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HomeMy WebLinkAbout11-6199! t l 1 e.: L -L C A I -V Steven M. Montresor smontresor(w ldylaw.com Attorney ID #74244 Latsha Davis & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Attorneys for Plaintiff, Tele: (717) 620-2424; Fax: (717) 620-2444 Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA SARAH A. TODD MEMORIAL HOME Plaintiff, NO. V CATHY LOVER Defendant. CIVIL ACTION PLAINTIFF'S MOTION FOR PRELIMINARY INJUNCTION AND NOW COMES, Plaintiff, Sarah A. Todd Memorial Home, pursuant to the provisions of Pa. R.C.P. 1531, and makes the following Motion for Preliminary Injunction against Cathy Louer, stating in support thereof as follows: 1. Sarah A. Todd Memorial Home mailed a Complaint against Cathy LOUer to the Court for filing on or about August 4, 2011. A true and correct copy of the Complaint is attached hereto as Exhibit "A" and incorporated by reference as if fully set forth herein. 2. The Complaint sets forth claims against Cathy Louer relating to breach of contract and statutory support obligation. 50667%1 3. As more fully set forth in the Complaint, these claims arise from the Defendant's failure to provide documentation regarding the financial assets and resources of Fayetta Bowman, who is a resident of Sarah A. Todd Memorial Home' nursing facility. 4. This documentation is necessary in securing a detenmination as to Fayetta Bowman's eligibility for Medical Assistance benefits. As more filly set forth in the Complaint, Cathy Louer failed to turn over certain information and documentation requested by the Comity Assistance Office ("CAO") 6. As a result of Cathy Louer's failure to turn over certain information and documentation requested by the CAO, the CAO denied the application for Medical Assistance benefits filed on Fayetta Bowman's behalf. On July 13, 2011, the CAO denied the application for Medical Assistance benefits for Fayetta Bowman. S. Accordingly, the failure of Cathy Louer to comply with her contractual obligations as set forth in the complaint presents issues of immediate and irreparable harm to Sarah A. Todd Memorial Home and to Fayetta Bowman. Sarah A. Todd Memorial Home is requesting an injunction compelling Cathy Louer to provide the CAO with the information and documentation needed to make a determination on Fayetta Bowman's Medical Assistance application. 10. The requested injunction would restore the parties to the status quo as it would return Cathy Louer to compliance with her contractual obligations to Sarah A. Todd Memorial Home, and return Fayetta Bowman and Cathy Louer to compliance with Medical Assistance laws and regulations. 506b7c1 2 1 1. Greater injury- would result from the denial of the requested injunction than from the granting of the same. 12. Sarah A. Todd Memorial Home's right to relief is clear. 13. Sarah A. Todd Memorial Home lacks an adequate remedy at law. WHEREFORE, Plaintiff, Sarah A. Todd Memorial Home respectfully requests that this Honorable Court schedule a hearing on its request for injunctive relief, and thereafter enter an Order directing Fayetta Bowman and Cathy Louer to take all steps necessary to produce the information and documentation requested by the CAO. Respectfully submitted, LATSHA DAVIS & McKENNA, P.C. Dated: )aq By: Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Phone: (717) 620-2424 Facsimile: (717) 620-2444 smontresor@ldylaw.com 50667v1 Attorneys for Plaintiff, Sarah A. Todd Memorial Home 3 VERIFICATION I, Mary Jane Walker, hereby verify that I am the Administrator of Sarah A. Todd Memorial Home; that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. 0 . Dated: ?Maiy JanWalker, NH 50660vl A ?1 Steven M. Montresor smontresor@ldylaw.com Attorney ID #74244 Latsha Davis & McKenna, P.C. 1700 Bent Creep Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA SARAH A. TODD MEMORIAL HOME 1000 West South Street Carlisle, PA 17013 Plaintiff, V. CATHY LOUER 646 South Catherine Street Middletown, PA 17057 Defendant. COMPLAINT NO. CIVIL ACTION AND NOW COMES, Plaintiff, Sarah A. Todd Memorial Home, by and through its attorneys, Latsha Davis & McKenna, P.C., and files the within Complaint against Defendant, Cathy Louer, and in support thereof, avers as follows: 50660v1 Plaintiff, Sarah A. Todd Memorial Home (hereinafter "Sarah Todd", is a Pennsylvania non-profit corporation and the owner and operator of a long-term care skilled nursing facility located at 1000 West South Street, Carlisle, Pennsylvania, 17013 2. Sarah Todd provides living accommodations and skilled nursing care (hereinafter "Nursing Care Services") at its skilled nursing facility. 3. Defendant Cathy Loner (hereinafter "Loner") is an adult individual currently residing at 646 South Catherine Street, Middletown Pennsylvania, 17057. 4. Fayetta Bowman is an adult individual currently residing at Sarah Todd's skilled nursing facility. 5. Louer is Fayetta Bowman's daughter. 6. Fayetta Bowman was admitted to Sarah Todd on or about February 4, 2011. 7. On or about February 4, 2011, Sarah Todd and Louer, on behalf of Fayetta Bowman, entered into a Nursing Home Admission Agreement, whereby Sarah Todd agreed to provide Fayetta Bowman with Nursing Care Services. A true and correct copy of the Nursing Care Agreement is attached hereto as Exhibit "A" and made a part hereof. 8. Pursuant to the terms of the Nursing Home Admission Agreement, Louer agreed to be bound frilly to the terms of the Agreement. See Exhibit "A," Section 4.1. 9. On or about February 4, 2011, Sarah Todd and Louer entered into a Responsible Person Agreement, a true and correct copy of which is attached hereto as Exhibit "B" and made a part hereof. 50660%,] 2 10. Pursuant to the terms of the Responsible Person Agreement, Louer agreed that: When the Resident's financial resources warrant it, Responsible Person shall take any and all actions necessary and appropriate to initiate, make and conclude application for Medical Assistance benefits on behalf of the Resident, including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals. Responsible Person shall exercise diligent efforts in the application and appeal processes to assure continued benefits from any third party or government: payor. See Exhibit "B," Section 3. 11. Louer, along with Jesse H. Bowman, was also appointed the agent for her mother pursuant to a Power of Attorney instrument duly executed on July 24, 2008. A true and correct copy of the Power of Attorney instrument is attached hereto as Exhibit "C" and made a part hereof. 12. At all times relevant, Sarah Todd provided Nursing Care Services to Fayetta Bowman in accordance with the Nursing Care Agreement. 13. Upon information and belief, Fayetta Bowman has exhausted her available assets and resources and according, does not have the financial means to pay for her care. 14. Fayetta Bowman's inability to pay for her care is evidenced by the outstanding balance on her account, which currently stands at $46,936.85. A true and correct copy of the most recent invoice for her account is attached hereto as Exhibit "D" and made a part hereof. 15. No payment has been made on Fayetta Bowman's account since the date of her admission. 16. On May 26, 2011, Sarah Todd submitted a Medical Assistance application to the County Assistance Office ("CAO") on behalf of Fayetta Bowman. 17. Staff at Sarah Todd communicated to Louer the precise documentation information that was needed to process the application for Medial Assistance benefits. i0660vl 1 8. Louer never provided said documentation to the CAO. 19. On July 13, 2011, the CAO denied Fayetta Bowman's application for Medical Assistance benefits as a result of Loner's failure to produce the documentation needed to make a determination on the application. A true and correct copy of the denial is attached hereto as Exhibit "E" and made a part hereof. 20. Sarah Todd intends to file an appeal of this denial. 21. However, if Louer does not cooperate in the application process and produce the documentation requested by the CAO, the denial of benefits will be affinned, and any further appeal would be meritless. COUNT I - INJUNCTIVE RELIEF/SPECIFIC PERFORMANCE 22. Paragraphs 1 through 21 above are incorporated herein by reference as if fully set forth at length. 23. Louer entered into a Nursing Home Admission Agreement and a Responsible Party Agreement with Sarah Todd as more fully set forth above. 24. At all times relevant, Sarah Todd provided Nursing Care Services to Fayetta Bowman pursuant to the aforementioned Nursing Home Admission Agreement. 25. Upon information and belief, Fayetta Bowman is unable to compensate Sarah Todd for the services it has provided to her. 26. Pursuant to Section 3 of the Responsible Person Agreement, Louer is required to take any and all actions necessary and appropriate to initiate, make and conclude an application for Medical Assistance benefits on Fayetta Bowman's behalf, including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals. See Exhibit "B". 50660%1 4 27. By failing to provide the necessary documentation to the CAO, Louer has breached this contractual obligation. 28. Upon information and belief, Fayetta Bowman would have been detenmined to have been eligible for Medical Assistance benefits had Louer complied with her contractual obligations. 29. Louer's breach of the Agreement will result in irreparable hanm to Sarah Todd and Fayetta Bowman if Sara Todd's request for injunctive relief is not granted. 30. The documentation requested by the CAO is necessary to ensure that the CAO can make a determination as to Fayetta Bowman's eligibility for Medical Assistance benefits. 31. The breach of the Agreement is ongoing, as Cathy Louer has not yet provided the information and documentation requested by the CAO. 32. Sarah Todd has no adequate remedy at law. WHEREFORE, Sarah A. Todd Memorial Home requests this Honorable Court enter an Order pursuant to Pa.R.C.P. 1531 compelling Cathy Louer to perform her contractual obligations. COUNT II - STATUTORY DUTY OF SUPPORT 33. Paragraphs 1 through 32 above are incorporated herein by reference as if fully set forth at length. 34. Cathy Louer is the daughter of Fayetta Bowman. 35. Pursuant to 23 Pa.C.S. §4603, Cathy Louer has a statutory obligation to care for, maintain or financial assist her mother. 36. Upon information and belief, Fayetta Bowman is indigent. S06GOv1 5 37. Said indigency is evidenced by the outstanding balance on Fayetta Bowman's account, which currently stands at $46,936.85. 38. Cathy Louer has not financially supported her mother. 39. The above-referenced duty of support goes beyond financial support and includes care and maintenance. 40. The care and maintenance referenced in the statutory duty of support includes participating in the Medical Assistance application process so that her mother can receive all financial benefits to which she is entitled. 41. By failing to cooperate in the MA application process and produce the information and documentation requested by the CAO and Sarah Todd, Cathy Louer has failed to care for, maintain or financially assist her mother. 42. Cathy Louer has the means to care for, maintain and provide financial assistance to her mother. s066ov1 6 WHEREFORE, Sarah A. Todd Memorial Home requests this Honorable Court enter an Order compelling Cathy Louer to comply with the statutory duty of support by taking all steps necessary to provide any information and documentation that may be requested by the Montgomery County Assistance Office with respect to the application for Medical Assistance benefits made on behalf of Fayetta Bowman. Respectfully submitted, LATSHA DAVIS & McKENNA, P.C. Dated:' ?{ ?Jl By: Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Phone: (717) 620-2424 Facsimile: (717) 620-2444 sontresor@ldylaw.com Attorneys for Plaintiff, Sarah A. Todd Memorial Home 50660NI VERIFICATION I, Mary Jane Walker, hereby verify that I am the Administrator of Sarah A. Todd Memorial Home; that I am authorized to make the within Verification; and the statements of fact in the foregoing Motion are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: 1 n """Jed -))'o Mary Jane W ker, NHA 50667v] Exhibit "A" UNITED CHURCH OF CHRIST HOMES NURSING HOME ADMISSION AGREEMENT This Agreement is made by and between a Pennsylvania non-profit nursing home, (hereinafter called "Facility") and Resident and his/her legal representative and/or the individual who has access to Resident's income and financial resources available to pay for nursing care (hereinafter called "Responsible Person") for the provision of nursing services for _'? ? i A LwIA (hereinafter called "Resident"). Resident and Responsible Person affirm that the information provided in the Admission Application is true and correct to the best of their knowledge, and acknowledge that the submission of any false information may constitute grounds to terminate this Agreement. Therefore, the Facility, Resident and Responsible Person, intending to be legally bound, agree to the following terms and conditions: 1. PROVISION OF SERVICES. 1.1 Nursing Services. Beginning on ?) 4? ' , the designated admission date, the Facility will provide Resident with (a) the routine nursing services described in the Schedule of Charges, attached to this Agreement and incorporated by reference; (b) private or semi-private accommodations, as applicable; (c) three meals each day, except as otherwise medically indicated; (d) blankets, bed linens, towels and wash cloths; (e) laundering of linens and towels; (f) housekeeping services; and (g) activity programs and social services as established by the Facility. 1.2 Ancillary Services and Supplies. The Facility will provide ancillary services and supplies as identified on the Schedule of Charges, and such other ancillary services and supplies at the option and upon the request of the Resident, or upon the direction of Resident's treating physician or the Facility's Medical Director. The ancillary services and supplies identified on the Schedule of Charges are subject to change from time to time at the discretion of the Facility. 1.3 Services of Other Providers. The services of outside providers such as a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, rehabilitation therapies and diagnostic services, laboratory, x-ray, podiatry, optometry, medications, ambulance services and hearing aid repair are available from time to time at the Facility. These services are available under guidelines and procedures established by the Facility and may be utilized by Resident at his or her own expense. 1723 Nursing Agreement 12-15-04; 5-06 1.4 Role of Attending Physician and Medical Director. The Resident shall select a. qualified physician, from a list of Facility credentialed physicians, who will provide medical care during the Resident's stay at the Facility and who shall comply with the Facility's rules, regulations, policies and procedures. The Facility is not permitted to provide Resident with any medicines, treatments, special diets or equipment without specific orders or directions from Resident's attending physician. In the event Resident's personal physician is unavailable, the Facility's Medical Director may issue appropriate orders. Resident is responsible to pay for all services or equipment ordered by Resident's attending physician or the Facility's Medical Director for Resident's care. 2. CHARGES. 2.1 Recurring/Periodic Charges for Routine Nursing Services. Resident shall pay the Daily Routine Service Charge, specified in the Schedule of Charges in effect at the time the service is rendered, for routine nursing services provided to Resident. The Daily Routine Service Charge may be changed from time-to- time in accordance with the provisions of Section 3.3. Charges for a resident whose payor source is other than Medicare Part A or Medicaid will begin on the designated admission date or actual admission, whichever is earlier; charges for a resident whose payor source is Medicare Part A or Medicaid will begin no earlier than the date of admission. 2.2 Additional Charges for Ancillary Services and Supplies. Resident shall pay for other services and supplies provided by or through the Facility which are not covered by the Daily Routine Service Charge as set forth in the Schedule of Charges in effect at the time such ancillary services or supplies are rendered. Any items ordered by a physician, which are not identified on the Schedule of Charges, will be provided at charges identified by the Facility. The charges for ancillary services and supplies are subject to change from time to time. 2.3 Charges for Outside and Non-Facility Services. In addition to the Facility's charges, Resident shall pay all fees and costs for goods or services furnished to or for Resident by anyone other than the Facility as described in Subsection 1.3 (Services of Other Providers) unless otherwise covered in full by Medicare or Medicaid or another third-party payor. Resident or Responsible Person is obligated to pay such fees and costs whether the goods and services are furnished by a person or provider made available by the Facility, or by a person or provider selected by Resident, and whether the goods or services are provided at the Facility or elsewhere. These fees and costs are not included in the Daily Routine Service Charge. Fees for professional services rendered by a physician are not included in the Daily Routine Service Charge and will be charged directly to the Resident by the physician. 1723 Nursing Agreement 12-15-04 3. PERIODIC BILLINGS AND PAYMENT DUE DATE. 3.1 Monthly Statements and Other Billings. If permitted, prepayment for one month of the basic monthly rate is required at the time of admission. The Facility will mail Resident or Responsible Person on or about the tenth (10th) calendar day of the month a billing statement reflecting charges for nursing services for the upcoming month and charges for ancillary services and supplies which were incurred in the prior month. Statements are due and payable upon receipt of the Monthly Statement. 3.2 Late Charges and Cost of Collection. Any monthly statements not paid within thirty (30) days of the date of the statement are subject to a late charge of one and one-quarter percent (1.25%) per month (annual rate of fifteen percent (15%)), and Resident or Responsible Person is obligated to pay any late charges. In the event the Facility initiates any legal actions or proceedings to collect payments due from Resident under this Agreement, Resident or Responsible Person shall be responsible to pay all attorney's fees and costs incurred by the Facility in pursuing the enforcement of Resident's financial obligations under this Agreement. 3.3 Modification of Charges. The Facility reserves the right to change the Schedule of Charges reflecting the amount of any of its charges or how and when charges are computed, billed or become due. The Facility shall provide thirty (30) days advance written notice of any such changes. 3.4 Obligations of Resident's Estate and Assignment of Property. Resident and Responsible Person acknowledge the charges for services provided under this Agreement remain due and payable until fully satisfied. In the event of Resident's discharge for any reason, including death, this Agreement shall operate as an assignment, transfer and conveyance to the Facility of so much of Resident's property as is equal in value to the amount of any unpaid obligations under this Agreement. This assignment shall be an obligation of Resident's estate and may be enforced against Resident's estate. Resident's estate shall be liable to and shall pay to the Facility an amount equivalent to any unpaid obligations of Resident under this Agreement. 4. OBLIGATIONS OF RESPONSIBLE PERSON. 4.1 General Obligations. Resident has the right to identify a Responsible Person (usually the Agent in the Resident's Power of Attorney or Guardian), who shall be entitled to receive notice in the event of transfer or discharge or material changes,rin the Resident's condition, and changes to this Agreement. Resident elects to name , LU tkv"v- of d C ? ? i"Gyy1'? 1723 Nursing Agreement 12-15-04 3 [address], as the Responsible Person. The Resident's selected Responsible Person shall sign this Agreement and the Responsible Person Agreement in recognition of this designation with the intent to be legally bound by all provisions in this Agreement and the Responsible Person Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of the Resident imposed by this Agreement and the Responsible Person Agreement in accordance with the law governing fiduciary duties. The Facility may petition a court to appoint a Guardian and take other legal action if the Facility reasonably believes that the Resident's needs are not being properly met or the duties imposed by this Agreement or the Responsible Person Agreement are not being fulfilled by the Responsible Person. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. 4.2 Potential Liability. The Responsible Persons duties, obligations and responsibilities are set forth in the Responsible Person Agreement, which is incorporated by reference herein in its entirety. By signing this Agreement, Responsible Person acknowledges he/she has read the Responsible Person Agreement, understands the terms therein, and that he/she shall be bound by all terms set forth in the Responsible Person Agreement. 5. MEDICARF/MEDICAID PROGRAMS. 5.1 Participation in Pro ams. The Facility currently participates in the Pennsylvania Medical Assistance program ("Medicaid") and the federal Medicare program. The Facility reserves the right to withdraw from the Medicaid or Medicare programs at any time in accordance with law. 5.2 Actions of Medicaid and Medicare Agencies. The Pennsylvania Department of Public Welfare ("DPW") is responsible for administering benefits under the Medicaid program. The Centers for Medicare and Medicaid Services ("CMS"), of the United States Department of Health and Human Services, is responsible for administering the Medicare program through an intermediary. Resident acknowledges that the Facility is not responsible for, and has made no representations regarding, the actions or decisions of DPW, CMS or the Medicare intermediary in administering the programs. 5.3 Medicaid Benefits (a) Obligations of Resident. Resident is obligated to make full and complete disclosure regarding all financial resources and income during the application process. Failure to identify all resources and income, or the submission of false information, may result in the termination of this Agreement. Resident is obligated to notify the Facility when Resident's resources available to satisfy the 1723 Nursing Agreement 12-15-04 4 Resident's financial obligations under this Agreement have been reduced to Fifteen Thousand Dollars ($15,000). Resident is obligated to apply for Medicaid benefits at such time as Resident's resources will no longer be sufficient to pay all the Facility charges for Resident's care and stay or when directed to do so by the Facility. In the event Resident applies for Medicaid benefits, Resident shall continue to pay and apply all of Resident's available resources toward the fulfillment of Resident's financial obligations under this Agreement while the Medicaid application is pending an eligibility determination by DPW. (b) Patient Pay Amount. For residents approved for Medicaid benefits, the Facility will accept payment from the Commonwealth of Pennsylvania and, if applicable, the Resident's Patient Pay Amount as determined by DPW as payment in full only for those services covered by the Medicaid program. Resident remains obligated to pay such Patient Pay Amount, less any qualified medical expense deductions, on a monthly basis. Services not covered by Medicaid are identified in the Schedule of Charges and Resident remains obligated to pay for such services. In the event Resident applies for Medical Assistance benefits, Resident or Responsible Person, to the extent permitted by law, shall arrange for assignment to the Facility of any payment on behalf of Resident in an amount equivalent to the Patient Pay Amount as determined by DPW. (c) Determination of Eligibility. Resident and Responsible Person are obligated to cooperate fully in any Medicaid eligibility determination or redetermination process. In the event that Resident's eligibility for Medicaid benefits is denied, interrupted or terminated due to the failure of Resident or Responsible Person to cooperate in the Medical Assistance application, redetermination or appeal process, the Resident and Responsible Person shall be liable for the Daily Routine Service Charge plus charges for ancillary services and supplies during any non-payment, and the Facility may terminate this Agreement. (d) Authorization to Appeal (Medicaid). In the event of Resident's incapacity and in situations where Resident's resources are depleted or appear to be depleted to the extent that Resident can no longer pay privately for nursing care, and it appears that Resident has become or will become eligible for Medicaid benefits to cover the cost of Resident's continued stay in the Facility; and if there is no other legal representative of Resident known to the Facility or other friend or relative known to the Facility who is authorized and/or is available or willing to act on Resident's behalf, after the Facility has made a good faith effort to identify such persons; then Resident hereby authorizes the Facility to request, file and/or apply for Medicaid benefits on behalf of Resident for the limited purpose of assisting Resident to secure payment through the Medical Assistance program for Resident's continued stay in the Facility. In the event the application for Medicaid benefits filed on behalf of the Resident is denied, or in the event Medicaid benefits are granted and subsequently 1723 Nursing Agreement 12-15-04 5 discontinued, Resident hereby authorizes the Facility to file on Resident's behalf an appeal of any such denial of Medicaid eligibility or discontinuance of Medicaid benefits, and to take such actions to secure Resident's Medicaid benefits as the Facility deems reasonably necessary or appropriate and consistent with law. Resident warrants and represents that the financial information disclosed in the Admission Application is true and accurate and may be relied on by the Facility in pursuing Medicaid benefits on behalf of Resident. (e) Authorization to File a Hardship Waiver with DPW on Behalf of Resident. If DPW's application of the "transfer of assets" or "look-back period" requirements for Medical Assistance Eligibility as established by the federal Deficit Reduction Act of 2005 operates to deprive Resident of medical care, food, clothing or shelter, or if Resident's life would be endangered as a result of DPW's Medical Assistance Eligibility decisions, then in the event of Resident's incapacity, and if there is no other legal representative of Resident known to the Facility or any other friend or relative known to the Facility who is authorized and/or is promptly available or willing to act timely on behalf of Resident, Resident authorizes Facility to file a Hardship Waiver with DPW on Resident's behalf, consistent with the procedures established by DPW pursuant to the requirements of Section 6011 of the Deficit Reduction Act of 2005. 5.4 Medicare Part A and Part B Benefits. To the extent that Resident is a beneficiary under either Medicare Part A or Medicare Part B insurance and the nursing services or ancillary services or supplies ordered by a physician are covered by such insurance, the Facility or other provider will bill the charges for the covered services or supplies to the Medicare program. The Resident is responsible for and shall pay any co-insurance or deductible amounts under Medicare Part A or Part B insurance. The Facility shall accept payment from the Medicare intermediary as payment in full only for those services deemed to be covered in full under the Medicare Part A or the Medicare Part B program. Services not covered by Medicare are identified in the Schedule of Charges. 5.5 Non-Covered Services. Resident is and remains obligated to pay the Facility for services and supplies not covered by the Medicaid or the Medicare programs. 5.6 Medicare Part B Payment Limitations: Therapy Caps. (a) General. Effective January 1, 2006, the Centers for Medicare and Medicaid Services ("CMS") imposed payment limitations on covered therapy services provided to individuals who are eligible beneficiaries under Medicare Part B. Under this financial limitation, Medicare will pay an annual capped amount for physical and speech therapy (combined) and an annual capped amount for 1723 Nursing Agreement 12-I5-04 occupational therapy. The capped amounts are revised by CMS annually. Facility shall provide resident and/or Responsible Person with notice of the current capped amounts as appropriate. (b) Resident's Responsibility to Pay for Therapy Services Beyond the Capped Amounts. Resident is responsible to pay the charges for all medically necessary therapy services in excess of the annual capped amounts, unless such therapy services are covered in whole or in part by private insurance or another government reimbursement program. In the event that another government reimbursement program or available third party payor or insurance program denies coverage for therapy services provided to Resident after exhaustion of the annual capped amount, then Resident of responsible Person shall remain responsible to pay all fees and costs for all such therapy services. If resident is not eligible for Medical assistance, then failure to pay for therapy services rendered above the capped amount shall be grounds for termination and discharge from Facility pursuant to Section 11 of this Agreement. (c) Exception Requests. Medicare beneficiaries are entitled to request an exception to the annual therapy caps, for up to fifteen (15) additional treatment days. In the event that resident has exhausted the annual capped amount, then the following shall apply: i) Resident and/or Responsible Person may submit an exception request to the applicable CMS Medicare contractor; or ii) In the event of Resident's incapacity, and if there is no other legal representative of resident known to the Facility or any other friend of relative known to the Facility who is authorized and/ or is promptly available or willing to act timely on behalf of Resident, then Resident authorizes Facility to submit an appropriate exception request to the applicable CMS Medicare contractor. iii) If the exception request is granted, then therapy services provided to resident shall be covered by Medicare for the number of additional treatments approved. Once the additional approved treatments have been exhausted, Resident shall be responsible to pay all fees and costs for additional therapy services provided as noted in this Section 5.6(b). 1723 Nursing Agreement 12-15-04 iv) If the exception request is denied, then Resident shall be responsible to pay all fees and costs for additional therapy services provided as noted in this Section 5.6(b). 6. MANAGED CARE ORGANIZATIONS. 6.1 Participation in Managed Care Organizations. The Facility is an authorized provider of skilled nursing services to members of certain managed care organizations (MCOs). The Resident will be given a list of the MCOs for whom the Facility is an authorized provider. 6.2 Enrollment in a Managed Care Organization. Resident or Responsible Person shall notify the Facility in writing prior to enrolling with a MCO or switching Resident's MCO enrollment. 6.3 Actions of Managed Care Organization. Resident acknowledges that an MCO for whom the Facility is not an authorized provider may not approve payment for services provided by the Facility. Resident acknowledges that the Facility is not responsible for and has made no representations regarding the actions or decisions of any MCO for whom the Facility is an authorized provider, including decisions relating to a denial of coverage. 6.4 Obligations of Resident. The Facility will accept payment from the MCO as payment in full only for those services and supplies covered by the MCO. Resident is responsible for any co-payments or other costs assigned to Resident under the specific terms of the managed care plan. Resident also shall pay for any services or supplies not covered by the MCO under the specific terms of the managed care plan. Co-payments and other costs assigned to Resident and charges for services or supplies not covered by the specific terms of the managed care plan are identified in the Schedule of Charges. Managed care plans typically require pre-authorization of services by the MCO. If Resident chooses to have services which the MCO refuses to pre- authorize, Resident shall pay the Facility for those services. Resident shall pay the Facility in a timely manner for all non-covered services retroactive to the date of the initial delivery of services. 6.5 Withdrawal from Participation in the MCO. The Facility reserves the right to terminate its contractual relationship and its status as a network or authorized provider with one or more of the listed MCOs at any time in accordance with law and the terms of the applicable agreement. In the event that the Facility terminates its contractual relationship with the MCO in which Resident is enrolled, Resident may convert his or her coverage to a health plan for whom the Facility is an 1723 Nursing Agreement 12-15-04 8 authorized provider or transfer to a facility that is an authorized provider for Resident's MCO. The Facility shall provide thirty (30) days advance notice of its decision to withdraw as a participating provider from Resident's MCO so Resident and the MCO can coordinate a transfer to another facility. 6.6 Notice of Change in Insurance Coverage. Resident and/or Responsible Person shall notify the Facility immediately of any change in Resident's insurance status or coverage made by the insurance carrier including, but not limited to, being dropped by the insurance carrier for any reason, or a decrease or increase in insurance benefits. Resident and/or Responsible Person shall give the Facility notice before Resident is unable to meet Resident's insurance premium or before Resident implements an increase, decrease or termination from insurance coverage. 7. DURABLE FINANCIAL/HEALTH CARE POWER-OF-ATTORNEY. Resident is strongly encouraged to furnish to Facility, no later than the date of admission, a durable Financial/ Health Care Power-of-Attorney executed by Resident as Principal designating someone other than the Facility or a representative or affiliate of Facility as Agent, for the limited purpose of health care decisions, financial decisions and payment of services. In the event Resident fails to designate an Agent under a Power-of-Attorney, Resident shall be responsible to pay for any guardianship proceedings related to the appointment of someone or a legal entity to make decisions on behalf of Resident, if and when Resident lacks capacity to make such decisions as determined by Facility. 8. THIRD-PARTY PAYMENTS. 8.1 , Eligibility for Third-Party Payments. Resident may be or may become eligible to receive financial assistance, reimbursement, or other benefits from third parties, such as private insurance, employee benefit plans, Medical Assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, managed care coverage, supplementary medical or other health insurance, supplemental security income insurance, or old-age survivors' or disability insurance. It is the responsibility of the Resident and/or Responsible Person to apply for these benefits. If Resident is or becomes eligible to receive payments from any third parties for Resident's stay and care, the Facility reserves the right to collect such payments directly from the third- party source. The Resident and Responsible Person shall at all times cooperate fully with the Facility and each third-party payor to secure payment. Cooperation includes providing information; signing and delivering documents; and assigning to the Facility (to the extent permitted by law) any payments for the Resident from federal or state governmental assistance programs or any other reimbursement or benefits to the extent of all amounts due the Facility. 1723 Nursing Agreement 12-15-04 9 8.2 Assignment of Payments. Resident irrevocably authorizes the Facility to make claims and to take other actions to secure for the Facility receipt of third-party payments to reimburse the Facility for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment of the Facility's charges, Resident hereby assigns to the Facility all of Resident's rights to any third-party payments now or subsequently payable to the extent of all charges due under this Agreement. Resident or Responsible Person promptly shall endorse and turn over to the Facility any payments received from third parties to the extent necessary to satisfy the charges under this Agreement. Resident or Responsible Person shall sign any necessary documents to forward third-party payments directly from the payor to the Facility. 8.3 Insurance. In the event of an initial or subsequent denial of coverage by the Resident's insurance carrier, Resident shall pay the Facility timely for all noncovered services retroactive to the date of the initial delivery of services, so long as such payment obligation is consistent with the regulations governing the Facility's participation in the Medicare and Medicaid Programs. 9. PERSONAL FINANCES. 9.1 Personal Funds Management. Resident is responsible to provide his or her personal funds, and Resident has the right to manage his or her personal funds. Resident may authorize the Facility, in writing on a document provided by the Facility, to hold Resident's personal funds, and may revoke at any time the Facility 's authorization by providing the Facility with a written notice signed and dated by Resident or Responsible Person. If Resident authorizes the Facility to hold Resident's personal funds, the Facility shall hold, safeguard and account for Resident's personal funds in accordance with applicable policies available to the Resident on request. 9.2 Refunds of Personal Funds. Any personal funds or valuables of Resident held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due the Facility, such as any costs incurred by Facility to repair Resident's room for damages caused by Resident, within thirty (30) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such entities or persons entitled to the refund under current law. 9.3 Refunds of Prepayments or Overpayments. Any prepayments or overpayments made by Resident and held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due the Facility, within sixty (60) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's 1723 Nursing Agreement 12-15-04 10 estate or to such other entities or persons entitled to the refund under current law. No interest shall accrue on any funds required to be refunded under this Agreement. 10. CHANGES IN ROOM ASSIGNMENTS. The Facility reserves the right and discretion to transfer Resident to another room or bed within the Facility, and the right and discretion to transfer Resident's roommate, if any, at any time consistent with the needs of the Facility. 11. TERMINATION, TRANSFER OR DISCHARGE. 11.1 Resident Initiated. Resident may terminate this Agreement upon seven (7) days written notice to the Facility. If Resident leaves the Facility for any reason other than a medical emergency or death, Resident must give written notice to the Facility at least seven (7) days in advance of transfer, discharge or termination of this Agreement. 11.2 Facility Initiated. The Facility may terminate this Agreement and Resident's stay and transfer or discharge Resident if: (a) the transfer or discharge is necessary to meet Resident's welfare and Resident's needs cannot be met in the Facility; (b) Resident's health has improved sufficiently so that Resident no longer needs the services provided by the Facility; (c) the safety or health of individuals in the Facility is or otherwise would be endangered; (d) Resident has failed, after notice, to pay for (or to have paid or treated as paid under the Medicare or Medicaid Programs) charges for Resident's care and stay at the Facility; or (e) The Facility ceases to operate. 11.3 Notice and Waiver of Notice. The Facility will notify Resident and Responsible Person (or if none, a family member or legal representative of the Resident, if known to the Facility) at least thirty (30) days in advance of transfer or discharge, except in situations when appropriate plans that are acceptable to the Resident can be implemented earlier, and except in cases of emergencies, including those situations 1723 Nursing Agreement 12-15-04 11 described in subparagraphs (a) and (c) above, then only such notice as is reasonable under the circumstances shall be provided. 11.4 Withdrawal Against Advice. In the event Resident withdraws from the Facility against the advice of his/her attending physician and/or without approval of the Facility, all of Facility's responsibilities for the care of Resident are terminated. 12. READMISSION - BED HOLD POLICY. 12.1 Private Pav Residents. If Resident leaves the Facility for a period of hospitalization, therapeutic leave, or any other reason (other than Resident's death), and if Resident is not eligible for, or receiving, Medical Assistance benefits, Resident's bed will be reserved and Resident shall be obligated to pay the current Daily Routine Service Charge for any days that Resident's bed is reserved. The Facility will continue to hold the bed until notified in writing by Resident or Responsible Person that the bed is no longer desired. If Resident elects in writing not to reserve a bed, then Resident will be discharged from the Facility and readmission to the Facility shall be subject to bed availability. 12.2 Medical Assistance Residents. If Resident is eligible for, or is receiving Medical Assistance benefits, and Resident leaves the Facility for a period of hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable maximum number of days paid for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation . period may be subject to change in accordance with any changes in the Pennsylvania Medical Assistance Program. If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Pennsylvania Medical Assistance Program, Resident will be entitled to the first available accommodation suitable for Resident's level of care if, at the time of readmission, Resident requires the services provided by the Facility. Alternatively, following the lapse of the bed reservation period covered by the Medical Assistance Program, Resident may reserve a bed by electing to pay the Medical Assistance :per diem rate charged immediately prior to the leave, and by providing written notice and advance payment for the days included in the reservation period. 12.3 Medicare Residents. In the event that a Resident eligible for Medicare Part A benefits is transferred to or readmitted to a hospital, Medicare Part A eligibility will be terminated on the day the Resident is admitted to the hospital. Resident's bed will be reserved at the Daily Routine Service Charge unless Resident or Responsible Person elects, in writing, not to reserve a bed, or under the Medical Assistance program (as described above) if Resident is eligible for benefits. 13. FACILITY RULES, REGULATIONS, POLICIES AND PROCEDURES. 1723 Nursing Agreement 12-15-04 12 Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement, and the Facility 's rules, regulations, policies and procedures as published in the Facility 's Resident Handbook or other documents or publications made available by the Facility. The Facility reserves the right to amend or change its rules, regulations, policies and procedures. The Facility's rules, regulations, policies and procedures shall not be construed as imposing contractual obligations on the Facility or granting any contractual rights to Resident, and are subject to change from time-to-time. The Facility does not permit smoking anywhere in the building. 14. PERSONAL AND OTHER PROPERTY. 14.1 Responsibility for Maintenance and Loss. Resident is responsible for furnishing and maintaining his or her own clothing and other items of property as needed or desired. Resident is encouraged to and may obtain at his or her own expense, casualty insurance to cover potential damage to or loss of any of Resident's personal property. If damage or loss occurs to Resident's property, the Facility will investigate each incident of loss or damage to determine liability and assess responsibility depending on the facts and circumstances of each incident. The Facility shall be responsible for only such losses or damages as are attributed by the Facility to the negligence or fault of the Facility. 14.2 Disposition and Storage Upon Resident's Death. Upon the Resident's death, Facility shall contact Resident's authorized representative within twenty-four (24) hours to arrange for an inventory of Resident's personal property. Facility is authorized to transfer Resident's personal property to a duly authorized representative of Resident's estate or to such parties or persons entitled to the property under current law. The duly authorized representative of Resident's estate or other persons entitled to property under current law must acknowledge, in writing, the receipt of the personal property transferred to his or her custody by Facility. After completing an inventory, Facility, in its sole discretion, may move and place Resident's personal property into storage at Facility's expense. If property held in storage is not claimed within thirty (30) days, Facility shall send a notice to the authorized representative via certified mail that if items in storage are not removed within fourteen (14) days of receipt of the letter, then Facility may dispose of Resident's property. 14.3 Disposition and Storage Upon Resident's Transfer or Discharge. If Resident's personal property is not claimed or removed within twenty-four (24) hours of Resident's permanent transfer or discharge, the Facility shall move and place Resident's personal property in storage until claimed. If Resident's personal property remains unclaimed for seven (7) days after permanent transfer or discharge, Resident shall be obligated to pay a storage fee as assessed by Facility. After a thirty (30) day period in storage, the Facility may dispose of Resident's property. The Facility is not 1723 Nursing Agreement 12-15-04 13 responsible for any damages incurred to Resident's property if storage becomes necessary. Resident or Resident's estate shall be obligated to pay all costs of storage or disposition and shall bear the risk of loss or damage to the property. 14.4 Damage to Room or Facili Property. Resident or Resident's estate is responsible for any damages caused to the Facility property beyond normal wear and tear, and shall pay for the repair and replacement of damaged property, based on the actual charge or cost to the Facility for such repair or replacement. 15. RESIDENT RECORDS. . Resident consents to the release of Resident's personal and medical records maintained by the Facility for treatment, payment and operations as determined reasonably necessary by the Facility. Any such release may be to the Facility's employees, agents and to other health care providers from whom the Resident receives services, to third-party payors of health care services, to any MCO in which Resident may be enrolled, or to others deemed reasonably necessary by the Facility for purposes of treatment, payment and operations. Release of records for other purposes shall be done in accordance with applicable law, with a specific authorization from the Resident where required. Authorized agents of the state or federal government, including the Long Term Care Ombudsman, may obtain Resident's records without the written consent or authorization of Resident. 16. TREATMENT AUTHORIZATION. Resident authorizes the Facility to provide care and treatment consistent with the terms of this Agreement. Resident also authorizes the Facility to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident may be transferring. 17. DEATH OF RESIDENT. In the event of Resident's death, the Facility shall notify the person(s) designated by Resident. The Facility is authorized to arrange for the transfer of Resident's body to the designated funeral home. Resident's estate is responsible for the payment of all costs associated with the transfer and funeral expenses. Resident shall notify the Facility of any changes of the person(s) or funeral home to be notified in the event of death. 18. CAPACITY OF RESIDENT AND GUARDIANSHIP. If Resident is, or becomes unable, to understand or communicate, and is determined after admission to be incapacitated by Resident's Physician or the Facility's Medical Director, the Facility shall have the right, in the absence of Resident's prior 1723 Nursing Agreement 12-15-04 14 designation of an authorized legal representative, or upon the unwillingness or inability of the legal representative to act, to commence a legal proceeding to adjudicate Resident incapacitated and to have a court appoint a guardian for Resident. The cost of the legal proceedings, including attorney's fees, shall be paid by Resident or Resident's estate. 19. FACILITY'S GRIEVANCE PROCEDURE. 19.1 Reporting Complaints. If Resident, Responsible Person, or Resident's Attorney-in-Fact believe(s) that Resident is being mistreated in any way or Resident's rights have been or are being violated by staff or another resident, Resident or Responsible Person shall make his/her complaint known to the Facility's Director of Nursing or Administrator. Resident, Responsible Person, or Resident's Attorney-in- Fact must first notify the Facility of any such complaints, and provide the Facility with sixty (60) days to resolve the complaint satisfactorily to Resident before the Resident may pursue arbitration. This notice requirement is not intended to preclude Resident, Responsible Person, or Resident's Attorney-in-Fact from filing a complaint with any appropriate governmental regulatory agency at any time. 19.2 Facility's Obligations. complaint and provide a response to Responsible Person. The Facility will review and investigate the Resident/ Resident's Attorney-in-Fact or 19.3 Mandatory Arbitration. Arbitration is a specific process of dispute resolution utilized instead of the traditional state or federal court system. Instead of a judge and/or jury determining the outcome of a dispute, a neutral third party (" Arbitrator(s)") chosen by the parties to this Agreement renders the decision, which is binding on both parties. Generally an Arbitrator's decision is final and not open to appeal. The Arbitrator will hear both sides of the story and render a decision based on fairness, law, common sense and the rules established by the Arbitration Association selected by the parties. When Arbitration is mandatory, it is the only legal process available to the parties. Mandatory Arbitration has been selected with the goal of reducing the time, formalities and cost of utilizing the court system. (a) Contractual and/or Property Damage Disputes. Any controversy, dispute, disagreement or claim of any kind or nature, arising from, or relating to this Agreement, or concerning any rights arising from or relating to an alleged breach of this Agreement, with the exception of (1) guardianship proceedings resulting from the alleged incapacity of the Resident; (2) collection actions initiated by the Facility for nonpayment of stay or failure of Responsible Person to fulfill their obligations under this Agreement or the Responsible Person Agreement which results in a financial loss to the Facility; and (3) disputes involving amounts in controversy of less than Eight Thousand Dollars ($8,000), shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to resolve any 1723 Nursing Agreement 12-15-04 15 disputes or claims that the Resident may have against the Facility. It also means that the Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to resolve any disputes or claims against the Facility. It also means that the Facility is giving up any rights it may have to a jury trial or to bring claims in a court against the Resident. Subject to Section 193(f), the Arbitration shall be administered by ADR Options, Inc., in accordance with the ADR Options Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/ or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up their rights to a jury trial on any matter submitted to arbitration under this Agreement. (b) Personal Injury or Medical Malpractice. Any claim that the Resident may have against the Facility for any personal injuries sustained by the Resident arising from or relating to any alleged medical malpractice, inadequate care, or any other cause or reason while residing in the Facility, shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to bring any claims that the Resident may have against the Facility for personal injuries incurred while residing in the Facility. It also means that the Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to litigate any claims for damages or losses allegedly incurred as a result of personal injuries sustained while residing in the Facility. Subject to Section 193(f), the Arbitration shall be administered by ADR Options, Inc., in accordance with the ADR Options Rules of Procedure, and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up the Resident's right to a jury trial on any claims for damages arising from personal injuries to the Resident which are submitted to arbitration under this Agreement. (c) Exclusion From Arbitration. Those disputes which have been excluded from mandatory arbitration (i.e., guardianship proceedings, collection actions initiated by the Facility, and disputes involving amounts in controversy of less than $8,000) may be resolved through the use of the judicial system. In situations involving any of the matters excluded from mandatory arbitration, neither Resident nor the Facility is required to use the arbitration process. Any legal actions related to those matters may be filed and litigated in any court which may have jurisdiction over the dispute. This arbitration provision shall not impair the rights of Resident to appeal any transfer and/or discharge action initiated by the Facility to the appropriate administrative agency, and after the exhaustion of such administrative appeals, to appeal to the court exercising appellate jurisdiction over the administrative agency. 1723 Nursing Agreement 12-15-04 16 (d) Right to Legal Counsel. Resident has the right to be represented by legal counsel in any proceedings initiated under this arbitration provision. Because this arbitration provision addresses important legal rights, the Facility encourages and recommends that Resident obtain the advice and assistance of legal counsel to review the legal significance of this mandatory arbitration provision prior to signing this Agreement. (e) Location of Arbitration. The Arbitration will be conducted at a site selected by the Facility, which shall be at the Facility or at a site within a reasonable distance of the Facility. (f) Time Limitation for Arbitration. Any request for arbitration of a dispute must be requested and submitted to ADR Options, Inc., prior to the lapse of two (2) years from the date on which the event giving rise to the dispute occurred. In the event ADR Options, Inc., is unable or unwilling to serve, then the request for Arbitration must be submitted to Facility within thirty (30) days of receipt of notice of ADR Options, Inc.'s, unwillingness or inability to serve as a neutral arbitrator. Facility shall select an alternative neutral arbitration service within thirty (30) days thereafter and the selected Arbitration Agency's procedural rules shall apply to the arbitration proceeding. The failure to submit a request for Arbitration to ADR Options, Inc., or an alternate neutral arbitration service selected by Facility, within the designated time (i.e., two (2) years) shall operate as a bar to any subsequent request for Arbitration, or for any claim for relief or a remedy, or to any action or legal proceeding of any kind or nature, and the parties will be forever barred from arbitrating or litigating a resolution to any such dispute. (g) Limitation on Damages and Allocation of Costs for Arbitration. The costs of the arbitration shall be borne equally by each party, and each party shall be responsible for their own legal fees. (h) Limited Resident Right to Rescind this Mandatory Arbitration Clause (Sections 19.3(a-h) of this Agreement). Resident, or Resident's spouse or personal representative in the event of Resident's incapacity, have the right to rescind this arbitration clause by notifying the Facility in writing within thirty (30) days. (Notice of Right to Rescind form is available upon request.) Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post marked within 30 days of the execution of this Agreement. The notice may also be hand-delivered to the Administrator within the same 30-day period. The filing of a claim in a court of law within the 30 days provided for above will automatically rescind the arbitration clause without any further action by Resident, or Resident's spouse or personal representative. 20. NOTICE. 1723 Nursing Agreement 12-15-04 17 Wherever written notice is required to be given to the Facility under this Agreement, it shall be sufficient if notice is provided by personally delivering it or by first-class mail, return receipt requested, addressed to: Mary Jane Walker Administrator Sarah A. Todd Memorial Home Facility Name 1000 West South Street [Address] Carlisle, Pa. 17013 Notice to Resident will be provided by personal delivery to Resident's room, or where applicable, by first-class mail to Responsible Person or other designated person. 21. INDEMNIFICATION. Resident shall indemnify and hold the Facility harmless from, and is responsible to pay for any damages or injuries to other persons and residents or to the property of other persons or residents caused by the acts or omissions of Resident, to the fullest extent permitted by law. 22. RELATIONSHIP OF NURSING HOME ADMISSION AGREEMENT TO OTHER ADMISSION AGREEMENTS. Upon permanent transfer to a new level of care the existing admission agreement will be terminated. 23. MISCELLANEOUS PROVISIONS. 23.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. 23.2 Severability. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction and authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. 23.3 Captions. The captions used in connection with the sections and subsections of this Agreement are inserted only for the purpose of reference. Such captions shall not be deemed to govern, limit, modify, or in any manner affect the 1723 Nursing Agreement 12-15-04 18 scope, meaning or intent of the provisions of this Agreement, nor shall such captions be given any legal effect. 23.4 Entire Agreement. This Agreement, the Responsible Person Agreement and the Admission Application represent the entire Agreement and understanding between the parties and supersedes, merges and replaces, all prior negotiations, offers, warranties and previous representations, understandings or agreements, oral or written, between the parties. 23.5 Modifications. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in law, regulation or operations. To the extent reasonably possible, the Facility will give Resident and Resident's Responsible Person thirty (30) days advance written notice of any such modifications. The Resident may not modify this Agreement except by a written statement signed by the facility. 23.6 Waiver of Provisions. The Facility reserves the right to waive any obligation of Resident under the provisions of this Agreement in its sole and absolute discretion. No term, provision or obligation of this Agreement shall be deemed to have been waived by the Facility unless such waiver is in writing by the Facility. Any waiver by the Facility shall not be deemed a waiver of any other term, provision or obligation of this Agreement, and the other obligations of Resident and this Agreement shall remain in full force and effect. 24. ACKNOWLEDGMENTS. 24.1 Schedule of Charges. Resident and Responsible Person acknowledge the receipt of a copy of the Schedule of Charges and the opportunity to ask questions about the Facility's charges. 24.2 Resident Rights. Resident and Responsible Person acknowledge being informed orally and in writing of Resident's Rights as reflected in the publication attached to this Agreement, and further acknowledge having an opportunity to ask questions about those rights. The Notice of Rights of Nursing Facility Residents (MA- 401) is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on the Facility or granting any contractual rights to Resident. 24.3 Advance Directives. Resident and Responsible Person acknowledge being informed, orally and in writing, of the Facility's policy on advance directives and medical treatment decisions. 24.4 Agreement. Resident and Responsible Person acknowledge that they have read and understand the terms of this Agreement, that the terms have been 1723 Nursing Agreement 12-15-04 19 explained to them by a representative of the Facility, and that they have had an opportunity to ask questions about this Agreement. 24.5 Resident Handbook. Resident and Responsible Person acknowledge the receipt of a copy of the Resident Handbook and the opportunity to ask questions about the Facility's policies contained in the Resident Handbook. The Resident Handbook is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on the Facility or granting any contractual rights to Resident. IN WITNESS WHEREOF, the parties, intending to be legally bound, have signed this Agreement on the date written below. Witness Resident T Witness Responsibl Person (if any) 1 Facility thorized Representative Date ?W I 1 Date ?1 Date 1723 Nursing Agreement 12-15-04 20 UNITED CHURCH OF CHRIST HOMES RESPONSIBLE PERSON AGREEMENT This Responsible Person Agreement (hereinafter "Agreement") is made between j ?A , (hereinafter referred to as "Facility") and N u i i r the legal representative or representative individ al hereinafter referred to as "Responsible Person") of the Resident, C (hereinafter referred to as "Resident"). WHEREAS, the Responsible Person and Facility enter into this Agreement to facilitate the provision of care to the Resident. WHEREAS, the Responsible Person may be the Guardian, the Agent under a valid Power of Attorney, or any person authorized by Resident to serve as Resident's Responsible Person. WHEREAS, Facility shall discuss and consult with Responsible Person regarding pertinent decisions related to Resident's stay and care at the Facility. THEREFORE, Facility and Responsible Person agree to the following terms and conditions: 1. Responsible Person affirms that the information provided in the Admission Application and related documents are true and correct to the best of his or her knowledge. Responsible Person acknowledges that the submission of any false information, misrepresentation or lack of disclosure may result in the termination of the Nursing Home Admission Agreement (hereinafter "Admission Agreement") and may result in the discharge of the Resident from the Facility at the Resident and/or Responsible Person's expense. 2. If the Resident selects a Responsible Person, then said Responsible Person shall sign this Agreement and the Admission Agreement in recognition of this designation with the intent to be legally bound by this Agreement and the Admission Agreement. The Responsible Person shall be obligated to fulfill the duties on behalf of the Resident imposed by the Admission Agreement in accordance with the law governing fiduciary duties. Facility may petition a court to appoint a Guardian and take other legal action if Facility reasonably believes that the Resident's needs are not being properly met or the duties imposed by the Admission Agreement are not being fulfilled by the Responsible Person. Resident, Resident's estate, or Responsible Person shall pay the cost of such Guardianship proceedings, including attorneys' fees. 1725 Nursing Responsible Person Agreement 12-15-04 3. Responsible Person affirms that he or she has access to Resident's income and resources and that Resident's income and resources are available to pay for Resident's care in the Facility. The Responsible Person shall provide payment from Resident's income and resources for such care. Responsible Person shall apply Resident's income and resources to the costs and charges incurred during Resident's stay unless and until such costs are paid by private insurance or other benefits such as Medicare, Veterans Health Insurance or Medical Assistance. When the Resident's financial resources warrant it, Responsible Person shall take any and all actions necessary and appropriate to initiate, make and conclude application for Medical Assistance benefits on behalf of the Resident, including providing all necessary documentation, complying with deadlines and pursuing all necessary appeals. Responsible Person shall exercise diligent efforts in the application and appeal processes to assure continued benefits from any third party or government payor. Responsible Person shall utilize Resident's income and resources only for Resident and shall not utilize any of Resident's income or resources for Responsible Persons benefit nor transfer any of Resident's real property except for proceeds at fair market value for the benefit of Resident. 4. Responsible Person is obligated to pay Facility from Resident's financial resources for services and supplies provided to Resident in accordance with the Admission Agreement. If the Responsible Person withholds or misappropriates Resident's financial resources for personal use or gifts, or otherwise does not use the Resident's financial resources to fulfill Resident's financial obligations to Facility for services and supplies provided to Resident in accordance with the Admission Agreement, then Responsible Person shall be personally liable for payment. Responsible Person is also obligated to pay Facility for all losses or damages incurred by Facility by the failure of the Responsible Person to fulfill his/her duties under the Admission Agreement. Failure to do so will result in legal action by Facility to assure payment for amounts that are Resident's obligations. In the event that Facility initiates any legal actions or proceedings to collect payments due from Resident and Responsible Person under this Agreement, or to enforce Responsible Person's obligations under the Admission Agreement, then Resident and Responsible Person shall pay all damages, attorneys' fees and costs incurred by Facility in pursuing the enforcement of Resident's and/or Responsible Persons financial or other obligations under the Admission Agreement. Such damages, fees and costs may include, in the discretion of Facility, an amount equivalent to revenue lost by Facility due to Responsible Persons failure to timely submit or complete a Medical Assistance application or to cooperate with the Department of Public Welfare (hereinafter "DPW") in the Medical Assistance eligibility determination. Responsible Person shall timely assist Resident in the preparation, completion and submission, if applicable, of Resident's application for Medical Assistance benefits. If Facility, in its sole discretion, decides to assist in the Medical Assistance application, Resident and Responsible Person Nursing Responsible Person Agreement 12-15-04 2 are still fully obligated to initiate, make and complete the Medical Assistance application. Facility's assistance in the Medical Assistance application process does not waive Resident's or Responsible Persons duty or responsibility to timely complete and submit a Medical Assistance application if the Resident's financial resources become insufficient to pay amounts under the Admission Agreement. The failure to initiate, make and complete the Medical Assistance application process may result in the discharge of Resident for non-payment and in personal liability to Responsible Person for losses incurred by Facility for Responsible Person's failure to apply timely for Medical Assistance benefits. In the event Resident applies for Medical Assistance benefits, Responsible Person shall pay the Patient Pay Amount monthly to Facility. Responsible Party, at the request of Facility and to the extent permitted by law, shall immediately sign over and/or designate the Facility as the representative/ designated payee for any income available to Resident in an amount not to exceed the Patient Pay Amount as determined by DPW. Responsible party should take whatever action as may be necessary to insure that such payments are made directly to Facility. Patient Pay Amount is determined by DPW and described in Section 53(b) of the Admission Agreement. If Resident is determined to be ineligible for Medical Assistance because Responsible Person fails to provide or submit necessary documents or fails to appeal timely so that Facility is unable to obtain Medical Assistance reimbursement, then Facility may terminate the Admission Agreement for non-payment of stay and Responsible Person shall be personally liable for any losses sustained by Facility as a result of such failure. Responsible Person shall be responsible personally for compliance with all other terms of the Admission Agreement. 5. Responsible Person understands that if he or she fulfills his or her obligation under this Agreement, he or she shall not be held personally liable for the Resident's charges. However, Responsible Person understands that if he or she does not fulfill his or her obligation under this Agreement he or she shall be liable to Facility for whatever loss Facility sustains as a result of the Responsible Person's breach of this Agreement. 6. Responsible Person is obligated to perform all provisions in the Admission Agreement related to Responsible Person. 7. The Responsible Person attests that the information set forth in the Application Agreement is true and correct to the best of his or her knowledge, information and belief. 8. The Responsible Person acknowledges that he or she has received a copy of the Admission Agreement and understands the terms and conditions contained therein. Nursing Responsible Person Agreement 12-15-04 3 9. Responsible Person acknowledges he or she has reviewed this Responsible Person Agreement and understands the information set forth herein. IN WITNESS WHEREOF, the parties, intending to be legally bound hereby, have signed this Responsible Person Agreement on this 4 day of A (u- 1 M1. J Witness Witness O- Responsible?3 erson nA A kLt4--,) Facility's u orized Representative Nursing Responsible Person Agreement 12-15-04 25 _72,159733 SARAr TODD hq? ^A' = DURABLE POWER OF ATTORNEY NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GrVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WFUCH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LII'ETIIvIE, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP' YOUR FUNDS SEPARATE FROM YOUR. AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S.. CH 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. J l 0 , 2008 FAYEr m?. ]BOWMAN /;?) A? Page I of 4 Pages L .. _.. : ?• L 2? L l 1 !L 4 J 973.?J - ? SARAH TDDD HOME PAGE 04/07 KNOW ALL MEN BY THESE PRESENTS that the undersigned does hereby revolve all Letter(s) and/or Powers of attorney(s) or prior appointment, in Fury form, of an Agent on my behalf heretofore made by me and does here make, constitute and appoint JESSE H. BOWMAN, JR. and CATHY LOUER, individually and not jointly, my true and lawful agent and durable power of, attorney, as defined in 20 Pa.C.S. Section 5604, for me and in my name, to do and exercise the following powers or authorities, as defined fiirthex in 20 Pa.C.S_ Section 5603 and to exercise all powers granted herein are to be construed in the broadest manner provided by law, and to repeat any exercise or exercises thereof, in whole or in part, as often. as deemed appropriate by my said agent: 1. To make limited gifts. 2. To create a trust for my benefit. 3. To make additions to an existing trust for my benefit. 4. To claim an elective share of the estate of my deceased spouse. 5. To disclaim any interest in property. 6. To renounce fiduciary positions. 7. To withdraw and receive the income or corpus of a trust. , 8. To authorize xny admission to a rmedical, nursing, residential or similar facility and to enter into agreements for my care. 9. To authorize medical and surgical procedures. 10. To engage in real property transactions. 11. To engage in tangible personal property transactions. 12. To engage in stock, bond an other securities transactions. 13. To engage in commodity and option transactions. 14. To engage in, banking and financial transactions. 1.5. To borrow money. 16. To enter safe deposit boxes. FAYETTA, M. BONVAJAN Page 2 of 4 Pages f p<- L tn 1n /1. .. _ . ?p p-r1nA7.i1 7-DD nr PAGE L ? rG ?'7( ?f 17. To engage in insurance transactions. ].8. To engage in retirement plan transactions. 19. To handle interests in estates and trusts. 20. To pursue claims and litigation. 21. To receive government benefits. 22. To pursue tax matters. 23. To make an anatomical. gift of all or part of my body. 24. To exercise all powers granted herein generally, in the Commonwealth or elsewhere, as defined in 20 Pa.C.S. Section 5604. 25. To terminate, or modify my employment, whether indulged in by me for profit or otherwise, including the modification and/or winding up of any partnerships or close corporations in which I am in any way involved. To terminate by resignation or otherwise, any or all fiduciary positions and to take action appropriate to final settlement of same, to resigning any official position which I might hold, and to enter into such arrangements as may be necessary and useful to terminate my responsibility in the subject, and to terminate, renounce or resign from any other. relationships which l may have, including any and all. organizational memberships of any nature whatsoever. 26. My agent may appoint successors to him/her without limit, and for whatever reason, he/she deems the same to be useful or appropriate. 27. I hereby .riominate m.y agent as guardian, of my estate and of my person for every and all purposes whatsoever. 28. In addition to, in furtherance of, and separate and independent of the foregoing powers, my agent may generally do and perform all matters and things, transact all business, snake, execute and acknowledge, or any thereof, all wri.tangs, assurances and instruments requisite and proper to carry out the purposes hereof and ALL VVIT,FI THE, SAME FORCE AND EFFECT as I might do, if personally present; hereby RATIFYNG AND CONFIRMING all that is done by my agent by reason hereof. 29. Use of the words "undersigned", "agent", or any other, pronoun in the first person singular or third person, singular shall include the feminine and plural thereof as the sense may appear. ,1a FAYETT4At B()W A,N Page 3 of 4 Pages r Ila "E2S/2 -- 25 7:_'24. 9732 SARA" 'M uCY7 PAGE a]?'P7 IN7ENDING TO BE LEGALLY BOUND HERE$Y, this Durable Power of Attorney is signed by me at the end h of on this fourth d 1 t age and is also signed by me on the preceding two pages this 0) D-day of 9V , 2008. SIGNED, SEALED AND DELIVERED IN T14E PRESENCE OF: Witness COMMONWEALTH OF PENNSYLVANIA.: ss COUNTY OF -JUNIATA_ F.A,YETTA, A BUWMAN On this, the day o 2008, before me, the undersi ed office personally appeared FAYETTTA X. B known to me or satisfactorU ov r, C&405 person whose name is subscribed to the within instrument, and acknowledged.tha proven) be the executed the same for the purposes contained therein. IN VV=ESS WFMREOF, I hereunto set my a1QlVWEAI,TH OF PENN21'LMAPOA -? -,.? NoWW %W a. How, MM Br , ry PWe ???2b17,.20(f9 N??h'efrr, P?trt?syhar? ? ? Page 4 of 4 Pages ry1! 1,0/2- 27 7_724 9733 SARAH TODD HONE PAGE P_7/P_7 AA OnMj-- ? MENT BX AGENT We, JESSE R. BOWMAN, JR. and CATHY LOUER, have read the attached power of attorney and are the persons identified as the agents for the principal. We hereby acknowledge that in. the absence of a specific provision to the contrary in the power of attorney or in 20 Pa. C_S. when T act as agent: We sbali exercise the powers for the benefit of the principal. We shall keep the assets of the principal separate form my assets. We shall exercise reasonable caution and, prudence. We shall keep a fula and accurate record, of all actions, receipts and disbursement on. behalf of the principal. ta?)- 3` 12008 I __r- , 2008 SE .T.I. BOWMAN, .M CATAY OUER 4 Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013-2798 Telephone: (717) 245-2187 STATEMENT Statement Date: 07/12/20 11 Due Date: 07/25/2011 Amount Enclosed $ Account #: 102264 RE: Fayetta Bowman Cathy Louer 646 S. Catherine Street Middletown, PA 17057 Balance B/F 38,705.66 38,705.6 06/01/11 Medical Supplies 95 .68 99.90 38,805.5 06/03/11 Incontinence Supplies 10 10.40 110.15 38,915.7 06/04/11 Personal Supplies 3 1 1.18 18 00 6.14 18 00 38,921.8 8 38 939 06/22/11 Beauty & Barber . . , . 06/30/11 Personal Laundry Services 1 30.00 30.00 38,969.8 /01/11 - 07/31/11 Room & Board - Semi-Private 31, 257.00 7,967.00 46,936.8 ??fnr?y ,'n IT 114L•74 3-- Current 1-30 Days 31-60 Days 61-90 Days Over 90 Days Amount Due .00 8,231.19 7,973.89 8,148.57 22,583.20 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT your statement. Include the ACCT# from the statement on the MEMO of your check. Payments after 7/7/11 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** Fayetta Bowman - Account #: 102264 Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013-2798 Telephone: (717) 245-2187 Statement Date: 07/12/2011 Due Date: 07/25/2011 C?1111BERLAND CAO 3' VIESTMINSTER DRIVE CFFLISLE PA 17013-9976 FAYETTA BOWMAN TODD MEMORIAL HOME 1000 W SOUTH ST CARLISLE PA 1701 pennsyimania DEPARTMENT OF I UBL1C WELFARE MA www.dpw.state.pa. As NOT ELIGIBLE OFFICE OF INCOME MAINTENANCE NOTICE COMPASS wwwxompass.sstate.pa.us Notice ID: 119529048 Record Number: 21 0160848 District: 0 Case Load: 0000 Worker: M BYERS Phone: 1-(800) 269-0173 Mailing Date: 07/13/2011 Reason: 042 Option: D Type: N Category: LTC PSC: 00 TT: You have been determined not eligible for benefits based on your application dated 06/03/2011. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 07/11/11 Items: Name: COMPLETION OF APPLICATION FORM - FAYETTA M BOWMAN VERIFICATION OF INCOME + RESOURCES - Citation: 55 Pa. Code 201.1, 201.3 If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of. your right to appeal and to a fair heal: TODD MEMORIAL HOME 1000 W SOUTH ST CARLISLE PA 17013 CUMBERLAND CAO 33 WESTMINSTER DRIVE CARLISLE PA 17013-9976 Alliance Rehab HVA l? ? M TIP- Pbone (724)588-3299 www.hranet.o"?) MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 21 0160848 0 LTC 00 Notice ID: 119529048 Worker: M BYERS Phone: 1-(800) 269-0173 Mailing Date: 07/13/2011 Reason: 042 Option: D Type: N IF YOU WISH TO APPEAL, COMPLETE THE BACK'OFTHIS FORM AND RETURN THE BOTTOM PORTION TO CAD. PA MA/LTC-X 162-10/08 5`1 ?? ? N? Cpptl(`t -1?t ` ??NSY ?V AN1 A Steven M. Montresor smontresor@ldylaw.com Attorney ID 474244 Latsha Davis & McKenna 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, Sarah A. Todd Memorial Home IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SARAH A. TODD MEMORIAL HOME Plaintiff, NO. 11-6199 V. CATHY LOUER Defendant. CIVIL ACTION PRAECIPE TO DISCONTINUE AND END TO THE PROTHONOTARY: Kindly mark the above-captioned matter discontinued and ended without prejudice. 60799vI Respectfully submitted, LATSHA DAVIS & McKENNA Dated: By: 4, Steven . Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 smontresor@ldylaw.com Tele: (717) 620-2424 Fax: (717) 620-2444 Attorneys for Plaintiff, Sarah A. Todd Memorial Home 6o799v]