HomeMy WebLinkAbout11-4126PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2011- -I 1 a Lf CIVIL TERM
SALLY A. MUSSER, _?
Defendant
NOTICE >n i
ca m
You have been sued in court. If you wish to defend against the claims set forth inge
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 an 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
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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 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
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PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
SALLY A. MUSSER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2011-
COMPLAINT
CIVIL TERM
NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a
Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys, BARIC
SCHERER, and files the within Complaint and, in support thereof, sets forth the following:
1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Sally A. Musser, is an adult individual with a residence address of
5985 Molly Pitcher Highway, Shippensburg, Cumberland County, Pennsylvania 17257.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
4. On or about September 10, 2010, Ruth L. Shreiner sought to be admitted to the
Shippensburg Health facility.
5. On or about September 10, 2010, Sally A. Musser, as the legal representative of
Ruth L. Shreiner, executed an Admission Agreement on behalf of Ruth L. Shreiner, at the
facility. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A"
and is incorporated.
6. Pursuant to the Admission Agreement, Ruth L. Shreiner would be responsible to
pay any costs of care which were not covered by a third party payer.
7. On or about September 10, 2010, Ruth L. Shreiner became a resident of the
Shippensburg Health facility and remained a resident to January 20, 2011.
8. Pursuant to the Admission Agreement, Sally A. Musser agreed, as the responsible
party for Ruth L. Shreiner, to pay the costs of care provided from the income of Ruth L. Shreiner.
9. On or about September 10, 2010, Sally A. Musser executed and Application For
Admission wherein she represented to Shippensburg Health that she was handling the funds of
Ruth L. Shreiner. A true and correct copy of the Application for Admission is attached hereto as
Exhibit "B" and is incorporated.
10. As of January 20, 2011, Ruth L. Shreiner owed Shippensburg Health the sum of
$4,507.00 for the costs of care provided by Shippensburg Health to her A true and correct copy
of the Statement reflecting the balance due is attached hereto as Exhibit "C" and is incorporated.
11. Upon information and belief, Ruth L. Shreiner passed away on January 21, 2011.
12. Demand has been made upon Sally A. Musser to pay the amount due for the costs
of care provided to Ruth L. Shreiner.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. SALLY A. MUSSER
13. Plaintiff incorporates by reference paragraphs one through twelve as though set
forth at length.
14. Sally A. Musser has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
15. As a consequence of that breach, Shippensburg Health is owed the sum of
$4,507.00 to January 20, 2011.
16. The accrued debt consists of the private pay obligation of Ruth L. Shreiner. Sally
A. Musser has failed to pay the private pay obligation from the benefits and funds she has
received in the name of Ruth L. Shreiner.
17. The Admission Agreement bound Ruth L. Shreiner to pay for the costs of her care
at the facility and bound Sally A. Musser to pay the costs of care from the assets and income of
Ruth L. Shreiner.
18. The Admission Agreement provides for the recovery of a penalty for late
payments in the amount of 1.5% per month.
19. The Admission Agreement provides for the recovery of reasonable attorney fees
and costs incurred by Shippensburg Health to collect a debt due and owing to Shippensburg
Health.
WHEREFORE, Plaintiff requests judgment in its favor and against Sally A. Musser for
the sum of $4,507.00 plus interest, costs and expenses, late fees and any additional amount
coming due to the date of award and attorney fees and costs.
COUNT II-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. SALLY A. MUSSER
20. Plaintiff incorporates by reference paragraphs one through nineteen as though set
forth at length.
21. During the period of Ruth L. Shreiner's residence at the facility, Sally A. Musser
has been receiving social security and pension benefits of Ruth L. Shreiner.
22. The proper use of those funds would have been to pay the costs of care accruing
for the care of Ruth L. Shreiner at Shippensburg Health.
23. At the time of receipt of those funds, Sally A. Musser knew that these funds
should be paid over to Shippensburg Health for the costs of Ruth L. Shreiner's care.
24. Sally A. Musser gave no consideration for the funds of Ruth L. Shreiner she has
received.
25. Demand has been made upon Sally A. Musser to tender the funds of Ruth L.
Shreiner to Shippensburg Health and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Sally A. Musser
requiring her to:
a) return the subject matter in specie;
b) pay over the value if Sally A. Musser has consumed the money in beneficial use;
C) pay its value if Sally A. Musser has disposed of the funds received; and
d) award costs, expenses and interest.
Respectfully submitted,
5 -1 1A, RI r
27R#
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/shreiner/complaint.pld
VERIFICATION
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they are true and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §
4904 relating to unsworn falsifications to authorities.
i
DATE:
Allison Klimowicz
Corporate Operations Center Direc r
SHIPPENSBURG HEALTH CARE CENTER
ADMISSION AGREEMENT
THIS AGRESIVIENT, made this day of
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
"SHIPPENSBURG") and Box) LL-6
(hereafter "Resident"), previously residing at (Street Address and Post Office
. _. r ti A
and
(hereafter
I') ?"), PC ?
"Legal Representative"), residing at (Street Address and Post office Box)
C1 l e eaat
Representative's relationship with the Resident is that of
!. PROVISION OF SERVICES
A. NURSING SERVICES: SHIPPENSBURG will provide the Resident with
routine nursing services, semi-private accommodations, three meals each day
(except as otherwise medically indicated), blankets, bed linens, towels and
wash cloths, laundering of blankets, linens, towels, and wash cloths,
housekeeping services, and activity programs and social services as
established by the facility, as identified on the Rate Schedule. The Rate
Schedule is attached to this Agreement and is incorporated herein as if set forth
in full. The Rate Schedule sets forth the list of supplies and services included in
SHIPPENSBURG's daily rates, those supplies and services which are. not
covered by the daily rates for which the Resident will be separately charged,
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EXHIBIT "A"
The staff of SHIPPENSBURG will take whatever time is necessary to answer
all of your questions. Please continue to ask questions
until you are sure that you understand.
and those supplies and services covered by the Medicare and/or Medicaid
programs for enrolled Residents.
Federal and state laws and regulations dhange regularly and frequently
require changes related to the care and services SHIPPENSBURG provides.
Additionally, other financial factors may require SHIPPENSBURG to make
changes related to provision of its care and services. On this basis, the Rate
Schedule may be changed, upon notice to the resident.
B. ANCILLARY SERVICES AND_ SUPP JES: SHIPPENSBURG will also
provide ancillary services and supplies as set forth in the Rate Schedule, and
private accommodations upon the direction of the Resident's physician. The
ancillary services and supplies are subject to change from time to time at the
discretion of SHIPPENSBURG.
C. OUTSIDE PROVIDERS AND NON-FACILITY SERVICES:
SHIPPENSBURG makes available, from time to time, the services of outside
providers and non-facility services. These services will be available under
SHIPPENSBURG's policies and procedures, and at the Resident's sole
expense unless the charges for such services are covered by a third party
payer. Should the Resident arrange for the services of outside providers, the
providers must be properly licensed or registered under state and federal law,
and must comply with all SHIPPENSBURG policies and procedures, including,
but not limited to, providing SHIPPENSBURG, with documented proof of their
legally required liability insurance coverage. All outside providers must be
approved in writing by SHIPPENSBURG before providing any services, At
SHIPPENSBURG's sole discretion, only providers deemed by
SHIPPENSBURG to fulfill all of the requirements set forth in federal and state
law, as well as SHIPPENSBURG's policies and procedures, may provide
services to Residents.
The Resident recognizes and agrees that all outside providers, including
those designated by SHIPPENSBURG, are independent contractors. The
Resident recognizes and agrees that such providers are not associates or
agents of SHIPPENSBURG, and that SHIPPENSBURG is not liable for-any
outside providers acts or omissions. The Resident shalt be solely responsible
for payment of all charges of any provider who renders care to the Resident in
SHIPPENSBURG, unless the charges are covered by a third party payer.
Furthermore, the Resident agrees to confirm that any Resident initiated,
approved outside provider (i.e. private duty nurse, etc.) has worker's
compensation Insurance coverage as required by law, as well as liability
insurance. To the extent that the outside provider does not have the legally
required worker's compensation insurance coverage, the Resident will provide
and pay for such coverage.
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II. RESIDENT'S FIGHTS
SHIPPENSBURG welcomes all persons in need of its services
and does not discriminate on the basis of age, disability, race, color,
national origin, ancestry, religion, or sex. Furthermore, SHIPPENSBURG does
not. discriminate among persons based on their sources of payment.
A. Consent for Treatment
? • SHIPPENSBURG SERVICES: By signing this Agreement,
the Resident consents to SHIPPENSBURG providing routine nursing and other
health care services and administering all medication as directed by the
attending physician, or when the attending physician is unavailable,
SHIPPENSBURG's Medical Director. SHIPPENSBURG is not obligated to
provide the Resident with any medications, treatments, special diets or
equipment without specific orders or directions from the Resident's physician or
SHIPPENSBURG's Medical Director. From time to time SHIPPENSBURG may
participate in training programs for persons seeking licensure or certification as
health care workers. In the course of this participation, care may be rendered
to the Resident by such trainees under supervision as required by law.
Consent to routine nursing care provided by SHIPPENSBURG shall include
consent for care by such trainees.
2. PHYSICIAN SERVICES: The Resident acknowledges that
he or she is under the medical care of a personal attending physician, and that
SHIPPENSBURG provides services based on the general and specific
instructions of that physician, or when unavailable, SHIPPENSBURG's Medical
Director. The Resident has a right to select his or her own attending physician.
if, however, the Resident does not select an attending physician, or is unable to
select an attending physician, an attending physician may be designated by
SHIPPENSBURG or in accordance with state law. All attending physicians
must meet and conform with all of SHIPPENSBURG's policies and procedures,
and are subject to the terms set forth in the Outside Providers and Non-facility
Services section of this Agreement.
3. RIGHT TO REFUSE TREATMENT: The Resident has the
right to refuse treatment and to revoke consent for treatment. The Resident
also has the right to be informed of the medical consequences of such refusal
or revocation of consent, and to be informed of alternate treatments available.
Where, in the opinion of the attending physician or by judgment of a court of
law, the Resident is determined to be mentally incompetent to make a decision
regarding refusal of treatment, the decision to refuse treatment may be made by
a Legal Representative or other surrogate decision-maker, subject to state and
federal law.
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B. Resident's Personal Pro erty
SHIPPENSBURG strongly discourages the keeping of valuable jewelry,
papers, large sums of money, or other items considered of value in
SHIPPENSBURG. However, the Resident shall be permitted to retain and use
personal clothing and poss@ssions as space permits, unless to do so would
infringe upon the' right of other residents or unless determined medically
inadvisable as documented by the Resident's physician in the Resident's
medical record. SHIPPENSBURG shall make reasonable efforts to properly
handle and safeguard the Resident's personal property in SHIPPENSBURG.
The Resident agrees to inform SHIPPENSBURG of all valuable property upon
admission. if, at any time during the Resident's stay, new items of value are
added to the Resident's possessions in SHIPPENSBURG, the Resident agrees
to so inform SHIPPENSBURG's Administrator or designee.
The Resident is responsible for obtaining at his or her own expense any
insurance coverage necessary to cover potential damage to or loss of any of
Resident's personal property. SHIPPENSBURG shall not be liable for damage
to or loss of any of Resident's personal property. Should the Resident lose his
or her property, or believe that his or her property has been otherwise removed
from his or her possession, the Resident agrees to follow SHIPPENSBURG's
procedure for filing reports of lost or stolen property.
In the event that Resident is transferred or discharged from
SHIPPENSBURG, or if the Resident expires, the Resident hereby authorizes
SHIPPENSBURG to transfer the Resident's personal property to the Resident's
Legal Representative, or to any duly authorized representative of Resident's
estate. If the Resident's personal property is not claimed or removed within
twenty-four (24) hours of the Resident's transfer or discharge, or expiration, the
Resident authorizes SHIPPENSBURG to place his personal property into
storage until claimed. Standard daily storage charges will continue while the
Resident's property remains in SHIPPENSBURG.
Should the Resident's property fall to be claimed within fourteen (14)
days of the Resident's transfer, discharge, or expiration, the Resident and
SHIPPENSBURG hereby agree to a storage and safe arrangement. Under this
arrangement, SHIPPENSBURG agrees to bear any and all costs of the storage
of the Resident's property, not including any insurance thereon. However, in
consideration of SHIPPENSBURG's storage of the Resident's property, should
the Resident's property fall to be claimed within thirty (30) days of placement by
SHIPPENSBURG into storage, the Resident hereby agrees that
SHIPPENSBURG may dispose of the Resident's property with and at
SHIPPENSBURG's discretion, including retaining all proceeds from any sale
thereof:
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C. Resident's Records
1. CONFIDENTIALITY: Information included in the Resident's
medical records is confidential. Unauthorized persons shall not be allowed to
review these records without the Resident's written consent, except as required
or permitted by law.
2. CONSENT TO RELEASE BY S IPPENSBURG: The Resident
authorizes SHIPPENSSR- to release all or any part of the Resident's medical
or financial records to any person or entity which has or may have a legal or
contractual obligation to provide the Resident with medical services, or tv pay
all or a portion of the costs of care provided to the Resident, including but not
limited to hospital or medical services companies, insurance companies,
workers' compensation carriers, welfare funds, and/or the Resident's employer.
The Resident also authorizes' release of information from medical or financial
records to any medical professional or Institution responsible for the Resident's
medical or nursing care when the Resident is transferred or discharged from
SHIPPENSBURG. The Resident hereby releases SHIPPENSBURG from any
liability for damages or other loss suffered in or incurred by the Resident and
arising out of or directly or indirectly related to the reliance by the facility upon
the foregoing authorization.
3. PHOTOGRAPHS: The Resident authorizes SHIPPENSBURG to
photograph or videotape the Resident as a means of identification or for health
related purposes. The photographs or videotapes may also be used to help
locate the Resident in the event of an unauthorized absence from
SHIPPENSBURG, but shall otherwise be kept confidential. If SHIPPENSBURG
intends to use the photograph or videotape for purposes other than those noted
above, SHIPPENSBURG shall get written permission from the Resident in
advance of such use (SHIPPENSBURG sometimes requests Resident to permit
the use of their photograph and written impressions about SHIPPENSBURG in
marketing and other public information materials). The Resident retains the
right to refuse the taking of a photograph at any particular time.
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®: RESIDENT'S RESPONSIBILITIES
1. RULES AND REGULATIONS: The Resident agrees that
SHIPPENSBURG may, to maintain orderly and economical operations, adopt
reasonable rules and regulations to govern the conduct and responsibilities of
the Resident. These rules and regulations include that SHIPPENSBURG is a
SMOKE FREE CAMPUS, with no smoking or use of smokeless tobacco
products permitted in all its buildings, grounds and parking areas, for new
residents, their visitors, staff, vendors, physicians, contractors, and volunteers.
The Resident agrees to follow those rules and regulations. It Is understood that
these rules and regulations may be amended from time to time as
SHIPPENSBURG may require. Any changes to the rules and regulations shall
be given to the Resident in writing. NOTE: Some residents admitted prior to the
effective date of the SMOKE FREE CAMPUS Policy will be allowed to continue
smoking in special designated areas as required by Federal regulations.
2. DIET: The Resident understands that his or her diet is medically
prescribed and, therefore, must be monitored by SHIPPENSBURG. The
Resident agrees to- consult with Nursing or Dietary staff when food or
beverages are brought into SHIPPENSBURG.
3. MEDICATIONS: No medications or drugs may be brought upon
SHIPPENSBURG premises unie§s the medications or drugs are labeled
according to the requirements of state and federal law. Packaging of
medications must be compatible with SHIPPENSBURG's medication
distribution system. No drugs or medications may be brought into
SHIPPENSBURG unless they are delivered directly to the nurses' station.
4. CARE OF SHIPPENSBURG'S PROPERTY: To preserve the
value of SHIPPENSBURG's property for future residents' use, the Resident
agrees to use due care to avoid damaging SHIPPENSBURG's property and
premises. The Resident shall be responsible for the costs of repair or
replacement of SHIPPENSBURG's property damaged or destroyed by the
Resident. However, the Resident shall not be responsible for such damage as
is to be expected from ordinary wear and tear.
5. CARE OF THE RESIDENT'S ROOM: SHIPPENSBURG
encourages the Resident to*have a SHIPPENSBURG-like environment, and will
attempt to accommodate all reasonable requests to individualize resident
rooms. For safety reasons, SHIPPENSBURG must approve any addition or
rearrangement of furniture, hanging of pictures, posters, or other similar
activities.
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6. INDEMNIFICATION; The Resident hereby agrees to indemnify
and hold harmless SHIPPENSBURG, its officers, directors, agents, and
employees from and against any and all claims, demands or causes of action
for injury or death to person or damage to property, including all costs and
attorneys fees incurred in defending any claim, demand or cause of action
which is caused by the Resident and which is not caused by any Wilful or
negligent action of SHIPPENSBURG. This lndemnlfication includes, but is not
limited to, all claims, demands or causes of action stemming from the acts or
omissions of the Resident, Including but not limited to Resident's refusal of any
nursing care, medical or other treatment, or any other item or service deemed
necessary by SHIPPENSBURG or any other treating health professional.
Ill. POLICY REGARDING THE IMPLEMENTATION
OF THE PATIENT SE F-DETERMINATION ACT
The following information is being provided to the Resident as a result of
a federal law which requires certain health care institutions, including
SHIPPENSBURG, to disclose to the Resident his or her rights under federal
and state law to make decisions regarding his or her health care.
A. iNTRODUCTiON,
1. SHIPPENSBURG recognizes and appreciates the dignity and value
of each Resident's life, and the right of each Resident to make decisions
regarding his or her care.
2. SHIPPENSBURG recognizes the Resident's right to have these
decisions made on his/her behalf by a substitute decision-maker in accordance
with state law when the Resident. is no longer able to make them.
3. SHIPPENSBURG recognizes the right of each Resident to utilize
those health care advance directives recognized under state taw, and will honor
such advance directives developed and implemented in accordance with state
law and consistent with the level of care SHIPPENSBURG is licensed to
provide. A health care advance directive is a written document that states
choices for health care and/or names or precludes those individuals who the
Resident wishes to make those choices. These choices may include the refusal
of certain types of care. A Living Will and a Durable Power of Attorney for
Health Care are examples of such advance directives.
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PENNSYLVANIA LAW PERMITS SHIPPENSBURG TO REFUSE TO
HONOR DECISIONS BY THE INDIVIDUAL YOU APPOINT AS YOUR
AGENT IN AN ADVANCE DIRECTIVE OR BY A "HEALTH CARE
REPRESENTATIVE" WHO SEEKS TO MAKE SUCH DECISIONS FOR
YOU UNDER PENNSYLVANIA LAW IF SHIPPENSBURG HAS A GOOD
FAITH BELIEF THAT THE INDIVIDUAL IS NOT REALLY AUTHORIZED
TO MAKE DECISIONS FOR YOU UNDER THE LAW OR THAT THE
DECISIONS BEING MADE ARE NOT CONSISTENT WITH THE RULES
FOR SUCH INDIVIDUALS TO MAKE DECISIONS ON YOUR BEHALF
ESTABLISHED BY PENNSYLVANIA LAW.
B. HEALTH CARE ADVANCE DIRECTIVE. A health care advance
directive is not necessary In order to be admitte to or to continue to re_ s_Id_ a In
SHIPPENSBURG. However if the Resident has a health care advance
directive, he or she must provide a validly executed orfatna? advance direc#iVP
to SHIPPENSBURG`s Administrator or desi nee so that it can be reviewed and
made a art of his or her medical record. It is essential that SHIPPENSBURG
receives a validl executed on final document or documents to ensure that it is
authorized to foltaw the directives therein.
RECENT CHANGES IN PENNSYLVANIA LAW (discussed further below
in Subsection C) PROVIDE SOME ADDITIONAL REASONS TO
CONSIDER HAVING AN ADVANCE DIRECTIVE.
0. HEALTH CARE REPRESENTATIVE. PENNSYLVANIA LAW PERMITS'
AN INDIVIDUAL QUALIFYING AS A "HEALTH CARE REPRESENTATIVE"
UNDER 20 PA. C.S. § 5481 TO MAKE HEALTH CARE DECISIONS FOR
INCAPACITATED PERSONS, WHO HAVE AN END-STAGE MEDICAL
CONDITION OR ARE PERMANENTLY UNCONSCIOUS, WITHOUT THAT
WHILE SHIPPENSBURG WILL REQUIRE A "HEALTH CARE
REPRESENATIVES" TO CERTIFY THAT THEY HAVE KNOWLEDGE
OF THE INCAPACITATED PERSON'S PREFERENCES, VALUES,
AND MORAL AND RELIGIOUS BELIEFS, THE LAW PERMITS THEM
TO MAKE SOME DECISIONS BASED ON THEIR OWN EVALUATION
OF THE INFORMATION ABOUT THE INCAPACITATED PERSON'S
CONDITION WHERE INSTRUCTIONS FROM THE INCAPACITATED
PERSON IS LACKING.
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AN ADVANCE DIRECTIVE CAN PROVIDE SPECIFIC INSTRUCTIONS
FOR AND ALSO LIMIT WHO CAN QUALIFY AS A "HEALTH CARE
REPRESENTATIVE" OR CAN PROVIDE THEM WITH ADDITIONAL,
AUTHORITY TO ACT ON ONE'S BEHALF. IF A RESIDENT WISHES
TO PLACE SUCH LIMITS ON THE ABILITY OF OTHERS TO ACT AS
THEIR "HEALTH CARE REPRESENTATIVE" OR TO PROVIDE
ADDITIONAL INSTRUCTIONS FOR THEM, THE RESIDENT SHOULD
CONSIDER HAVING A WRITTEN ADVANCE DIRECTIVE THAT
STATES THEIR WISHES; AND, THE RESIDENT MAY WISH TO
CONSULT WITH THEIR FAMILY AND LEGAL COUNSEL ON THIS
QUESTION.
D. ASSISTANCE AVAILABLE.
1. Questions about SHIPPENSBURG's policies regarding health care
decision-making and/or advance directives may be presented to
SHIPPENSBURG's Administrator.
2. Questions regarding whether and haw to execute health care
advance directives and about their content should be discussed with the
Resident's family, physician and attorney.
3. SAMPLE HEALTH CARE ADVANCE DIRECTIVE FORMS
included in the ourrent Pennsvivania Living Will Statute accompanies this
Agreement for the Resident's information
4. Resident should consult with their family, physician, and
attorney before using any Advance Directive Forms.
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IV. CAPACITY OF R SlDEIVT AND GUARDIANSHIP
If the Resident is or becomes unable to understand or communicate, and
is determined to be incapacitated by the Resident's physician, in the absence of
the Resident's prior designation of an authorized Legal Representative, or upon
the unwillingness or inability of the Legal Representative to act,
SHIPPENSBURG shall have the right to commence a legal proceeding to
adjudicate the Resident incapacitated, As a result of such a legal proceeding
SHIPPENSBURG shall have a court appoint a legal guardian for the Resident.
SHIPPENSBURG also shall have the right to commence a legal proceeding to
have a court replace an authorized Legal Representative with a new one br with
a legal guardian when SHIPPENSBURG has a good faith belief that the Legal
Representative is not acting in the best interests of the Resident. The cost of
the legal proceedings, including attorney's fees and costs, if not covered by the
Commonwealth, shall be paid promptly by the Resident or the Resident's
estate.
i=ItVANCIAL ASPIECTS OF THE AGREEIylEIyT
V.
A. Legal Re resentatlve
1, STATUS. While not legally required, if the Resident is unable to make
decisions for himself or herself, a Legal Representative should be available to
make certain .decisions on behalf of the Resident. For the purposes of this
Agreement, the Resident's Legal Representative is the person selected by the
Resident and defined under state and federal law as the Resident's responsible
person, or as the person recognized under state law as having the authority to
make health care and/or financial decisions for the Resident. The Legal
Representative may or may not be court appointed, may be an attorney-in-fact
acting under a durable power of attorney for health care, guardian, conservator,
next-of--kin, or other person allowed to act for the Resident under state law. If
Legal Representative status has been conferred by a court of law or through
appointment by the Resident, verification of such status must be provided to
SHIPPENSBURG at the time of Admission, Such verification includes providing
SHIPPENSBURG with -a certified copy of any court order, or a validly executed
original Power of Attorney or other legal document.
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2. REQUIREMENTS. For purposes of this Agreement, LEGAL
'REPRESENTATIVES ARE REQUIRED TO SIGN THIS AGREEMENT FOR
ADMISSION, AND AGREE TO DISTRIBUTE TO SHIPPENSBURG, FROM
THE RESIDENT'S INCOME OR RESOURCES,
PAYMENT ITEMS/SERVICES PROVIDED TO THE RESIDENT. Legal RepreseDntativeOs
contractually bound by the terms of this Agreement and may become personally
liable for failure to perform their fiduciary duties under the Agreement. Legal
Representatives are also required to produce financial documentation as proof
of the Resident's ability to pay for charges when due. Wherever this
Agreement refers to the Resident's financial obligations under this
Agreement, the term "Resident" shall be construed to Include the
obligations of any Legal Representative to act on behalf of Resident.
B. Financial Arrangements
1. INCOME AND ASSETS/ CHANGES TO INCOME AND ASSETS; it
is essential that the Resident advise SHIPPENSBURG of the Resident's
income and assets, and to communicate changes in the Resident's income or
assets to SHIPPENSBURG as quickly as possible. The Resident hereby
agrees to notify SHIPPENSBURG ninety (90) days prior to the time when the
Resident has reason to believe that his income and assets will no longer be
sufficient to fulfill his financial obligations under the terms of this Agreement.
2. MECIC L ASSISTANCE. Generally, when
depleted, residents apply for Medical Assistance benefits undeprivate funds are
r Title XIX of the
Social Security Act and Article IV of the Pennsylvania Public Welfare Code.
The Medical Assistance application process can be complicated, and the
processing time can be lengthy. SHIPPENSBURG is experienced in the
Medical Assistance Application process, and can be of great assistance to the
Resident in this process. To be of assistance. SHIPPENSBURG must have
accurate record of the history and depletion of the Resident's income and
significant assets.
3. DISCLOSURE FORM On this basis, please set forth the
Resident's income and assets below:
11
Income?n nQ r? C?
Social Securfty: A ?e
Account Number:
Monthly Income:
Payee:
Pe sfon:
Account Nu
Monthly fncc
Financial Ins
Payee:
Trusts:
Account Numl
Monthly Incom
J
12
Financial Institution(s):
13
Vehicles
Year, Make and Model:
State of Re
Bank Accounts;
Account Nun
Financial Inst
insurance ioli?cie_s;
Account Numb(
Financial Institui
Beneficiary:
14
Qther Sfgnificant Assets folease descrlbel•
Liabilities
Describe nature and extant:
Has a Will been completed: , yes No If yes, Executor's
Executor's PAdress:
i8
v. Receipt of Incc:irne/ Rearesentativs Pa 22. Many Residents find
security in appointing SHIPPENSBURG as the "Payee" or "Representative
Payee" of the Resident's income., including social security income. By
appointing SHIPPENSBURG as the "payee" or the "Representative Payee", the
Resident directs that his or her income be directed to SHIPPENSBURG for the
purposes of paying for the Resident's care and services. Any excess funds
accumulated are refunded to the Resident or the Resident's Legal
Representative on or before the tenth (10) day of the month following the
receipt of the benefits. This is not required. However, if the Resident is
interested- in a ointi SHIPPENSBURG as the Resident' "Pa op" or
"Re resentative Pa ee" lease nofi SHiPPENSBURG's Administrator or the
Administrator's desianee. SHIPPENSBURG will assist you in making thse
e
arrangements.
6. PRIVATE RESIDENTS: A Resident is considered private (or private pay)
when no state or federal program is paying for the Resident's room and board.
A private=pay Resident may have private insurance or another third party, which
pays all or some of his or her charges.
a.) Daily Rate. The Resident agrees to pay SHiPPENSBURG's private
pay per diem rate as described in the Rate Schedule. The Resident agrees to
pay SHIPPENSBURG In advance for one month's private daily rate. For each
additional month's stay, the Resident agrees to pay SHIPPENSBURG in
advance on or before the tenth (loth ) day of the month. Any unused advance
payment shall be refunded to the Resident ninety (90) days after the Resident's
discharge if the Resident becomes covered by Medicaid or Medicare, or leaves
SHIPPENSBURG before the end of the month.
b.) Rate Adjustments. SHIPPENSBURG may occasionally need to
increase the daily rate or optional service charges. If this happens, the
Resident shall receive thirty (30) days advance written notice of the rate
adjustment. SHIPPENSBURG shall provide notice to the Resident, and if
known, the Resident's Legal Representative. When a notice of a rate
adjustment is reQeived, the Resident can choose to end this Agreement by
providing written notice to the Administrator. If the Resident falls to leave
SHIPPENSBURG prior to the effective date of the rate adjustment, the Resident
shall be considered to have consented to the increase.
16
c.) Private Insurance. Even when there Is private Insurance coverage,
the sldent emai s ri aril es onsible or a in all of SHIP'PENSBURG's
charges. Where the Resident's private insurer is a managed care plan with
which SHIPPENSBURG has a contract, SHIPPENSBURG agrees to invoice the
managed care plan directly for the Resident's care and services. However, all
charges that are not covered by the managed care plan are the responsibility of
the Resident. These non-covered charges include but are not limited to any
coinsurance and/or deductible amounts which the managed care plan requires
the Resident to pay, to the extent allowed under federal and state laws. Where
the Resident's private insurer is not a managed care plan with which
SHIPPENSBURG has a contract, SHIPPENSBURG will Invoice the Resident,
who is primarily responsible for payment of the invoice.
7. MEDICAL ASSISTANCE (MEDICAID) RESIDENTS; A Medicaid Resident is
one who receives benefits from the state Medicaid program for all or a majority
of his or her room and board charges. The services currently covered by
Medicaid are set forth in the attached Rate Schedule, which is subject to
change. SHIPPENSBURG makes no guarantee of any kind that the
Resident's care will be covered by Medicare, Medicaid, or any third party
Insurance or outer reimbursement source. SHIPPENSBURG, its agents
and associates are hereby released from any liability for the Resident's
potential claim for any failure to obtain such coverage.
With respect to applying for and receiving Medical Assistance through the
Medicaid Program, SHIPPENSBURG will assist the Resident in the application
process. The Resident agrees to the following:
a.) Qualifying for Medicaid Assistance. If the Resident elects coverage
under the Medicaid Program, the Resident agrees to act as quickly as possible
to establish and maintain eligibility for Medicaid. These actions must include,
but are not limited to, taking any and all steps necessary to ensure that the
Resident's assets and income are within the required limits and that these
assets and Income remain within allowable limits for Medicaid.
17
b.) Providing Application Information. The Resident agrees to provide
all financial and other Information required for completion of the Medicaid
application accbrately and truthfully, as requested by applicable state%ounty
agencies. Additionally, the Resident agrees to provide this information in the.
manner requested by the applicable agencies, and in compliance with any
deadlines set by the applicable agencies. Furthermore, the Resident agrees to
attend any and all interviews necessary for completion of the Medical
Assistance eligibility process, as requested by the applicable state/county
agencies. Failure to provide all financial and other information required for
completion and support of the Medicaid application accurately and truthfully, as
requested by applicable State/county agencies, may result in personal liability
for SHIPPENSBURG's charges.
c.) Keeping SHIP PENSBURG Informed. The Resident agrees to keep
SHIPPENSBURG informed of the status and progress of the Medicaid
application. The Resident agrees to provide SHIPPENSBURG with copies of
any financial and other information related to the Medicaid application, including
a copy of the completed application.
d.) Transferring Assets. It the Resident transfers assets, this transfer may
disqualify the Resident for Medicaid and/or cause a discontinuance of the
Resident's Medicaid benefits. The Resident acknowledges that this may result
in discharge of the Resident due to nonpayment, and personal liability for
SHIPPENSBURG's charges.
e.) Legal Representative Controlling Resident's Funds. If the
Resident's Legal Representative has control of or access to the Resident's
income and/or assets, the Legal Representative agrees to use these funds
solely for the Resident's welfare. This includes, but is not limited to, making
prompt payment for care and services provided to the Resident as specifidd
and required by the terms of this Agreement. Failure to use these funds solely
for the Resident's welfare may result In personal liability for SHiPPENSBURG's
charges.
f) Providing Financial Information. The Resident certifies that any
financial information regarding the Resident's income and assets required by
SHIPPENSBURG and provided by the Resident is complete and accurate.
g.) Dally Rate Payment. The Resident agrees to pay the co81$ or
SHIPPENSBURG's per diem rate as described in the Rate Schedule.
18
h.) Termination or Denial of Coverage. The Resident may remain in
SHIPPENSBURG for as long as he or she is certified eligible for Medicaid
coverage, or for as long as any share of cost owed by the Resident Is paid as
due. A Resident who remains in SHIPPENSBURG after Medicaid coverage
has been denied and a final determination has been made must pay
SHIPPENSBURG charges as a private resident. In this event, the Resident will
pay based on. the private rates, charges, and terms in effect at the time of
service. Where the Resident falls to pay the private rates and charges, the
Resident agrees to seek immediate placement at an alternate facility at the
earliest possible time. Residents who have not Tread been determined
eligible for Medicaid coverage will continue to be charged based on
SHIPPENSBURG's rivate ates and will be liable to a SHIPPENSBURG orf
Any-charges; that are not covers b Medical As istance r other third. art
payors after the Resident's ell lbility for and effective date of Medicaid coverage
erase
has been finally determined Resident is expected to make , paVmenf to
SHIPPENSBURG white any application for Medical Asslstance benefits ?s
nnnrhnn final
vwsN..Jt 14 i GI?V ?({?
Funds Allowance (the current amount Is listed on the attached Rate Schedule
Any. refunds due to the Resident after the final determination of Medicaid
coverage will be-made within ten l1 t}) business davs of SHIPPENS UB R 'sG
receipt of notlce of such coverage
I.) Resident's Share of Cost. The Medicaid program reviews the available
monthly income of all persons requesting Medicaid. Based on this review, the
Medicaid program requires most Medicaid residents to pay for a reasonable
share of the cost of their care. The amount of the Resident's share of the cost
of their care can change based upon the services the Resident chooses, and
the Medicaid program can adjust the amount of the. Resident's share of the cost
bf their care based upon changes in the Resident's income. Payment of that
share is the responsibility of the Resident.
J.) Appeal of Finding of Ineligibility. Where the Resident applies for
Medical Assistance benefits, the applicable statelcounty agency may deny or
limit benefits. While Resident retains all legal responsibility for obtaining his or
her benefits, Resident authorizes SHIPPENSBURG to assist Resident in
making any claims and to take all other actions necessary to secure the
Resident's benefits, including, but not limited to, assisting the Resident in
appealing any state/county agency determination and requesting Interim
Assistance benefits. The Resident agrees to provide SHIPPENSBURG with all
information related to obtaining benefits upon receipt, including, but not limited
to, notices of denial. This paragraph shall not create any responsibility on
behalf of SHIPPENSBURG to obtain benefits or any portion of benefits, nor any
liability for failure to obtain same. To facilitate this authorization, but not in lieu
thereof, the Resident agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION MEDICAID statement attached to this Agreement.
19
B. MEDICARE RESIDENTS; A Medicare Resident is one who receives
benefits from the federal Medicare program for his or her SHIPPENSBURG
care. The services currently covered by Medicaid are set forth in the attached
Rate Schedule, which is subject to change. Some additional items and services
may be also covered by Medicare. SHIPPENSBURG makes no guarantee of
any kind that the Resldent's care will be covered by Medicare, Medicaid,
or any third party Insurance or other reimbursement source.
SHIPPENSBURG, its agents and associates are hereby released from any
liability for the Resident's potential claim for any failure to obtain such coverage,
a.) Continuing Payment of SHIPPENSBURG Charges Pending
Eligibility. Where the Resident is not currently covered by Medicare,
the Resident agrees that while coverage is being pursued the Resident
shall pay the private pay rate as a private pay resident as described
within this Agreement. If the Resident Is unable to pay the private pay
rate, the Resident agrees to pay SHIPPENSBURG an amount that is at
least equal to the Resident's monthly income from all of the Resident's
income sources. This amount, minus any amount not covered by
Medicare, shall be refunded to the Resident within thirty (30) days of
payment by Medicare should the Resident be found eligible by Medicare.
Once the Resident is determindd to be eligible for Medicare, the amount
of the Resident's share of cost not covered by Medicare shall be paid to
SHIPPENSBURG on or before the tenth (10`h) day of each month.
Furthermore, the Resident shall immediately pay to SHIPPENSBURG any
amount the Resident is in arrears. If payment of any outstanding amount
cannot be made immediately, the Resident shall immediately discuss same
with SHiPPENSBURG's Administrator or the Administrator's designee, and
shall make arrangements to bring his or her account into balance within the
shortest possible time.
b.) Daily Rate Payment. The Resident agrees to pay the costs of
SHIPPENSBURG's per diem rate as described in the Rate Schedule for those
supplies and services not paid for by the Medicare program,
c.) Coinsurance and Deductibles. The Resident is responsible for
payment of any Medicare coinsurance and/or deductibles that are not paid to
SHIPPENSBURG by the Medicaid program or private insurance.
d,) Limited Coverage. The Resident understands that Medicare coverage
is established by federal guidelines and not by SHIPPENSBURG. Medicare
coverage is limited in that only a specified level of care is covered for a
specified number of days (benefit period). If the Resident no longer meets
Medicare coverage criteria, coverage can be ended before the use of all allotted
days in the current benefit period.
20
e.) Expiration of Benefits, Prior to admission, the Resident must be able
to demonstrate the ability to pay SHIPPENSBURG (either privately or through
Medicaid) for services rendered after Medicare benefits expire. When Medicare
coverage expires, the Resident may remain in SHIPPENSBURG if private pay
or other payment arrangements have been made. If the Resident wishes to be
discharged from SHIPPENSBURG upon expiration of Medicare benefits, he or
she must so advise SHIPPENSBURG at the time of the Resident's admission.
If the Resident Intends to become private pay when Medicare benefits expire,
the Resident agrees to pay in advance for one month's private daily rate when
the Resident changes to private pay status. No advance payment is required
from Medicare Residents who are eligible for Medicaid coverage.
L) Appeals of Denials of Coverage. Where the Resident -applies for
Medicare benefits, the applicable intermediary, carrier or government agency
may deny the Resident these benefits or some portion of these benefits. Where
a denial occurs, the Resident retains all responsibility for obtaining his or her
benefits. However, the Resident authorizes SHIPPENSBURG to assist the
Resident In making all claims and to taking all other actions necessary to
secure his or her benefits, including, but not limited to, appealing any initial or
subsequent adverse determinations, including requests for Reconsideration.
The Resident agrees to provide SHIPPENSBURG with all information related to
obtaining benefits upon receipt, including, but not limited to, notices of denial.
This paragraph does not apply to benefits for which SHIPPENSBURG has
determined the Resident is not eligible, and does not affect the Resident's right
to have a Demand Bill filed. This paragraph shall not create any responsibility
on behalf of SHIPPENSBURG to obtain any portion of benefits, nor any liability
for failure to obtain same. To facilitate this authorization, but not in lieu thereof,
the Resident hereby agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION - MEDICARE statement attached to this Agreement.
9. MANAGED CARE ORGANIZATIONS: Where the Resident enrolls in or
switches the Reside- enrollment to any managed care organization
(hereafter "MCO"), including MCOs that provide Medicare or Medicaid benefits,
the Resident agrees as follows:
a.) The Resident shall advise SHIPPENSBURG prior to enrolling in or
switching the Resident's enrollment to any MCO,
b.) The Resident acknowledges that SHIPPENSBURG is not responsible
for and has made no representations regarding the actions or decisions of any
MCO with which SHIPPENSBURG is a participating provider, including
decisions relating to a denial of coverage.
21
c.) SHIPPENSBURG will accept payment from the MCO as payment in
full only for those services and supplies covered by the MOO. The Resident is
responsible for any co-payments or other costs assigned to the Resident under
the managed care plan, or not covered by the MCO under the terms of the
managed care plan. If the Resident utilizes services which the MCO refuses to
pre-authorize, the Resident shall pay SHIPPENSBURG for those services.
Further, the Resident shall pay SHIPPENSBURG for services for which the
MOO has denied payment because the Resident failed to supply information to
the MOO, or for services which are denied subsequently by the MOO.
d.) SHIPPENSBURG reserves the right to withdraw as a participating
provider in any MOO at any time and for any reason. In the event that
SHIPPENSBURG withdraws as a participating provider, the Resident may
convert his or her coverage to a health plan in which SHIPPENSBURG is a
participating provider. Effective the date of SHiPPENSBURG's withdrawal from
the Resident's MOO, the Resident is obligated to pay for services and supplies
provided to the Resident as a private pay resident. If possible,
SHIPPENSBURG will provide the Resident with advance written notice of its
withdrawal from the Resident's MOO thirty (30) days before SHIPPENSBURG's
withdrawal.
10. ASSIGNMENT OF THIRD PARTY PAYMENTS. The Resident irrevocably
authorizes SHIPPENSBURG to make claims and to take all other actions to
secure receipt of third party payments to reimburse SHIPPENSBURG for its
charges. To the fullest extent permitted by law, and as security for payment of
SHIPPENSBURG's charges, the Resident hereby assigns to SHIPPENSBURG
all of the Resident's rights to any third party payments now or subsequently
payable to the extent -of all charges due under this Agreement. Resident shall
promptly endorse and deliver to SHIPPENSBURG any payments received from
third parties to the extent necessary to satisfy the charges under this
Agreement. To facilitate this assignment, but not in lieu thereof, the Resident
hereby agrees to properly execute the ASSIGNMENT OF THIRD PARTY
PAYMENTS statement attached to this Agreement.
11. FINANCIAL POWER OF ATTORNEY, The Resident agrees that upon
admission the Resident, if able, will supply SHIPPENSBURG with a fully
executed and legally valid original Financial Power of Attorney appointing an
individual chosen at the Resident's sole discretion to be his financial attorney-
in-fact should the Resident become medically incompetent. If not able, the
Resident agrees to work with SHIPPENSBURG to pursue guardianship. This
Power Qf_Attorney need only become effectlv_e if the Resident becomes
medically incompetent. If, in the judgment of the Resident, no such individual is
available, the Resident agrees to appoint such an individual when one becomes
available. Judgment of the Resident's incompetence shall not require a court
22
adjudication, but shall require the written order of Resident's physician plus
confirmation by a second examining physician. The Resident's financial
attorney-in-fact shall be granted the authority to make financial decisions for the
Resident, including the unlimited power to pay SHIPPENSBURG's charges and
invoices from the Resident's income, and from the proceeds of the attorney-in.
fact's sale of the Resident's assets.
The selection of this attorney-in-fact serves at the complete discretion of
the Resident. However, should the Resident revoke the power of his or her
appointed attorney-in-fact, or should the Power of Attorney become inoperable
for any reason, the Resident hereby agrees to immediately appoint a successor
attorney-in-fact for the financial purposes set forth herein, if such an individual is
available. Upon receiving a duly executed copy or facsimile of this Agreement
noting the Resident's appointed financial attorney-in-fact, SHIPPENSBURG
may act hereunder. Revocation of the attorney-In-fact shall be Ineffective as to
SHIPPENSSURG unless and until written or actual notice or knowledge of such
revocation is received. The attorney-in-fact's power shall continue in full force
and effect and may be relied upon by SHIPPENSSURG despite purported
revocation until written notice of revocation is received by SHIPPENSSURG.
Mn?nnie! Dnufar _F A48.-...
Residents should first consult with his or her family and attorney
before executing any Financial Power of Attorney form.
Vi. PAYMENT INFORMATION'
A. DUE [SATES AND THE OBLIGATION __OF TIMELY PAYMENT:
SHIPPENSBURG's charges for services provided shall be billed on a monthly
basis to the Resident. These charges are due and payable by the tenth (1011)
day of each month. If payment is not received by the fifteenth (150') day of each
month, the account balance is considered past due, and SHIPPENSBURG may
add late charges to the Resident's account. These late charges shall be
assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one
and one-half percent) or the maximum amount permitted by law. This late
charge does not alter any.obligations of SHIPPENSBURG or Resident under
this Agreement.
The Resident recognizes that SHIPPENSBURG does not offer credit or
accept installment payments. SHIPPENSBURG's acceptance of a partial
payment does not limit SHIPPENSBURG's rights under this Agreement to full
payment for the care and services provided.
23
S. BiLLING ADDRESS: All of.SHIPPENSBURG's invoices are to be mailed to
the following address for prompt- payment (either Resident's address or Legal
Representative's address, when applicable):
G. FAILURE TO PAY AND DEFAUL OF AGREEMENT; SHIPPENSBURG's
due date for Its payments falls on the fifteenth (15#h) day of each month.
Resident's failure to remit a required payment within twenty-one (21) days of
the due date constitutes DEFAULT of this Agreement, and SHIPPENSBURG
may require the Resident to vacate SHIPPENSBURG after appropriate
advance notice. If the Resident is required to vacate SHIPPENSBURG for
failure to pay, SHIPPENSBURG shall provide advance notice as set forth in
Termination section of this Agreement. SHIPPENSBURG retains the right
under federal taw and social security regulations to request the regional social
security field office to change the name of Representative in the event of
DEFAULT of this Agreement or the Representative Payee is consistently late
with payments.
24
D. V. ENUE. It Is hereby agreed that this Admission Agreement Is a
transaction entered Into and accepted by the parties herein at the offices
of SHIPPENSBURG, In Cumberland County, Pennsylvania. Resident
agrees that, in event of DEFAULT, SHIPPENSBURG may bring a civil
action in the Court of Common Pleas of Cumberland County,
Pennsylvania, to collect any amounts owed to SHIPPENSBURG under the
terms of this Agreement.
E. ATTO&NEY'S FEES AND COSTS OF COLLECTION: In the event that
SHIPPENSBURG institutes and is a prevailing'party In litigation in court against
any party to this Agreement arising from DEFAULT or other non-payment under
Agreement, SHIPPENSBURG shall be entitled to receive from the losing party
reasonable attorneys' fees and costs of collection.
F. FEE FOR RETURNED CHECKS: A service fee of $26,00 (twenty-five
dollars) or the actual fee charged by the bank, whichever Is greater, will be
charged for any returned check,
G. OBLIGATIONS OF RE (DENT'S ESTATE AND AS$IGNME T Op
PROPERTY: This Agreement shall operate as an assignment, transfer and
conveyance to SHIPPENSBURG of as much of the Resident's property as is
equal in value to the amount of any unpaid obligations under this Agreement,
and this assignment shalt be an obligation of the Resident's estate and may be
enforced against the Resident's estate. The Resident's estate shall be liable to
and shall pay SHIPPENSBURG an amount equivalent to any unpaid obligations
of the Resident under this Agreement. This assignment shall apply whether or
not the Resident Is residing in SHIPPENSBURG at the time of the Resident's
death.
25
VII. BED HOLDS
A. N TICS. The Resident may need to be absent from SHIPPENSBURG
temporarily for hospitalization or therapeutic leave. The Resident may request
that SHIPPENSBURG hold open the Resident's bed during this time. This is
known as a "bed hold." The Resident, and if known, the Resident's Legal
Representative shall be given notice of the bed hold option at the time of
hospitalization or therapeutic leave. A schedule of charges for bed holds is
located on the Rate Schedule attached to this Agreement.
B. MEDICAID RFSIDENTSI If the Resident's care is paid under the
Medicaid Program, Medicaid currently pays for up to 15 consecutive bed hold
days for each hospitalization and for up to 30 bed hold days each year for
therapeutic leave. If the Medicaid Resident's hospitalization or therapeutic
leave exceeds the bed-hold period paid under the Medicaid program, the
Resident may request an additional bed hold period from SHIPPENSBURG by
agreeing to pay the daily additional bed hold amount listed in the attacho Rate
Schedule. Otherwise, the Resident shall be readmitted upon the first availability
of a bed in a non-private room as long as the Resident requires the services
provided by SHIPPENSBURG and Is eligible for Medicaid benefits.
C. PRIVATE AND MEDICARE RESIDENTS; Any Private or Medicare
Resident may request a bed hold from SHIPPENSBURG. The Resident's
private insurance may or may not pay for bed holds. The Medicare program
does not pay for bed holds. However, if the Medicare Resident is also eligible
for Medicaid, and if proven to the satisfaction of SHIPPENSBURG, Medicaid
pays for 15 bed hold days. Otherwise, a Private or Medicare Resident
requesting a bed hold must pay SHIPPENSBURG's bed hold rate set forth in
the Rate Schedule for the bed being held during the bed hold period.
26
Vill. PERSONAL FUNDS
A. RESIDENT FUND AUTHORIZATION. The Resident has a right to
manage his or her own personal funds. If the Resident wants assistance with
management of personal funds, and requests so in writing through 'a Resident
Fund Authorization form, SHIPPENSBURG will hold, safeguard, manage, -and
account for these funds. A Resident Fund Authorization form can be obtained
from SHIPPENSBURG's Administrator or designee.
S. PROCEDURES. Resident personal funds deposited with
SHIPPENSBURG shall be handled as follows:
1. SHIPPENSBURG shall depositfunds in excess of fifty dollars ($50.00) in
an Interest-bearing account insured by the Federal Deposit Insurance
Corporation (FDIC) that is separate from any SHIPPENSBURG operating
accounts. All interest earned on the Resident's funds shall be credited to his
or her account. SHIPPENSBURG shall have the option of depositing funds
of less than fifty dollars in a non-interest bearing account, an interest bearing
account, or a petty cash fund. SHIPPENSBURG shall inform the Resident
as to how his or her funds are being held. SHIPPENSBURG's policy is to
maintain all resident funds in a separate account, except for a nominal
amount maintained in a petty cash fund for the Resident's convenience.
2. SHIPPENSBURG shall have a system that ensures a complete and
separate accounting, based on generally accepted accounting principles, of
the personaffunds deposited with SHIPPENSBURG by each Resident or on
his or her behalf. This system shall also ensure that the Resident's funds
are not commingled with SHIPPENSBURG's funds or with any other funds
besides those of other residents. In addition to the required quarterly
accounting, SHIPPENSBURG shall provide individual financial records at
the-written request of the Resident.
3. The personal fund balance a resident receiving Medicaid benefits must
remain within a certain dollar range for the Resident to continue to receive
benefits. SHIPPENSBURG shall notify a Medicaid resident if his or her
account balance is within two hundred dollars ($200.00) of the federal
Supplemental Security Income (hereafter "SSI") limit. SHIPPENSBURG
shall also notify the Resident if the account balance, in addition to the
Resident's known non-exempt assets, reaches the 881 resource limit.
Furthermore, SHIPPENSBURG shall notify the Resident If the account
balance, in addition to the Resident's known non-exempt assets, reaches
the resource limits for Medicaid eligibility. A balance in excess of this limit
may cause the Resident to lose eligibility for Medicaid or SSI.
4_ if a Resident who has personal funds deposited with SHIPPENSBURG
expires, SHIPPENSBURG shall refund the Resident's personal account
27
balance within thirty (30) days, and provide a full accounting of these funds
to the individual, probate jurisdiction administering the Resident's estate, or
other entity as required by state law or regulation. However, any
outstanding balance owed to SHIPPENSBURG for the Residen#'s care and
services shall first be deducted from the Resident's personal account as
permitted by law.
5. SHIPPENSBURG shall ensure the security of all resident personal funds
deposited with SHIPPENSBURG, and shall not take money from a Medicare
and/or Medicaid resident's personal funds for any item or service for which
payment is covered by Medicare and/or Medicaid.
IX, FUNERAL ARRANGEMENTS
SHIPPENSBURG assumes no financial responsibility for the funeral or
funeral related expenses associated with a Resident's passing.
SHIPPENSBURG recognizes the emotional hardship that such an event may
have on the Resident's family and loved-ones. To assist during this difflcuit
time, SHIPPENSBURG will convey the Resident's wishes, as expressed below,
concerning arrangements to a designated funeral director.
Funeral Arrangements:
Funeral Director:
Burial Fund: -t!>i Q_ \b?
Cemetery Lot Location: _-Lj
Person Assuming
Responsibility for Burial:
28
X. TE MINATif3N OF AGREEMENT
RMINA
A. RIGHT IQ --T9 ---TE: An explanation of the Resident's rights
concerning termination, transfer, and discharge is contained In the Statement of
Resident Rights, which is attached to but separate from this Agreement.
S. RESIDENT INITIATED: Notice of resident initiated termination is
required for proper discharge planning. Other than in the case of a medical
emergency or death, the Resident will provide SHIPPENSBURG with written
notice two (2) business days before the Resident's termination of this
Agreement.
C. EFUNtiS: If a Resident has personal funds ' deposited with
SHIPPENSBURG upon termination of this Agreement, SHIPPENSBURG shall
refund the Resident's personal account balance within thirty (30) days, and
provide the Resident or the Resident's estate with a full accounting of these
funds. However, any outstanding balance owed to SHIPPENSBURG for the
Resident's care and services shall first be deducted from the Resident's
personal account as permitted by law.
Xi. RESIDENT GRIEVANCE/ COMPLAINT RESOLUTION
A. RESIDENT GR, IEVACES:
1.) All Residents, family members, and Resident representatives are
urged to bring any grievances concerning SHIPPENSBURG to the
attention of the SHIPPENSBURG Administrator or the Administrator's
designee.
2.) In addition to bringing grievances to the attention of
SHIPPENSBURG Administrator or designee, residents may also contact
the outside representative of his or her choice. 'Outside representatives
include the Governor's Action Line at (800) 932-0784, the Department of
Health Hot Line at (800) 254.6154, the Long Term Care Ombudsman
located within the Local Area Agency on Aging, and the Legal Services
Program. The telephone number of the local Long Term Care
Ombudsman and the Legal Services Program Is located within the
Resident's Bill of Rights accompanying this Agreement.
29
B.
(a) UNLESS OTHERWISE MUTUALLY AGREED UPON IN WRITING,
SHOULD GRIEVANCE PROCEDURES FAIL; THE RESIDENT AND
SHIPPENSBURG AGREE THAT ALL DISPUTES ARISING UNDER
THIS AGREEMENT, WITH THE EXCEPTION OF DISPUTES
CONCERNING DEFAULT (AS DEFINED ABOVE IN SECTION VI-C)
OR OTHER NON-PAYMENT FOR SERVICES RENDERED, SHALL BE
RESQLVED BY BINDING ARBITRATION BEFORE A NEUTRAL
ARBITRATOR, ASSIGNED TO THE MATTER IN ACCORDANCE WITH
THE AMERICAN HEALTH LAWYERS ASSOCIATION (AHLA)
ALTERNATIVE DISPUTE RESOLUTION SERVICE RULES OF
PROCEDURE FOR ARBITRATION.
(b) SUCH ARBITRATION SHALL TAKE PLACE AT SHIPPENSBURG
AT A MUTUALLY AGREED UPON TIME. ANY TIME A DISPUTE
ARISES, ANY PARTY MAY REQUEST THE APPOINTMENT OF AN
ARBITRATOR TO RESOLVE THE DISPUTE.
(c) THE REQUESTING PARTY SHALL NOTIFY THE OTHER PARTY
IN WRITING A MINIMUM OF SEVEN (7) BUSINESS DAYS PRIOR TO
REQUESTING THE APPOINTMENT OF THE ARBITRATOR.
(4) THE COSTS OF THE ARBITRATOR AND ALL COSTS
ASSOCIATED WITH THE ARBITRATION, INCLUDING ATTORNEYS
FEES, COSTS, AND EXPENSES SHALL BE BORNE BY THE LOSING
PARTY.
(a) THE DECISION OF THE ARBITRATOR WILL BE FINAL AND
BINDING, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT
HAVING COMPETENT JURISDICTION.
30
x1l. ISCELLANEOUS PROVISIONS
A. CLINICAL/ MMA CIAL INFORMATION: With and at
SHIPPENSBURG-s discretion, the Resident hereby authorizes
SHIPPENSBURG to obtain all of the necessary clinical and/or financial
documentation from the Resident prior or transferring hospital or nursing facility.
B. SOLE AGREEMENT: This Agreement, along with any documents
attached or Included by reference, is the only agreement between
SHIPPENSBURG and parties. Changes to this Agreement are valid only if
made in writing and signed by all parties. If changes in state or federal law
make any part of this Agreement invalid, the remaining terms remain valid and
enforceable.
C. NON ASSIGNABLE AGREEMENT: The Resident agrees that the right
of the Resident to reside at SHIPPENSBURG is personal and not assignable.
The Resident may not transfer his or her rights under this Agreement to any
other person.
D. GQVERNZNG LAW: This Agreement shall be governed by and construed
by the laws of the Commonwealth of Pennsylvania, and shall be binding upon
and shall be for the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
E. $EVERABiLITY: The Resident and SHIPPENSBURG agree that each
separate obilgatlon contained in this Agreement shall be deemed a separate
and Independent agreement. If any term, condition, clause or provision of this
Agreement shalt- be determined or declared to be void or invalid in law or
otherwise, then only that term, condition, clause or provision shall be stricken
from this Agreement, and in all other respects this Agreement shall be valid and
continue in full force, effect and operation.
F. CAPTIONS: The captions used in this Agreement are inserted only for
the purpose of reference. Such captions shall not be deemed to govern, limit,
modify or in any manner affect the scope, meaning or intent of the provisions of
this Agreement. The captions shalt be given no legal effect.
G. WAIVER: A waiver by either party at any time of any of the terms,
conditions, or covenants of this Agreement, or of any default or breach shall not
be deemed or taken as a waiver at any time thereafter of the same or any other
term, condition or covenant herein contained, nor of the strict and prompt
performance thereof.
31
H. MODIFICATIONS: SHIPPENSBURG reserves the right to unilaterally
modify this Agreement to the extent necessary to conform the Agreement with
subsequent changes in law or regulation. SHIPPENSBURG will notify the.
Resident thirty days (30) before such modification, if possible.
Xlll. ACKNOWLEDGMENTS
A. RATE SCHEDULE: The Resident and the Resident's Legal Representative
hereby acknowledge the receipt of a copy of the Rate Schedule and sufficient
opportunity to ask questions about the Rate Schedule to answer all of their
questions about SHIPPENSBURG's charges. The Resident and the Legal
Representative hereby acknowledge that SHIPPENSBURG can and will alter
the Rate Schedule from time to time, and that Resident will be subject to those
changes. The Resident and the Resident's Legal Representative hereby agree
to be subject to those changes as provided in this Agreement.
B. STATEMENT OF RESIDENT'S RIGHTS: The Resident and the Resident's
Legal Representative hereby acknowledge being informed orally and of
receiving a written copy of the Resident's Rights, as set forth in this Agreement,
and as further set forth in the accompanying SHIPPENSBURG's Statement of
Resident's Rights. Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Residents rights and have received appropriate responses.
The Resident and the Resident's Legal Representative hereby acknowledge
that the accompanying Statement of Resident's Rights is subject to change
from time to time, and shall not be construed as imposing any contractual
obligations on SHIPPENSBURG or granting any contractual rights to the
Resident.
C. COMMONWEALTH'S ADMISSIONS NOTICE PACKET: The Resident and
the Resident's Legal Representative hereby acknowledge being informed orally
and of receiving a written copy of the Commonwealth's Admissions Notice
Packet, accompanying this Agreement. Furthermore, the Resident and the
Resident's Legal Representative hereby acknowledge having sufficient
opportunity to ask questions about the Resident's rights and have received
appropriate responses. The Resident and the Resident's Legal Representative
hereby acknowledge that the Commonwealth's Admissions Notice Packet is
subject to change from time to time, and shall not be construed as imposing any
contractual obligations on SHIPPENSBURG or granting any contractual rights
to the Resident.
32
D. PRIVACY ACT STATE tI?E T - HEALTH CARE RECORDS: The Resident
and the Restdent's Legal Representative hereby acknowledge being informed
orally of and receiving a written copy of the Privacy Act Statement - Health
Care Records, in compliance with the Privacy Act of 1974. Furthermore, the
Resident and the Resident's Legal Representative hereby acknowledge'having
sufficient opportunity to ask questions about the Privacy Act Statement and
have received appropriate responses.
E. HEALTH CARE ADVANCE DIRECTIVES:
Legal Representative hereby acknowledge beingeinform d o a?tytand ,nsW tnt's
about health care advance directives, including receiving a copy of the
Commonwealth's Medical and Treatment Self Directive Statement, and of
SHIPPENSBURG's policy concerning health care advance directives and
medical treatment decisions. F=urthermore, the Resident and the Resident's
Legal Representative hereby acknowledge having sufficient opportunity to ask
questions about .advance directives, the Commonwealth's Medical and
Treatment Self-Directive Statement, and SHIPPENSBURG's policy thereon,
and have received appropriate responses to all of their questions.
F. STATEMENT OF PRIVACY PRACTICES: The Resident and the Resident's
Legal Representative hereby acknowledge having been informed orally of and
receiving a written copy of SHIPPENSBURG's Statement of Privacy Practices,
in compliance with the Health Insurance Portability and Accountability Act of
1996 (HIPAA). Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Statement and have received appropriate responses.
G. GREEMENT: The Resident and the Resident's Legal Representative
hereby acknowledge that they have carefully read and understand the terms of
this Agreement, and that the terms have been explained to them by a
representative of SHIPPENSBURG. Furthermore, the Resident and the
Resident's Legal Representativd hereby acknowledge having sufficient
opportunity to ask questions about the Agreement and have received
appropriate responses.
33
IN WITNESS WHEREOF, INTENDING TO BE LEGALLY BOUND, the
parties hereto have executed this Agreement the ?
day of
and same shall be
considered binding upon all parties, and shall remain in full force and effect
unless'and until cancelled according to the terms of this Agreement.
Resident Date ?? '--
*Lea *ppe ive Date
SH P ENSBU epres?tative
Date
Witness
Witness
Date
Date
34
iloa - )_
A#0"_1dff I
HEALTH CARE CENTER
717.530-8300 121 Walnut Bottom Road, Shippensburg, PA 172f1 0 www.Shippensburghcc.org
PLEASE TYPE OR PRINT
Notice of Confidentiality Under the Privacy Act of 1974, you must safeguard all information reflected on this Form and, if applicable,
all attachments. This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance
Portability and Accountability Act (PL 104-191) and its various implementing regulations and must be protected in accordance with
those provisions. Healthcare information is personal and sensitive and must be treated accordingly.
Today's Date: 91 I CAN
1. Applicant's Personal Data
Full Name of Applicant: ICe" ?r 1 r? t n It-f Social Security Number: g Oa 7-a-0-483b
Home phone 171)10i - 5 o0o Work phone: Cell phone:
eMail address:
Permanent Address: 13 be JO I t I OUf1?? fl 1? . ?2tR'C ?_t/ + 2Sii5c?e (cla e??a 1Y14
Current Addresslcgl IA)nQncl?- ? 64Y1 .?r1,i ? c1 ft t7o? ince (date):
Date of Birth: ) ' I ( S 01 Current Age: Sex: Citizen of USA: Yes 0 No
Marital Status: Ingle Q Married ? Divorced Q Separated &Wdowed
Name of Spouse:
Religious Affiliation: Li+-` a Pastors /Clergy's Name:
Name of Church: ) t t? t EI l:t`y i?1 Church Address: _ Ct?111? v , P 13
Education: I+ S Occupation:
\ (past or current, including ar refired)
Name of Physician: Al )-, BE it a, Physician Address: ?S+,, 80 0'h b _ K}- I _S)
Hospital Preference: 0-KY1& -s bvt!qj U 15e, Hospital Address: I f X 0 14_' 1"7201
EXHIBIT "B"
Application for Admission
if. Responsible ('arty
Who will be paying for the cost of the Applicant's care not paid for by C
Medicare / Medicaid / other third party payors (i.e. the "Responsible Party')? d (?
The following information pertains to the Responsible Party.
Relationship to Applicant: nn n
Address: w 76r im61(u tYl?Gyil r "t..- City: Sh 6p • SEatOgg Zip Code: t 7?7
PO Box)
Rome phone: Work phone: Cell phone: '717 `?oZ-4X4 9
eMail address: wVAY- Social Security Number:/,!OQ -Sr - Driver's License Number: K /97 7
What are the sources of funds the Responsible Party will use to pay (g line Applicant's care not covered by Medicare / Medicaid / other
third party payors?: ldA n + „c4,z
Who will be responsible for handling these funds?
Responsible Party agrees to: (please check one)
O an automatic charge re-occurring monthly on your: C1 Credit Card 0 Debit Card
? an automatic bank draft re-occurring monthly. (please complete the separate form)
111. Prior Admissions
Was Applicant admitted to a skilled nursing facility or hospital during the last 12 months?
If yes, where? - Name of facility:
Address:
Dates of Service:
Payor Sources:
IV. Applicant's Financial Data
A. Bank Accounts
Name of Bank: 0114 Savings Account a: 131 ? Amount: $ 0 la-
Name on Account: 1`1 fa . (if payor source is Medicare or Medicaid, please provide bank statements for
each of the past 60 months for this bank account.)
Name of Bank:_ Checking Account #: - qbq8 Amount: $a
Name on Account: (If payor source is Medicare or Medicaid, please provide bank statements for
each of the past 60 months for this bank account.)
Name of Bank: Certificates of Deposit: fJ I pt Amount: $ of *
Name on Account:
(please complete the separate form)
ED >>1101'
City:
State: Zip Code:
N h
Is any of the cash held in any of the above bank accounts the result of the disposition of any real-estate in the past 5 years? ? Yes ? No
Note: If, within the past S years, real-estate was sold for less than the fair market value as determined by
Medicaid eligibility guidelines, you may be responsible for paying the difference.
Stocks Bonds: !Jj A Trust Funds: /,.S I Iq Cash on Hand:
List real-estate owned / co-owned by Applicant currently or in the past five years: j Y3
If any real-estate listed above is not currently owned, when was it last owned?.
To whom was it sold or transferred? : Iy? Date :
B. Income
Social Security Number: x203 `J? d -13 3 0 _ Amount SSA Payment.$ Medicare Number: o?6 aQO 133 0
Pension 11: 6?'>51 Amount:$ 5)4/q'c)
Pension 02: P + p
Is Applicant a Veteran? ? Yes No
Amount:$ _t? Y1?
Dates of Service from: N) 114 to: t'1I a
Veteran Pension Claim #< , 0 I p Military I.D. A:
rJ I ?q
VA Income Amount: $ YJ 119 Other. Income Amount: $ l\? r3
C .Insurance
Life Insurance
Name of Insurance Company
ra?jna tic
Policy Number
Health Insurance
Name of Insurance Company Policy Number Monthly Premium
primary: chide e aQa 2? c{ Sa64
secondary: ??
tertiary: _
Medicare Part A#: ? ?() q336 A_ Medicare Part BA: -' W Y"- Medicare Part Da: Lj (a-
V. Power Of Attorney / Guardianship
Does applicant have a Power of Attorney? 0 Yes Wo
If so, name: 0 ? q (please provide copy)
Does applicant have a Legal Guardian? 0 Yes 'to
If so, name: tiLn T (please provide copy)
VI. Burial Provisions
Financial Source: jig
Funeral hlome: N'
O Prepaid - or - 0 Irrevocable
Does applicant have a willies ? No
If so, who is the executor?: f4 rl,m_CtsS oz-
Address: - 59"7.5 IYldl ,:14d)gc -ALU_SI& z 1a- I:z s"7
Face Value Cash Surrender Value Beneficiary
to,000,00 '511
VII. Signature / Certification
Responsible Party hereby certifies that this information is complete, true and correct to the best of his / her knowledge and that he / she has not
intentionally witheld or omitted any requested information.
Responsible Party's signature:
- PLEASE DO NOT WRITE WITHIN THIS BOX -
FOR OFFICE USE ONLY
Check only one box for Nyor Source:
? Medicare A with co-insurance Q Managed Care with no co-pay 0 Veteran Q Medicaid with RPMS XPIther
Q if Payor Source above is "Other" check this box to confirm that a cdmpleted credit card or bank draft authorization form is attached.
Q check this box if 60 consecutive bank statements for each account are attached.
Please check box if copy is attached:
QDriver's License Q Social Security Card Q Medicare Card Q Medicaid Card QThird Party Insurance Card Q Medicare Part D Card
Q check box if P.O.A. has been copied and attached to this application
O check box if Legal Guardian has been copied and attached to this application
O check box if application has been scanned to the M drive (Label Facility Name /Admission Application /Applicaness Last name)
Notes: i ?f d 9 r? 0A m i VA d. MA Pi W 1111 rzC', - Off-,,?11 f-tld vv
Recommendation:
Person completing this section: Date:
FORM UPDATED OS/01108
INVOICE
MAGNOLIA MANAGEMENT I NC
1710 Underpass way, Suite 201 3/29/2011
Hagerstown, MD 21740
30(•745.8700, ext. 1245
Shlppesburg Health Care Center
TO, Ruth Shreiner For: Ruth Shreiner
C/0 Sally Musser
5975 Molly Pitcher Highway Page 1
Shippesburg, PA 17257
DATE.FROIA.
•?_;:DAT?:TO.:::•:E
., Y.;::._:
•*:: •:,:.::.... ?r
:u? CkIP'1tb?t,-''-_:':€ sr :
_
: =rS+ll?rti:t =.t' YI.t?Hl ';is - RAtA)tt>
--- -
10/1110 10/31/10 Patient Liability $1, t 14.25
~} _
_ _ • r $ j,i 14.25
ii/1/10 11/30/10 Patient Liability $1,114.25 ';=j';:$2,228.50
12l1/10 12131/10 Patient Liability $1,114.25
42.75
.= 3311
1/11/1`1 1120111 Patient Liability $1,114.25 -.=$4,157.00
ANCILLARY CHARGES _ - - - " ? ?'•' ` `•
9/8/10 9/30/10 Cable $10.00 %::- r$4,467,0D
10/1110 10131/10 Cable $10.00 :$4;A77;00.
11/1/10 11130110 Cable _$10.00 _ ;4¢7.00
12/1110 12/31/10 Cable $10.00 r $4, y7.00.
1/fllf 1/20/11 Cable $10.00
.....,......PAYMENTS ............
DAtANCE DUE $4,507.00
EXHIBIT "C"
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
Ronny R Anderson -?.
Sheriff
ct 4utttL? r
I r7
Jody S Smith
Chief Deputy N) '
Richard W Stewart
Solicitor OFF F shMFF
Perini Services/ South Hampton Manor, LP Case Number
vs.
Sally A. Musser 2011-4126
SHERIFF'S RETURN OF SERVICE
05/04/2011 Ronny R. Anderson, Sheriff who being duly sworn according to law states that he made a diligent search
and inquiry for the within named defendant, to wit: Sally A. Musser, but was unable to locate her in his
bailiwick. He therefore deputized the Sheriff of Franklin County, Pennsylvania to serve the within
Complaint and Notice according to law.
06/02/2011 04:28 PM - Franklin County Return: And now June 2, 2011 at 1628 hours I, Dane Anthony, Sheriff of
Franklin County, Pennsylvania, do hereby certify and return that I served a true copy of the within
Complaint and Notice, upon the within named defendant, to wit: Sally A. Musser by making known unto
herself personally, at The Franklin County Sheriffs Office, 157 Lincoln Way East, Chambersburg,
Pennsylvania 17201 its contents and at the same time handing to her personally the said true and correct
copy of the same.
SHERIFF COST: $37.44
June 20, 2011
SO ANSWERS,
RON R ANDERSON, SHERIFF
(c'! GountySuite Shenff. Teleosoft. In;.
SHERIFF'S RETURN - REGULAR
CASE NO: 2011-00113 T
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF FRANKLIN
PERINI SERVICES/SOUTH HAMPTON
VS
SALLY A MUSSER
ANGEL L LAVIENA , Deputy Sheriff of FRANKLIN
County, Pennsylvania, who being duly sworn according to law,
was served upon
says, the within COMP CIVIL ACTION
MUSSER SALLY A ------ the
2011
DEFENDANT at 1628:00 Hour, on the 2nd day of June
at FRANKLIN COUNTY SHERIFF'S OFFI 157 LINCOLN WAY EAST
CHAMBERSBURG, PA 17201
by handing to
SALLY A MUSSER
a true and attested copy of COMP CIVIL ACTION together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing .00
Service .00
Affidavit .00
Surcharge .00
00
.00
Sworn and subscribed to before
me this r/ day of
l? A.D.
` ?: .ems 1
COMMCRTIRIkiWOF PENNSYLVANIA
NOTARIAL SEAL
?tICHARD D. McCARTY, Notary Public
LOth,arnbeemrssiburg Boro., Franklin County
Comssion Expires Jan. 29, 2015
So Answers:
ANGEL L
BY Wu i
ty Sheriff
06/15/2011
BARIC AND SCHERER
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V. :
SALLY A. MUSSER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
rn CD
NO. 2011- 4126 CIVIL TERM ter'' C...
f-'
? y
J
U ?
C
PRAECIPE TO ENTER DEFAULT JUDGMENT --± ;
PURSUANT TO Pa.R.C.P. 1037 -`
TO THE PROTHONOTARY:
Please enter judgment in favor of the Plaintiff, Perini Services/South Hampton Manor,
L.P. and against the Defendant, Sally A. Musser, for failure to file an answer to the Complaint of
Plaintiff.
A true and correct copy of the Notice of Default is appended hereto as Exhibit "A."
A true and correct copy of the Certificate of Mailing for the Notice of Default is appended
hereto as Exhibit "B." I certify that the Notice of Default was given in accordance with
Pa.R.C.P. 237.1.
Plaintiff requests judgment in the amount of $4,507.00 as set forth in the Complaint,
together with attorney fees of $860.25 for a total of $5,367.25.
Respectfully submitted,
BARK SCHERER L
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
0 vv?k ?y P d 1?
k44 8g
ac01 (43-1
kb,kk wut(-ed
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
SALLY A. MUSSER,
Defendant
TO: Sally A. Musser
5985 Molly Pitcher Hwy.
j Shippensburg, Pennsylvania 17257
Date of Notice: June 23, 2011
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2011- 4126 CIVIL TERM
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST
YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR
CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND
OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
5BZARIC David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
EXHIBIT "A"
UAUMSMYO
PG571?kSERiR[E. Certificate Of Mailing z
This Certificate Of Mailing provides evidence that mail has been presented to USPSS for mailing. - m
This fND0?ICe01Q10MI_ alinteatal mad. FromD 3
To: ir?nijlh USSQ
l? 'i
m
-ff nZ M to
, -
c
?
I?1W1A
?
1
CrI
C
DC
rJ,?
Z. -r- 30
?• •Wrr, ?V)
.?.1
1 U1
c
J 3 m
PS Form 3817, April 2007 PSN 7530-02-000-9065
EXHIBIT "B"
CERTIFICATE OF SERVICE
I hereby certify that on July 5, 2011, I, David A. Baric, Esquire, of Baric Scherer did
serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first
class U.S. mail, postage prepaid, to the party listed below, as follows:
Sally A. Musser
5985 Molly Pitcher Highway
Shippensburg, Pennsylvania 17257
David A. Baric, Esquire
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
_
PRAECIPE FOR WRIT OF EXECUTION
t --
t:) -i _
Perini Services/South Hampton Manor ? Confessed Judgment ?n Jl M _--) , E
Plaintiff ?? Other .?' ; •
-? `??. ?
VS. File No. 2011-4126 -"
r --
Sally A. Musser Amount Due $5,367.25 _
-Iff ., _
v
--
Defendant Interest : -
Address: Atty's Comm
5975 Molly Pitcher Highway Costs
Shippensburg, PA 17257
TO THE PROTHONOTARY OF THE SAID COURT:
The undersigned hereby certifies that the below does not arise out of a retail installment sale,
contract, or account based on a confession of judgment, but if it does, it is based on the appropriate original
proceeding filed pursuant to act 7 of 1966 as amended; and for real property pursuant to Act 6 of 1974 as
amended.
Issue writ of execution in the above matter to the Sheriff of Cumberland
County, for debt, interest and costs, upon the following described property of the defendant (s)
please perform a levy on any and all personalty located 5975 Molly Pitcher Highway,
Shippensburg, Franklin County, Pennsylvania 17257
PRAECIPE FOR ATTACHMENT EXECUTION
Issue writ of attachment to the Sheriff of County, for debt, interest
and costs, as above, directing attachment against the above-named garnishee(s) for the following property
(if real estate, supply six copies of the description; supply four copies of lengthy personalty list)
and all other property of the defendant(s) in the possession, custody or control of the said garnishee(s).
Date
(Indicate) Index this writ against the garnishee (s) as a lis pe again I ate the
10 flelfgi?jnf(s) described in the attached exhibit.
Signature:
Print Name: David A. Baric, Esquire
31 ci q G6?
9 D. ao
lN. CO
Address: 19 West South Street
Carlisle, PA 17013
Attorney for: Plaintiff
Telephone: (717) 249-6873
Supreme Court ID No: 44853
Crei1 (?Slo?.
a(A N(P W
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
NO 11-4126 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF fyi?LntlL'rl- COUNTY:
To satisfy the debt, interest and costs due PERINI SERVICES/SOUTH HAMPTON MANOR
Plaintiff (s)
From SALLY A. MUSSER, 5975 MOLLY PITCHER HIGHWAY, SHIPPENSBURG, PA 17257
(1) You are directed to levy upon the property of the defendant (s)and to sell LEVY ON ANY AND
ALL PERSONALTY LOCATED AT 5975 MOLLY PITCHER HIGHWAY, SHIPPENSBURG,
PA 17257. .
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof,
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due $5,367.25
Interest
Atty's Comm %
Atty Paid $169.94
Plaintiff Paid
Date: OCTOBER 18, 2011
(Seal)
L.L. $.50
Due Prothy $2.00
Other Costs
David D. Buell, Prothonotary
Deputy
REQUESTING PARTY:
Name DAVID A. BARIC, ESQUIRE
Address: BARIC SCHERER LLC
19 WEST SOUTH STREET
CARLISLE, PA 17013
Attorney for: PLAINTIFF
Telephone: 717-249-6873
Supreme Court ID No. 44853