preliminary injunction and, in support thereof, avers: On June 22, 2004, ManorCare filed its Complaint against Defendant Phyllis Carothers. 2. The Complaint sets forth a single claim against Defendant Phyllis Carothers' relating to her breach of an Admission Agreement ("Agreement"). See Complaint, Exhibit "A." 3. The very nature of the breach of the Agreement, i.e., Defendant Phyllis Carothers' failure to provide information requested by the Cumberland County Assistance Office, presents an issue of immediate and irreparable harm to ManorCare. 5. The requested injunction would restore the parties to the status quo as it existed immediately prior to Defendant Phyllis Carothers' breach of the Agreement. 6. Greater injury would result from the denial of the requested injunction than from the granting of the same. 7. ManorCare's right to relief is clear. 8. ManorCare lacks an adequate remedy at law. 9. A bond in the amount of $100 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. WHEREFORE, Plaintiff, ManorCare, respectfully requests that this Honorable Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a Decree ordering specific performance of the Agreement by and between the parties hereto. Respectfully submitted, KENNEDY BOGAR LLC Dated: 'l Id OL? By 0 tadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 P.O. Box 959 Camp Hill, PA 17001-0959 Attorneys for the Plaintiff Rx Date/Time JUL-06-2004(TUE) 10:41 717 249 0547 .FUL 06 2004 12:24 FR MANOR CARE-CARLISLE 717 249 0647 TO 9095925 P.05i05 •?. "11.1 nanneuy / DDQar LLL (FPX)717 909 5925 VHRIFICATTON The undersigned hereby verifies that the statements o£ fact in the foregoing Petition for Preliminary Injunction 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 1S Pa. CS.A. § 4904, relating to unswarn falsification to authorities. Dated:_ (o dW JUN 26 2004 10:25 P. 005 P 005/005 rn? Amy h, ? Dz? A_`6iSttxn1 13usuKS6 A4 MBy. '119 9rA0 ca^ic ** TOTAL PAGE.05 ** EXHIBIT "A." IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. PHYLLIS CAROTHERS, Defendant. No. 0q-.2PB .: CIVIL ACTION -EQUITY NOTICE 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 OR CANNOT AFFORD ONE., GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 c> N (800) 990-9108 = . , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. PHYLLIS CAROTHERS, Defendant. CIVIL ACTION -EQUITY AVISO 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 O NO PUEDE PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Assoication 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. . No. PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION -EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("Plaintiff ManorCare"), by and through its attorneys, KENNEDY BOGAR LLC, and files the within complain]: against Defendant, Phyllis Carothers, and in support thereof, provides as follows: Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Defendant Phyllis Carothers is an adult individual who currently resides at 154 Lincoln Street, Carlisle, Pennsylvania 17013. 5. On or about October 8, 2003, Defendant Phyllis Carothers made application on behalf of her Mother, Christine Brady, for admission to Plaintiff ManorCare's skilled nursing facility. 6. On or about October 8, 2003, Plaintiff ManorCare and Defendant Phyllis Carothers entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Phyllis Carothers' Mother with skilled nursing care and services in exchange for her promise to pay a specific monetary fee from Catherine Brady's assets and to make timely and proper application for Medical Assistance benefits on Ms. Brady when she became eligible for such assistance and pursuing any subsequent appeals if said application. was denied. A true and correct copy of the Agreement is attached hereto as Exhibit "A". 8. Shortly after Christine Brady's admission to Plaintiff ManorCare's skilled nursing care facility, Ms. Brady allegedly became insolvent. As a result, pursuant to the Agreement Plaintiff ManorCare notified Defendant Phyllis Carothers of her contractual duty to make application for Medical Assistance, and she subsequently filed an application for Medical Assistance benefits on her Mother's behalf. 9. The application for Medical Assistance benefits referenced above was denied on June 3, 2004, because Defendant Phyllis Carothers failed to provide to the Cumberland County Assistance Office certain financial information. 10. Subsequently, Plaintiff ManorCare timely filed an appeal of the Cumberland Assistance Office's denial of Catherine Bra.dy's application for Medical Assistance benefits, and said appeal is currently pending before the Pennsylvania Bureau of Hearings and Appeals. 11. If Defendant Phyllis Carothers fails to provide the documents requested by the Cumberland County Assistance Office prior to or at the time of the hearing scheduled on the aforementioned appeal, it will be denied, and any further appeal to the Commonwealth Court would be without merit. COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE Plaintiff ManorCare v. Defendant Phyllis Carothers 12. The allegations contained in Paragraphs 1 through 11 are incorporated herein by reference as if fully set forth at length. 13. Defendant Phyllis Carothers breached her Agreement with Plaintiff ManorCare when she refused to make complete and proper application for Medical Assistance benefits when her Mother, Christine Brady, qualified for such benefits, and she continues to breach her Agreement with Plaintiff ManorCare by refusing to properly pursue the aforementioned appeal. 14. Defendant Phyllis Carothers' breach of her Agreement with Plaintiff ManorCare has irreparably harmed and continues to cause irreparable harm it. 15. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, Dated: 6 I` KENNEDY BOGAR LLC By?s? -- Chadwick: O. Bogar Attorney 1. D. No. 83755 Bradley A. Schutjer Attorney I.D. No. 75954 P.O. Box 959 Camp Hill, PA 17001-0959 717.909.5290 Attorneys for Plaintiff ltx Uate/lime JUN- I4-2004(MON) 13:44 717 249 0647 JUN 14 2004 15:26 FR MANOR CARE-CARLISLE 717 249 0647 TO 9095925 JUN-la-2006(MON) 10:38 Kenneog / Boear LLC (FAX)717 909 5925 VERMCATION P. 002 P. 02/02 P. 006/006 The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief-. I understand that any.false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to urwworn falsification to authorities. Datcd: C? Amy Marsk Director of Finance 5 EXHIBIT ".E?" HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among Manor Care Health Services, d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Christine R. Brady Responsible Party: Jennifer Reid Admission Date: 09/16/2003 Deposit: S 0 Term: This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. 1. RIGHTS AND RESPONSEBILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 1.05) or by a third party payor or managed care organization (see Section 1.06). 1.02 Ancillary Charges. The Resident will pay to Center all charges for additional' medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. 1.03 Collections/Late Payments. Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: x_Medicare, _x Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational., or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party PUors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third parry payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident andior Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the! Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resilient must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be bome by the Resident. 1.12 Pharmacy. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. U. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY 2.01 Legal Authority. The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf' of the Resident under Section 2.02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. M. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the. payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Responsible Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits. See Attachment C. b. SNF Medicare Determination Notice. See Attachment D. c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-1 and F-2. e. Center Supplement: 1. Policy and procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses anc phone numbers. 3. Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. f. The Resident Handbook. g. Resident/Patient Rights. h. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. i. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-1 and G-2. j. Privacy Act Notification. See Attachment H. k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and I-2. 1. Ancillary Services Management Form. See Attachment J. 4.05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Responsible Party Date: -eq? Center Representative: C -Date: (G ?' C?? ?' 1 N C:' I _ J 3v _{ fA T rn ^I^ Ti C, -j 7v i'q { JUL 0 7 2004 V IN THE COURT OF COMMON ;PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. 04-2873 Civil Term PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION -EQUITY ORDER AND NOW, this day of 2004, a hearing in the above-captioned matter on Plaintiff's petitio or the issuance of a preliminary injunction is scheduled for 2004, at V al 4.m. in Court Room No. J Cumberland County Courthouse,1 Courthouse Square, Carlisle, Pennsylvania. BY THE COURT: ' C- o 0 S? p °r T ° c T D3 77 O! jz . -o n r 77 I IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP, d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. PHYLLIS CAROTHERS, Defendant. No. 04-2873 Civil Term CIVIL ACTION - EQUITY AFFIDAVIT OF SERVICE I, Paul B. Kennedy-, being duly sworn according to law, depose and say that I served via hand delivery upon the Defendant, Phyllis Carothers, who identified herself tome, with the Complaint and Plaintiff's Petition for Preliminary Injunction in the above-captioned matter, at her respective place of residence on the 7 day of ui ly , 2004, at approximately 5:45 p.m. Dated:l U Sworn to iqLnd Subscribed before me this day of 2004. Notary Publ' My Commis ' Expires: Notarial Seal ic Christy A. Long, Notary Z& City of Harrisburg, DaupM1ty My Commission Expires Dec. 22, 2005 Paul 1B. Kennedy cn- ° O _- r T r l U.' c._ 2 MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff v PHYLLIS CAROTHERS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 04-2873 CIVIL TERM CIVIL ACTION - EQUITY IN RE: PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 14th day of July, 2004, upon consideration of Plaintiff's Petition for Preliminary Injunction, following a hearing held on this date, and the Court finding on the basis of the evidence presented (1) that the preliminary injunction is necessary to prevent immediate and irreparable harm which could not be compensated for by damages, (2) that greater injury will result from the denial of the preliminary injunction than from the granting of it, (3) that issuance of the preliminary injunction will operate to restore the parties to the status quo as it existed prior to the alleged wrongful conduct, (4) that Plaintiff's right to a preliminary injunction is clear, and (5) that general equity jurisdiction is warranted, the petition for a preliminary injunction is granted and Defendant is enjoined to cooperate with Plaintiff and Plaintiff's counsel with respect to the pending application for medical assistance benefits for her mother and to provide any and all records needed for the said application, or demonstrate to the satisfaction of the Cumberland County Assistance Office that such records are not required under the circumstances. THIS PRELIMINARY INJUNCTION shall be effective upon Plaintiff's posting of a bond or cash in the amount of $100.00, in accordance with Pennsylvania Rule of Civil Procedure 1531(b). In the event the requisite bond or cash is not posted or Go :b E_!'j 0' IFJ Uoz 3c, JO deposited within 10 days of the date of this order, the order shall be deemed automatically dissolved. By the Court, /Chadwick 0. Bogar, Esquire P.O. box 959 Camp Hill, PA 17001-0959 For the Plaintiff ?Phyllis Carothers, Pro Se 154 Lincoln Street Carlisle, PA 17013 :mae _r)Q -0 L IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, V. No. 04-2873 Civil Term PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION -EQUITY PLAINTIFF'S PETITION FOR CIVIL CONTEMPT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Carlisle, ("Plaintiff ManorCare") and files this Petition for Civil Contempt and, in support thereof, avers: On July 14, 2004, this Court granted Plaintiff ManorCare's petition for preliminary injunction and entered the Order attached hereto as Exhibit A. 2. Pursuant to the attached Order, Defendant Phyllis Carothers was required to produce documents previously requested by the Cumberland County Assistance Office to determine her Mother's eligibility for Medical Assistance benefits. These documents were to be produced on or before August 4, 2004-the date on which Plaintiff ManorCare's appeal referenced in its petition for preliminary injunction was to be heard by the Bureau of Hearings and Appeals. Unforitunately, Defendant Phyllis Carothers failed to produce any of the documents requested by the Cumberland County Assistance office on or before August 4, 2004, thereby violating this Court's Order. 3. On August 3, 2004, Administrative Law Judge Andrew P. Maloney of the Bureau of Hearings and Appeals denied Plaintiff ManorCare's motion for continuance and, further, advised Plaintiff ManorCare that it would be required to present evidence at the August 4, 2004 hearing in support of its appeal. Not having the requisite evidence to support its appeal because Defendant Phyllis Carothers failed to produce the documents requested by the Cumberland County Assistance Office in violation of this Court's Order attached hereto as Exhibit A, Plaintiff ManorCare withdrew its appeal. Fortunately, an agreement was reached between Plaintiff ManorCare and the Cumberland County Assistance, giving Plaintiff ManorCare additional time to qualify Defendant Phyllis Carother's Mother for Medical Assistance benefits. 4. Pursuant to the terms of the above-referenced agreement between Plaintiff ManorCare and the Cumberland County Assistance Office, Plaintiff ManorCare has until August 24, 2004 to seek additional judicial intervention to obtain the documents in question. If, however, ManorCare fails to produce the documents by August 24, 2004, the Cumberland County Assistance will again deny Defendant Phyllis Carother's Mother's application for Medical Assistance benefits, forcing ManorCare to seek yet another appeal. WHEREFORE, Plaintiff ManorCare respectfully requests that this Honorable Court schedule an immediate hearing on its Petition for Civil Contempt, and thereafter issue a Decree ordering Defendant Phyllis Carothers to produce the documents requested by the Cumberland County Assistance Office by August 23, 2004 or face incarceration until such time as this Honorable Court directs. Respectfully submitted, KENNEDY BOGAR LLC Dated: 6 O By C Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Bradley A.Schutjer Attorney I.D. No. 75954 (717) 909-5921 P.O. Box 959 Camp Hill, PA 17001-0959 Attorneys for the Plaintiff EXHIBIT "All MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff v PHYLLIS CAROTHERS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 04-2873 CIVIL TERM CIVIL ACTION - EQUITY IN RE: PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 14th day of July, 2004, upon consideration of Plaintiff's Petition for Preliminary Injunction, following a hearing held on this date, and the Court finding on the basis of the evidence presented (1) that the preliminary injunction is necessary to prevent immediate and irreparable harm which could not be compensated for by damages, (2) that greater injury will result from the denial of the preliminary injunction than from the granting of it, (3) that issuance of the preliminary injunction will operate to restore the parties to the status quo as it existed prior to the alleged wrongful conduct, (4) that Plaintiff's right to a preliminary injunction is clear, and (5) that general equity jurisdiction is warranted, the petition for a preliminary injunction is granted and Defendant is enjoined to cooperate with Plaintiff and Plaintiff's counsel with respect to the pending application for medical assistance benefits for her mother and to provide any and all records needed for the said application, or demonstrate to the satisfaction of the Cumberland County Assistance Office that such records are not required under the circumstances. THIS PRELIMINARY INJUNCTION shall be effective upon Plaintiff's posting of a bond or cash in the amount of $100.00, in accordance with Pennsylvania Rule of Civil Procedure 1531(b). In the event the requisite bond or cash is not posted or deposited within 10 days of the date of this order, the order shall be deemed automatically dissolved. By the Court, C dwick O. Bogar, Esquire 0. box 959 Camp Hill, PA 17001-0959 For the Plaintiff Phyllis Carothers, Pro Se 154 Lincoln Street Carlisle, PA 17013 mae CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Plaintiff's Petition for Civil Contempt was served via first-class, United States mail, postage prepaid, upon the following: Phyllis Carothers 154 Lincoln Street Carlisle, PA 17013 John Broujos, Esquire Broujos & Gilroy 4 North Hanover Street Carlisle, PA 17013 Dated: 9 0-& N By: Christy A. o g, Paralegal co 1 ' T1 ... 1 { TM Z T, 1 1 _: ' .1 i-n AUG 0 6 2004 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, V. PHYLLIS CAROTHERS, Plaintiff, No. 04-2'873 Civil Term Defendant. : CIVIL ACTION -EQUITY ORDER AND NOW, this day of _?5 2004, a hearing in the above-captioned matter on Plaintiff's ManorCare's Petition for Civil Contempt is scheduled for ?g 2004, at !/' 0 k-.m. in Court Room No. Cumberland County Courthouse,1 Courthouse Square, Carlisle, Pennsylvania. oy.o`I BY THE COURT: i1,! Y rooz MANOR HEALTHCARE CORP. IN THE COURT OF COMMON PLEAS OF d/b/a MANORCARE HEALTH CUMBERLAND COUNTY, PENNSYLVANIA SERVICES - CARLISLE, Plaintiff CIVIL ACTION - EQUITY v PHYLLIS CAROTHERS, Defendant 04-2873 CIVIL TERM IN RE: CIVIL CONTEMPT ORDER OF COURT AND NOW, this 18th day of August, 2004, upon consideration of Plaintiff's Petition for Civil Contempt, and following a hearing at which the Defendant did not appear and at which evidence was presented on behalf of the Plaintiff which fully supported the petition, the Court finds that the Defendant has intentionally, voluntarily, and willfully failed to comply with the terms of the Order of Court dated July 14, 2004, and she is adjudicated in contempt. The sanction for the Defendant's failure to comply with the preliminary injunction issued on July 14, 2004, is that the Defendant undergo imprisonment in the Cumberland County Prison for a period of 1 month. The condition of purge with respect to the sentence is that on or before August 25, 2004, the Defendant fully comply with the terms of the aforesaid order of Court. By the Court, .O Co _'.J1 v ' _...1. l .. r u A ? F - V KJ P Esquir .O. Box 95 9 e P.O. Box 9 Hill, PA 17001-0959 Camp For the Plaintiff ,/P?iyllis Carothers 154 Lincoln Street 2 Carlisle, PA 17013 Q?j 2yQ CCP mae MANOR HEALTHCARE CORP., d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff V. PHYLLIS CAROTHERS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 04-2873 CIVIL TERM ORDER OF COURT AND NOW, this 25 h day of August, 2004, upon consideration of the attached letter from Chadwick O. Bogar, attorney for Plaintiff; it is hereby determined that Defendant has met the condition of purge contained in the order of court dated August 18, 2004. J. Chadwick O. Bogar, Esq. P.O. Box 959 Camp Hill, PA 17001-0959 Attorney for Plaintiff Phyllis Carothers 154 Lincoln Street Carlisle, PA 17013 Defendant, pro se :rc BY THE COURT, VlWr\IXSNN31 Z 0 ? 11 b1tl LZ OOtl hQOZ ??Vi ????y 4113 kennedyl I Attorneys At law Email: Direct Dial: LLC cbogar@kennedybogar.com (717) 909-5920 August 25, 2004 VIA FACSIMILE - (717) 240-6462 The Honorable J. Wesley Oler, Jr. Cumberland County Court of Common Pleas 1 Courthouse Square Carlisle, PA 17013-3387 Re: Manor Healthcare Coro v Carothers Docket No. 04-2873 Dear Judge Oler: It has been represented to us by the Cumberland County Assistance Office that the Defendant in the above-referenced matter has fully complied with your Honor's Order of August 18, 2004, attached hereto, by producing all documents necessary to determine Defendant's Mother's eligibility for Medical Assistance benefits. If your Honor has any questions, please feel free to contact me. Si?IyGZ-C Chadwick O. Bogar cc: Phyllis Carothers W 2 ?j nz4 P.O. Box 959, Camp Hill, PA 17001-0959 • Fax: (717) 909.5925 Curtis R. Long Prothonotary (Office of the Protbonotarp Cumberlanb Cuuntp Renee K. Simpson Deputy Prothonotary John E. Slike Solicitor 041 -.2873 CIVIL TERM ORDER OF TERMINATION OF COURT CASES AND NOW THIS 5TH DAY OF NOVEMBER 2007 AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R C P 230.2. BY THE COURT, CURTIS R. LONG PROTHONOTARY One Courthouse Square • Carlisle, Pennsylvania 17013 • (717) 240-6195 • Fax (717) 240-6573