HomeMy WebLinkAbout11-4580PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff :
V N0.2011- ?&0 CIVIL TERM
MARY JO HOWES, : rnrn
Defendant N)
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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 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
you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
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PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2011- CIVIL TERM
MARY JO HOWES,
Defendant
COMPLAINT
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, Mary Jo Howes, is an adult individual with a residence address of 940
Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17015.
3. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257.
4. On or about May 7, 2010, Mary Jo Howes sought to be admitted to the
Shippensburg Health facility.
5. On or about May 7, 2010, Mary Jo Howes executed an Admission Agreement at
the facility. A true and correct copy of a portion of the Admission Agreement is attached hereto
as Exhibit "A" and is incorporated by reference.
6. Pursuant to the Admission Agreement, Mary Jo Howes would be responsible to
pay any costs of care which were not covered by a third party payer.
7. On or about May 7, 2010, Mary Jo Howes became a resident of the Shippensburg
Health facility and remained a resident to
8. As of the date of discharge, Mary Jo Howes owed Shippensburg Health the sum
of $12,429.34 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 "B" and is
incorporated by reference.
9. Demand has been made upon Mary Jo Howes to pay the amount due for the costs
of care provided to her.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. MARY JO HOWES
10. Plaintiff incorporates by reference paragraphs one through nine as though set forth
at length.
11. Mary Jo Howes has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
12. As a consequence of that breach, Shippensburg Health is owed the sum of
$12,429.34 plus interest.
13. The accrued debt consists of the private pay obligation of Mary Jo Howes.
14. The Admission Agreement bound Mary Jo Howes to pay for the costs of her care
at the facility.
15. The Admission Agreement provides for the recovery of a penalty for late
payments in the amount of 1.5% per month.
16. 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 Mary Jo Howes for
the sum of $12,429.34 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
SHIPPENSBURG HEALTH v. MARY JO HOWES
UNJUST ENRICHMENT
17. Plaintiff incorporates paragraphs one through seventeen as though set forth at
length herein.
18. Despite demand therefore, Mary Jo Howes has failed and refused to pay the costs
of her care accruing during her residency at the facility.
19. Mary Jo Howes has been unjustly enriched through her receipt of the care and
services provided without making payment therefore.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the
sum of $12,429.34, interest, costs and expenses and attorney fees.
Respectfully submitted,
RIC SCHERER
l.1,
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717)'249-6873
Attorney for Plaintiff
SHIPPENSBURG HEALTH CARE CENTER
ADMISSION AGREEMENT
THIS AGREEMENT, made this day of l O \(?
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
"SHIPPENSBURG°) and
(hereafter "Resident"), previously residing at (Street Address and Post Office
Box)
and
(hereafter
"Legal Representative"), residing at (Street Address and Post Office Box)
The Legal
Representative's relationship with the Resident is that of
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.
1. 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"
and those supplies and services covered by the Medicare and/or Medicaid
programs for enrolled Residents.
Federal and state laws and regulations change 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 SUPPLIES: 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 provider's acts or omissions. The Resident shall 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 parfy 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 RIGHTS
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
I. 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 REPUSE 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 conaentr and to pe 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. Resldent'j Personal Property
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 possessions 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 fail 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 sale 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 Res ont's_property,_should
the Resident's property fail 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 SHIPPENSBURG: The Resident
authorizes SHIPPENSBURG 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 to 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
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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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D: 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 unless 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.
6. 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 willful or
negligent action of SHIPPENSBURG. This indemnification 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 on'y
nursing care, medical or other treatment, or any other item or service deemed
necessary by SHIPPENSBURG or any other treating health professional.
Ili. POLICY REGARDING THE IMPLEMENTATION
OF THE PATIENT SELF-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 law, 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
esidentwishes 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. Ahealth are advance
SHIPPENSBURG. However, if the Resident has a health care advance
directive, he or she must provide a vglidilv executed original advance directive
to SHIPPENSBURG's Administrator or designee so that it can be reviewed and
made a part of his or her medical record it is essential that SHIPPENSBURG
receives a validly executed original document or documents to ensure that it is
authorized to follow the directives therein.
RECENT CHANGES IN PENNSYLVANIA LAW (discussed further below
in Subsection C) PROVIDE SOME ADDITIONAL REASONS TO
CONSIDER HAVING AN ADVANCE DIRECTIVE.
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 BEL!EF81THALAW PERMITS THEM
- - TO MAKESOME 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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C. HEALTH CARE REPRESENTATIVE. PENNSYLVANIA LAW PERMITS
AN INDIVIDUAL QUALIFYING AS A "HEALTH CARE REPRESENTATIVE"
UNDER 20 PA. C.S. § 6469 TO MAKE HEALTH CARE DECISIONS FOR
INCAPACITATED PERSONS, WHO HAVE AN END-STAGE MEDICAL
CONDITION OR ARE PERMANENTLY UNCONSCIOUS. WIT140t1T TWAT
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 how to execute health care
advance directives and about their content should be discussed with the
Resident's family, Physician and attorney.
4. Resident should consult with their family, physician, and
attorney before using any Advance Directive Forms.
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IV. CAPACITY OF RESIDENT qND 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 or 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.
V. FINANCU0.L ASPECTS OF THE AGREEMENT
A. Legal Representative
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 tiie 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 WHEN DUE FOR
ITEMS/SERVICES PROVIDED TO THE RESIDENT. Legal Representative is
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. Whitever 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 ASSETSI 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. MEDICAL ASSISTANCE. Generally, when private funds are
depleted, residents apply for Medical Assistance benefits under 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:
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Income
Soclal Security:
Account Number:
Monthly Income:
?V
Payee:
Pensln:
Account Number:
Monthly Income:
Financial Institution:
Payee:
Trusts:
Account Number(s):
Monthly Income:
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Financial Institution(s):
Beneficiary(s):
Type of Trust(s):
Other Income (please describe):
Payee(s):
Assets
Residence/Real Estate:
Address:
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Vehicles :
Year, Make and Model:
State of Registration:
Bank Accounts:
Account Number(s):
Financial Institution(s):
Insuranceyolicles:
Account Number(s):
Financial Institution(s):
Beneficiary:
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Other Sianificant Assets (please describe):
Liabilities
Describe nature and extent:
Has a Will been completed?:
If yes, Executor's Name:
Yes No
Executor's Address:
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5. Recelat of Income! Re resentative Payee. 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 appointing SHIPPENSBURG as the Resident's "Pause" or
"Representative Payee" please notifv SHIPPENSBURG's Administrato_ r_ or the
Administrator's desionee. SHIPPENSBURG wilt assist you in making these
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.) Dally 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 (10"') 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 received, the Resident can choose tp end this Agreement by
providing written notice to the Administrator, If the Resident fails 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 Resident remains arirnarill responsible for aayina all of SHiPPENSBURG's
charoes. 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 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.
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
ail financial and other information required for completion of the Medicaid
application accurately and truthfully, as requested by applicable state/county
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 SHIPPENSBURG 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. If 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 non-payment, 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 specified
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.) _ Daily Rate Payment. _The_ Resident-- agrees-to pay the-costs 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 fails 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 already been determined
eligible for Medicaid coverage will continue to be charged based on
SHIPPENSBURG's private rates and will be liable to pay SHIPPENSBURG for
any charges that are not covered by Medical Assistance or other third-party
payors after the Resident's eligibility for and effective date of Medicaid coveraae
pending final determination of at feast their monthly income (e.g. Social
Securlty, pension) less the amount established by law for the Resident Personal
Funds Allowance lthe current amount Is listed on the attached Rate Schedule
Any refunds due to the Resident after the final determination of Medicaid
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
of 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 state/county 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 lriterim
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 shad not create any responsibifity 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 property execute the AUTHORIZATION FOR
REPRESENTATION - MEDICAID statement attached to this Agreement.
19
8. 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 Resident'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 determined 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`x') 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_privatg 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,
f.) 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 Resident's 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
D. VENUE. 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. ATTORNEY'S Z=EES AND COSTS pF COLLECTION: In the event that
SHIPPENSBURG institutes and is a prevailing party in Mitigation 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. OBLIGATIO S OF RESIDENT'S ESTATE AND ASSIGNMENT OF
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 shall 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
Viii. 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,
B. PROCEDURES. Resident personal funds deposited with
SHIPPENSBURG shall be handled as follows:
1. SHIPPENSBURG shall deposit funds 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 personal funds 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__8SI._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 Resident'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 difficult
time, SHIPPENSBURG will convey the Resident's wishes, as expressed below,
concerning arrangements to a designated funeral director.
Funeral Arrangements: _ CSeS 6 E \ 4-r1
Funeral Director:
Burial Fund: -Tg 3 j-
Cemetery Lot Location:
Person Assuming
Responsibility for Burial:` oQ S
28
X. TERMINATION OF AGREEMENT
A, RIGHT TO TERMINATE: 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.
B. 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 befot-e 'the Resident's termination 'of this
Agreement.
C. REFUNDS: If a Resident has personal funds deposited with
SHIPPENSBURG upon termination of this Agreement, SHIPPENSBURG shall
refund the Residents 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 taw.
XI. RESIDENT GRIEVANCE/ COMPLAINT RESQLUTION
A. RESIDENT GRIEVANCES:
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
RESOLVED 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.
(;d) THE COSTS OF THE ARBITRATOR AND ALL COSTS
ASSOCIATED WITH THE ARBITRATION, INCLUDING ATTORNEY'S
FEES, COSTS, AND EXPENSES SHALL BE BORNE BY THE LOSING
PARTY.
(e) THE DECISION OF THE ARBITRATOR WILL BE FINAL AND
BINDING, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT
HAVING COMPETENT JURISDICTION.
30
XII. MISCELLANEOUS PROVISIONS
A. CLINICAL/ FINANCIAL 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. GOVERNING 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. SEVERABILiTY: The Resident and SHIPPENSBURG agree that each
separate obligation contained in this Agreement shall be deemed a separate
and independent agreement. If any term, condition, clause or provision of this
Agreement shall 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 shall 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.
X111. 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 Resident's 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 fha.t., 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
0, PRIV CY ACT STATEMENT - HE i4 TH CARE RECORDS; The Resident
and the Resident's Legal Representative hereby acknowledge being informed
oraity of and receiving a written copy of the Privacy Act Statement _ Health
Care Records, in compliance with the Privacy Act of 197'4. 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 ADVA CE DiREC IVES: The Resident and the Resident's
Legal Representative hereby acknowledge being informed orally and in writing
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. Furthermore, 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. STATEM NT OF PRIVACY PRACT CES: 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. AGREEMENT: 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 Representative 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
e P tafive
Date
SH-IIPPENSS Represents ivet
Date
Witness
Witness
Date
Date
r
34
INVOICE
MAGNOLIA MANAGEMENT INC
1710 Underpass Way, Suite 201
Hagerstown, MD 21740
301-745-8700, ext. 1245
Ship¢ensburg Health Care Center
T0: Mary Jo Howes
940 Walnut Bottom Rd
Carlisle, PA'17015 _
4/12/2014
For: Mary Jo Howes
Paoe 1
DATE FROM DATE TO QTY,
DESCRIPTION
CHARGE'
PAYMENT
'BALANCE
6/8/10 6/29/10 22 Days Coinsurance M $137.50 Per Day $3,025.00 $3,025.00
8/17110 8/29/10 Patient Liability $1,533.32 $4,558.32
9/1110 9/30110 Patient Liability $1,533.32 $6,091.64
10/1/10 10/31/10 Patient Liability $1,533.32 $7,624.96
11/1/10 11/30/10 Patient Liability $1,533.32 $9,158.28
12/1110 12/31/10 Patient Liability $1,533.32 $10,691.60
1/1/11 1/31/11 Patient Liability $1,533.32 $12,224.92
2/1/11 2/23/11 Patient Liability $1,533.32 $13,758.24
•"......•.. ANCILLARY CHARGES "•""`""`
6/1/10 6/30/10 Cable $t0.00 $13,768.24
7/1/10 7/31/10 Cable $10.00 $13,778.24
8/1/10 8131/10 Cable $10.00 $13,788.24
9/1/10 9/30/10 Cable $10.00 $13,798.24
10/1/10 10/31/10 Cable $10.00 $13,808.24
11/1/10 11/30/10 Cable $10.00 $13,818.24
12/1/10 12/31/10 Cable $10.00 $13,828.24
1/1/11 1/31/11 Cable $10.00 $13,838.24
••""""" PAYMENTS ...""""•
6/29110 Payment $8.60 $13,830.24
7/16/10 Payment $2.00 $13,828.24
10/1/10 Payment $110.00 $13,718.24
1/27/1-1 Payment $1,288.90 $12,429.34
BALANCE DUE $12,429.34
EXHIBIT "B"
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
MARY JO HOWES,
Defendant
TO THE PROTHONOTARY:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
L4 5 8b
NO. 20114?0 CIVIL TERM
M
"°
cn s rv c-b
PRAECIPE TO REINSTATE
Please reinstate the Complaint filed in the above matter on May 25, 2011.
Respectfully submitted,
Date: June 22, 2011
B SCHERE
v
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
6?-s
0L4 IIaEa
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
Ronny R Anderson
Sheriff
Jody S Smith
Chief Deputy
Richard W Stewart
Solicitor
-RIFF
(LEU-GiFFIC.:
i THE PP,0THONI OT?jly
2011 JUL 20 PH 1: 58
CUMBERLAND COUN TI)'
PENNSYLVANIA
Perini Services/ South Hampton Manor, LP
vs.
Mary Jo Howes
Case Number
2011-4580
SHERIFF'S RETURN OF SERVICE
06/24/2011 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: Mary Jo Howes, 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.
07/05/2011 02:00 PM - Franklin County Return: And now July 5, 2011 at 1400 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: Mary Jo Howes by making known unto
herself personally, at 1070 Stouffer Avenue, 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
July 18, 2011
SO ANSWERS,
RON R ANDERSON, SHERIFF
!': COLIM,SuitF Shenif. IeleCsoft. Ir .
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
T of cittrit?crt
Ronny R Anderson 01111
Sheriff
Jody S Smith
Chief Deputy
Z0((-( SZ<
Richard W Stewart
Solicitor
Perini Services/ South Hampton Manor, LP Case Number
vs. 2011-4580
Mary Jo Howes
SERVICE COVER SHEET
0 y
L-:
o Category: Civil Action Complaint & Notice Zone:
X Manner: Deputize Expires: 07/22/2011 Warrant:
Notes:
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Name: Mary Jo Howes Served: Pers nally Adult In Charge Posted Other
W Address: ti_ . ....... ?... w _.
Primary 107 1070 Stouffer Avenue Adult In
Q mbersburg, PA 17201 Charge:
v Relation:
Phone: C
Z Alternate Date: Time: c;;2 C3?1?
Address:
Q
LL Phone: Deputy: Mileage: I
Q Name: David A Baric Phone: ` 717.249.6873
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Deputy:
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Now, June 24, 2011 I, Sheriff of Cumberland County, Pennsylvania do hereby deputize the Sheriff of Franklin County to
< execute service of the documents herewith and make return thereof according to law.
W Return To: 21"--.?..
3 Cumberland County Sheriffs Office
= One Courthouse Square
Carlisle, PA 17013 onny R Anderson, Sheriff
l
SHERIFF'S RETURN - REGULAR
CASE NO: 2011-00152 T
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF FRANKLIN
PERINI SERVICES/SOUTH HAMPTON
VS
MARY JO HOWES
ANGEL L LAVIENA
Deputy Sheriff of FRANKLIN
County, Pennsylvania, who being duly sworn according to law,
says, the within COMP CIVIL ACTION
HOWES MARY JO
was served upon
the
DEFENDANT , at 1400:00 Hour, on the 5th day of July , 2011
at 1070 STOUFFER AVENUE
CHAMBERSBURG, PA 17201
MARY JO HOWES
by handing to
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
Service
Affidavit
Surcharge
So Answers:
.00
00 ANG L V NA _
,i
.00
.00 By
.00 Deputy Sheriff
.00 07/12/2011
DAVID A BARIC ESQ
Sworn and Subscribed to before
me t-h i day o f
A. D.
Notary
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
RICHARD D. McCARTY, Notary Public
Chambersburg Boro., Franklin County
My Commission Ices Jan. 29, 2015,
PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2011-4580 CIVIL TERM
MARY JO HOWES
,
Defendant
C.;J
rn
PRAECIPE TO ENTER DEFAULT JUDGMENT -<
PURSUANT TO Pa.R.C.P. 1037 - n
C: D
t
TO THE PROTHONOTARY: ar
Please enter judgment in favor of the Plaintiff, Perini Services/South Hampton Man or,
L.P. and against the Defendant, Mary Jo Howes, 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 $12,429.34 together with attorney fees of
$1,184.00 for a total of $13,613.34.
Respectfully submitted,
BARIC CHERER C
J
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
i
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
MARY JO HOWES,
Defendant
TO: Mary Jo Howes
1070 Stouffer Avenue
Chambersburg, Pennsylvania 17201
Date of Notice: July 26, 2011
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2011-4580 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
ARIC HERER
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
EXHIBIT "A"
i7W uNnNDs=7US
rorms?tWE
Certificate Of Mail 8 i
m
forma
This Certificate of Mailing provides evidence that mail has been presented to USPS C
This farm be used fordomeshCand intemetionel meil.
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rom:
aricS?mr U b
a 4
1!urlisl t; PA 17013
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00 :D 0
m
PS Form 3817, April 2007 PSN 7530-02-000-9065
EXHIBIT "B"
CERTIFICATE OF SERVICE
I hereby certify that on August 9, 2011, I, David A. Baric, Esquire, of Baric Scherer LLC
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 parry listed below, as follows:
Mary Jo Howes
1070 Stouffer Avenue
Chambersburg, Pe s vania 1720
David A. Baric, Esquire
PERINI SERVICES/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
v.
MARY JO HOWES,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2011-4580 CIVIL TERM
NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236
TO: Mary Jo Howes
1070 Stouffer Avenue
Chambersburg, Pennsylvania 17201
Notice is hereby given to you of entry of a judgment against you in the above matter.
w
09P
Prothonotary
Date: