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HomeMy WebLinkAbout07-1699IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. WILMA KERLIN and MARY PATRICK, Defendants. CIVIL ACTION - EQt1ITY 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 TAhE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE "I'O PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. WILMA KERLIN and MARY PATRICK, Defendants. CIVIL ACTION -EQUITY AVISO tJSTED HA SIDO DEMANDADO/A EN CORT'E. 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) dins 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 soma 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. LISTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI tJSTED NO TIENE UN ABOGADO, LL,AME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFURMACION A CERCA DE COMO CONSEGUIR UTd ABOGADO. SI LISTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZC AN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, v. Plaintiff, ~f `T' WILMA KERLIN and MARY PATRICK, Defendants. 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, Schutjer Bogar LLC, and files the within Complaint against Defendants, Wilma Kerlin ("Defendant Kerlin") and Mary Patrick, ("Defendant Patrick"), and in support thereof, provides as follows: 1. 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 Kerlin is an adult individual who resides at Plaintiff ManorCare nursing facility at 940 Walnut Bottom Road, Carlisle, Pennsylvania. 3. Defendant Patrick is an adult individual who resides at 415-417 Third Street, New Cumberland, Pennsylvania 17070. 4. On or about January 12, 2006, Defendant Kerlin made application for admission to Plaintiff ManorCare's skilled nursing facility. 5. On or about January 12, 2006, Plaintiff ManorCare and Defendant Kerlin entered into a written Admission Agreement ("Agreement"). Pursuant to the Agreement, Plaintiff ManorCare ,agreed to provide Defendant Kerlin with skilled nursing care and services in exchange for her promise to pay a specific monetary, and, in the event that she became insolvent, secure Medical Assistance benefits in a timely and proper manner. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 6. After Defend~rnt Kerlin's admission to Plaintiff ManorCare's skilled nursing care facility, she allegedly became insolvent. As a result, pursuant to the Agreement, an application for Medical Assistance benefits was filed on her behalf by Plaintiff ManorCare. 7. The Application for Medical Assistance benefits referred to above will be finally denied unless Defendant Kerlin provides the Cumberland County Assistance Office with the information and documentation needed to determine her eligibility for Medical Assistance benefits. COUNTI BREACH OF CONTRACT/SPECIFIC PERFORMANCE Plaintiff ManorCare v. Defendant Wilma Kerlin 8. Paragraphs 1 through 7 are incorporated herein by reference as if fully set forl;h. 9. Plaintiff ManorCare has provided skilled nursing care and services to Defendant Kerlin in accordance with the terms and conditions of the Agreement. 10. Defendant Kerlin breached the Agreement with Plaintiff• ManorCare when she failed to timely secure Medical Assistance benefits, and Defendant Kerlin continues to breach the Agreement with Plaintiff ::ManorCare by not providing the documentation needed by the Cumberland County Assistance Office to qualify herself for Medical Assistance benefits. 11. Defendant Kerlin's breach of the Agreement with Plaintiff ManorCare has irreparably harmed and continues to irreparably harm Plaintiff ManorCare. 12. upon information and belief, at all times material hereto, Defendant Kerlin has been financially unable to fully compensate Plaintiff ManorCare for the care and services that it has rendered and will render to her in accordance with the terms and conditions of the Agreement. 13. Accordingly, 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. WHERF,FORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. COUNT II -- SPECIFIC PERFORMANCE/STATUTORY DUTY OF SUPPORT Plaintiff ManorCare v. Defendant Marv Patrick 14. Paragraphs 1 rhrough 13 are incorporated by reference as though restated in full. 15. Defendant Patrick is the daughter of Defendant Kerlin. 16. At all times material hereto, upon information and belief, Defendant Kerlin has been indigent. 17. At all times material hereto, Defendant Patrick has had a statutory duty to financially support her mother. See 23 Pa.C.S. § 4603(a). 18. At all times material hereto, Defendant Patrick has failed to financially support her mother. 19. The statutory duty of Defendant to support her mother must reasonably include the duty to assist with securing financial support through the Medical Assistance system and the duty to not actively work against Medical Assistance approval. 3 20. At all times material hereto, Defendant Patrick has failed to care for, maintain or financially assist her mother by refusing to provide the documents requested by the Cumberland County Assistance Office to determine the eligibility of her mother for Medical Assistance benefits. WH1=;BEFORE, Plaintiff respectfully requests that this Honorable Court order Defendant Mary Patrick. to produce the documentation required for a determination of Defendant Wilma Kerlin's eligibility for Medical Assistance benefits, consistent with her duty to secure financial support for her mother. Respectfully submitted, SCHUTJER BOGAR LLC .~ / ,' Dated: '' ~' ~ `-~ " By; ~~ ~..:; ' +- Bradley A. Schutjer Attorney LD. No. 75954 305 North Front Street, Suite 401 Harrisburg, PA 17101 (717) 909-5921 Dara Lovitz Attorney LD. No. 91690 One Liberty Place 1650 Market Street, 36`" Floor Philadelphia, PA 19103 (267) 207-2871 Attorneys for Plaintiff 4 V1:R'11~ iCA'I'ION 73>,r unJ~~r,~igncd hrrrby verifies that the sta[emcnts of fact in the 1'ungaing Cam~laint are true and correct to the best #f my lcnawkdge, information and htrfiei', 1 undcrsttzncl that any false sta[ett?ents thcrcin arc subject to the penalties cxmtained in l8 Pa; C.S.A. § 49t)4, relating to un5worn talsilication to uutht~ritpes. T~ated. ~ Amy Marsh, cinetis Q1' ice Munaber ManorCarc 1-1t: I[h Scrviccs -- Ct~rtistc EXHIBIT "A" Ma'r 23 2007 9:32RM HP LRSERJET FRX p.2 `~ `~. FfCR 1Vlanor Care Pennsylvania ADMISSION AGREEMENT This Agreementrs entered into by and among Manor Caze 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 HC;R Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Wilma E. Kerlin Responsible Party: Admission Date: Oli 12/2006 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 Aoard Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible fGr the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not app]y if the Resident is covered under a governmental program (see Section 1.0.5) or by a third party payor or managed care organization (see Section 1.06). 1.02 Ancillary Chi. The Resident will pay to Center alI charges for additional medical, therapeutic, or personal care services or supplies that maybe 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. Mai^ 23 2007 9:32RM HP LRSERJET FRX p.3 ~; \ , 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 ternls 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 chazged 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 andlor __VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay fir 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, ar 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 Boaxd Rate from their monthly income. The Resident agrees to pay on a timely basis, as set Earth 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 m.ay take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Mana ed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organi~:ation ("HMO"), Preferred Provider Organization {"PPO"), Provider Sponsored Organization ("PSp"), 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. [f the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 `"a,r ~':' 2t~Q7 9.32RM HP LASERJET FRX p.4 ~`-~ \_ 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 far any governmental program or covered under any third party payor or managed care organization plan. The Resident andJor Responsible Parry 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 far 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 law;. 1.08 Admission Information. The Resident andlor Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission rand 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 (S) 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 parry payor, managed care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party arid, when applicable, a governmental program third party payar or managed care organization with which the Center is under contract. 1.10 Primary Responsibili for Parent Except for payments for services covered under governmental pro~ams 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 Parry that services provided at the Center may not be covered by a Ma'r 23 2007 9:32RM HP l_RSERJET FRX p.5 ~....- '~,- governmental payor, third party payor ar 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. I.11 Personal Ph sician. 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 hisfher 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 at-ide by applicable laws and regulations, the Center will call another physician- to attend to the Resident and the fees charged by such physician will he home 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. II. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY 2.tl~1 Le~a1 Authority. The Responsible Party represents that helshe 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- "l'he Responsible Part; unll 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 Fesident 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 ar 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.(a4 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 infomlation as Medicaid representatives may require to ciualify 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 d.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a Ma•r ~3 ?007 9:33RM HP LRSERJET FR}{ p.6 ~, timely and proper manner, the Responsible Party will be personally liable for all charges anal fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.45 Cooperation far 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 sha(1 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 anal 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,OZ or far 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 sanctians against the Responsible Party. III. RIGHTS AND RESPONSIBILITIES ~F 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 he 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. 5 Ma•r 23 2007 9:33AM HP LASERJET FRX P 7 ri ~.; 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incozporated 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. 1V. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident andbr 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 ar 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, carp 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. 6 Mar 23 2007 9:33RM HP LRSERJET FRX p.e .~~ , 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. Assigmnent 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 andlor 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 ancUor 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 and 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 anal 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. Res:identfPatient Rights. h. Medicare/Medicaid information and display of such information including 7 Mar 23 2007 9:33RM HP LRSERJET FRX P 9 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 IICR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct hismer medical treatment, See Attachments G-1 and G-2. 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. Ancillary Services Management Form. See Attachment J. 4.05 Assignment of Benefits. The Resident andJor Responsible Party request that payment of authorized government andlor 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 ar 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 ar benefits for related services. 4.06 Termination. Dischar;~e 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 natice 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 i~itit or Subacute Unit may require: less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident andlor 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 Mir 23 2007 8:37RM HP LRSERJET FRX p.2 ~,.. ~. 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 UNDERShGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ANll THAT ANY QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Residers ~_ ~~,~~ ~J'-~/~/,~ -Date: ~~~i Signature of Responsible Party: - _ Date: ~) Center Representative: /~' / ~ ~ ~ lla ~- ~ tc. ~ /~ Mar z3 ?007 9:34RM HP LRSERJET FRX p. 10 ~.- ~_,. 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. Mar 23 2007 9:34RM HP LRSERJET FRX p.ll ~- ATTACHMENT A ~~~ ROOM AND BOARD RATE The Resident will pay the following monthly rate: SEMI Private 3 Bed $5673.00 SEMI Private :? Bed $5828.00 pRI~aTE $6758.00 >> Mar 23 2007 9:34RM HP LRSERJET FRX p r2 ~~ ~_. ATTACHMENT B ANCILLARY CHARGES The services and supplies categorically described on this Attachment are not included in the basic Room and Board Rate. Therefore, the Resident will be individually billed for these items in accordance with Section 1.02 of the Admission Agreement. A complete list of ancillary items, together with the current price, is on file at the Center's business office. Dry cleaning. Beauty and Barber Shop services 'I'obaceo and smoking supplies, newspapers and periodicals Stationary, postage, and writing implements Kadios, televisions, cable service, room telephone Transportation for non-medical purposes and ambulance charges Photocopies of medical records Personal physicians and specialists Dental services and Dentures Optornetrist/~phthalmologist services and Eyeglasses Podiatry services Special nursing services, care for catheters, decubiti, incontinence, isolation and dressings Therapy services, including physical, speech, occupational, audiology and respiratory therapy Prescription and non-prescription medication Laboratory and x-ray tests Oxygen and related supplies IV Therapy and supplies Peritoneal dialysis Tracheotomy supplies Ventilator rental and reaated supplies Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes, surgical stockings, and all other supplies necessary for tlxe treatment, nursing care, or well- being of the Resident Incontinence supplies Special equipment (for some items, a rental, rather than purchase fee is charged), such as wheelchairs, wheelchair pad,. trapeze, canes, geri-chair, special mattresses, ports-chairs, etc. Special, supplementary, or very low calorie prescription dietary products, including liquid for gastric and naso-gastric, tubes, and any supply necessary to accomplish special feedings. l2 {' ~s " ` ~~ , _ ..-~. a, "ti i S`=EPI.~F' S RETURN - RE~~ULAR :T~S:7 NO: 200?-01599 P '--OMMONWEAL7'Fi OF PENNSYL~IANIA: [JNr' ~. `L?~iBER~AND .~-%_?~TO.~ HJALT?~CARE CORP D/B/A V :`i . _=IZLiN ';^~7i:N:A ET AL <';-'r3ERrI__BITNER Sheriff cr Deputy Sheriff o: -- , `-~ ~'~,~~~r ~r,~c? `~'ount0-, Pennsylvania, who being du~y sworn ac~~-rd_r_g t_o lays,,, ~~=~'.'s, t~,~e within COMPhAINT - E UITY -- - 4 _ _ was served u~or_ Y~I~F'L~i~~ `s1ILMA - ----------- --------- - - t h e DF,FENDANT at 11.20:00 HOURS, on the 20tH day of A~r__l 2007 ~~ 9 ~ ; _ WALNUT BOTTOM ~.OAD Ct'~RL=ISLE, PA _'_7013 °~I~. ~:ERLIN by handing to -~ ~,i~t ,n~_l attested copy of COMPLAINT - E _UITY ~.z~~-d at the same time directing Her attention to the contents thereof. ~,~.~c}_:iff'ti Costs: Docketing 18.00 S~~.vi ce 4.80 A` f idavit . 00 ~_~,rcharge 10.00 .00 >~J_~~'2 _~32.80 t~~~v.%L,i ~'~d -~Libsc~ibed to ~~ef,~~~e- ~~le this day ~,~ f So Answers: _ '..~. R . Thomas Kline ----- --- --- 04/23/2007 SCHUTJER BOGAR B y : f- ~ ~. Deputy Sheriff A.D. • _ w1 S`=EI<I2'~' c R=TURN - RE~~U~~~R "ASE NO: 200-01599 F r'JMMONV~]EALTH OF PENNSYL~IANIA '~,`1N'~,~~-' Op CU1~~IBERLAND "~"MANOR HEALTHCARE CORP D/B/A VS =ERLIN ~TlLN:A ET AL DAVID MCKINNEY She=Tiff or Deputy Sherif I ~,_ - - , ": ~:nhe _lar_d Ccuntl-, Pennsylvania, who being duly sworn according to law, sa'y's, the within COMPLAINT - E UITY - Q _ was served upon PATRICK MARY - - - - _ the DE~'~ENDANT _ _, at 1727:00 HOURS, on the 12th day of A r' _ , 2007 ~__ -- a 4-_`~_4i ~ `I'H?:RD STREET N_-Y~~ _CUMBERLANL), PA 17C 70 by Nandi nix to -- MARY PATRICK -~~uE. ~nd attes~ed copy of COMPLAINT - E UITY r-r Q _ _ toa~~.~r~~r with ar-~~ at the same time directing Her attention to the contents thereof. Sheriff ~ ~ Costs Iic>cket i°1G 6.00 Se_cvi~e ~ 16.3 Af-:idavit .00 S,.~rcharae 10.0 0 _ .00 t~t.~~r~`7 ~:. ~~ 32.32 .~~~~o_r :, :_~nd Suhscibed to ber._ r ~ rr~~e :,:`ii s __ day F ~J So Answers: R. Thomas Kline 04/?3/2007 SCHIJTJER BOGAR ,r r Deputy Sr eri f ~- ~~ A.D. ~Davicl ~D. Bue~C ~rotFionotary 7{yrkS. SoFionage, ~',SQ ~>oCicitor Office of the~E'rothonotary Cum6erCancfCounty, ~ennsyCvania knee ?~ Simpson Deputy ,1 rotho~aotary Irene ~E. 9l-lorrow 2n~Deputy Solicitor "' CIVIL TERM OF~DER OF TERMINATION OF COURT CASES AND NOW THIS 27T" DAY OF OCTOBER, 2010, AFTER MAILING NOTICE OF INTENTION TCi 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, DAVID D. BUELL PROTHONOTARY One CourtFiouse Square ~ Suite 100 ~ Car~isCe, r1'A 17013 ~ 717,1240-6195 • rFa~ (7171240-6573